bluuebunny/crossref_metadata_2025 huggingface dataset:
2928 Patients With Severe Ulcerative Colitis Are Infrequently Treated With Anti-TNFs in a County Hospital
Authors: Penninti Pranav , Pham Codey , Coss Elizabeth , Govani Shail
Published: October 2019

INTRODUCTION:

Patients with ulcerative colitis (UC) are prone to flares, many of which require hospitalization for administration of corticosteroids. Patients hospitalized with UC may need rescue therapy with anti-TNFs to prevent colectomy. We aimed to study outcomes for patients being treated for UC with corticosteroids at a county hospital in Texas.

METHODS:

A retrospective review of all hospitalizations with an ICD9/10 codes consistent with UC was performed from 2015 to 2017. The charts were manually reviewed to confirm the diagnosis of UC and to determine the hospital course. We included patients admitted for UC flare treated with either oral or intravenous (IV) corticosteroids and found to have severe UC on endoscopic exam. Patients with <30 days of follow up were excluded from evaluation unless they underwent colectomy after admission. Descriptive statistics were calculated using SAS 9.4.

RESULTS:

A total of 118 admissions for UC were reviewed. Of these 19 met our inclusion/exclusion criteria. The median age was 41 years [IQR: 26-53], 12 (63.2%) were of Hispanic ethnicity, 12 were female (63.2%) with a median disease duration of 4 years [IQR: 2-6]. Two patients (10.5%) were on anti-TNFs prior to admission. Median CRP on arrival was 5.8 mg/dL [IQR: 2.8-8.5] and median albumin was 2.9 g/dL [IQR: 2.5-3.0]. The majority (63.2%) were treated with oral steroids versus IV steroids. None of the patients were initiated on an anti-TNF during admission. After discharge, 5 patients were initiated on anti-TNFs. Three (15.8%) underwent colectomy within 90 days of admission. None of the 5 patients initiated on anti-TNF underwent colectomy within 90 days compared to 2 of the 12 (16.7%) who were not started on anti-TNF (P = 1.0). Patients without insurance were initiated on anti-TNF in 22.2% of cases compared to 37.5% of cases in which the patient had insurance coverage (P = 0.62).

CONCLUSION:

In this small study of patients admitted for severe ulcerative colitis, anti-TNF use was not commonly initiated during or after hospitalization. Despite endoscopic and lab evidence of severity, the overall colectomy rate is relatively low in this population. Larger studies of this cohort are necessary to better understand the barriers to anti-TNF use and the long term outcomes of severe UC.
2933 Outcomes of Endoscopic Submucosal Dissection (ESD): A Single Center Experience
Authors: Reyes Jonathan M. , Andrawes Sherif
Published: October 2019

INTRODUCTION:

Endoscopic submucosal dissection (ESD) is a new and advanced endoscopic resection technique; initially developed in Japan for therapeutic and diagnostic management of superficial gastrointestinal malignancies that has limited submucosal involvement and has not metastasized to any regional lymph nodes. ESD provides an accurate histopathological assessment of resected specimens, as en bloc resection of the entire lesions is necessary. ESD is a well-established treatment modality in the East while its interest is beginning to peak in the West.

METHODS:

This is a single-site, internal database review project that was included in a larger study with the University of Florida. The objective of this retrospective study is to evaluate the clinical utility of ESD and its impact on the diagnosis and management of colorectal lesions. This abstract focuses on a sub-sample of 10 patients, over the age of 18, from Staten Island University Hospital, who underwent the ESD procedure for colorectal lesions between July 2014 and September 2018. The team collected demographic information, disease and surgical details: location of lesion, procedural and pathological findings, and any complications.

RESULTS:

The sample size was determined based on the number of colorectal ESD procedures performed in July of 2014 through September of 2018 at SIUH – Northwell Health. The encounters of 10 patients were recorded. The average lesion size was 39.5 mm and average resection size was 43 mm. The average total procedure time was 1 hour and 46.5 minutes. There were no adverse events during any of the procedures. 70% of patients achieved R0 and curative resection while the other 30% went onto Endoscopic Full Thickness Resection or surgical resection.

CONCLUSION:

ESD has proven to be effective for en-bloc and R0 resection for colorectal lesions in both our small sample size and throughout the multicenter analysis. ESD has the potential to offer patients a safer and less invasive option for their early stage colorectal lesions with minimal risk for adverse events as presented from our data (0%) but also confirmed from the larger study. As ESD can be done as an outpatient procedure, patients can avoid hospital admission. Subsequently, ESD provides a better quality of life to patients offering them alternatives to chemotherapy and surgery. ESD should be considered in the treatment algorithm for select advanced lesions in the rectum. Further research will be done for quality improvement measures for this procedure.
2936 Use of Endoscopic Ultrasound for Pancreatic Cyst Surveillance
Authors: Merali Natasha , Gardner Timothy
Published: October 2019

INTRODUCTION:

Endoscopic ultrasound (EUS) is recommended by several society's guidelines for evaluation of asymptomatic pancreatic cysts. Though relatively low-risk, the procedure is costly and EUS-guided FNA has a low sensitivity for detecting malignant cytology. We evaluated a cohort of patients with pancreatic cysts who underwent EUS to determine if 1) EUS was warranted and 2) where EUS changed management.

METHODS:

We evaluated patients who underwent EUS for pancreatic cysts at our medical center. Cysts were evaluated for size, worrisome features and high risk stigmata. The primary outcomes, based on the Fukuoka guidelines, were whether the initial EUS was recommended and if the EUS procedure resulted in a change in clinical management (shortened surveillance interval, lengthened surveillance interval, or surgical intervention).

RESULTS:

204 patients were included in the study and the baseline characteristics are listed in Table 1. We found that EUS was warranted in only 30.9% of patients, all of whom had acute pancreatitis or worrisome features* seen on prior imaging. Though its use led to a change in management for 130 patients, it lengthened the surveillance interval in 70% of these cases (see Figure 1). In patients in whom shortened intervals were recommended, this was mostly due to worrisome features seen in 43.3% (see Figure 2). Additionally, benign cytology was found in 47.7% of cases, and was read as hypocellular or insufficient in 16.7% of cases (N = 174) (see Table 2). *Worrisome features are defined by the 2012 Fukuoka guidelines as: pancreatitis, cyst ≥3 cm, enhancing mural nodule <5 mm, thickened/enhancing cyst walls, main duct size 5-9 mm, abrupt change in caliber of pancreatic duct with distal pancreatic atrophy, lymphadenopathy, increased serum level of CA 19-9, or cyst growth rate ≥5 mm/2 years.

CONCLUSION:

Our findings demonstrate the overutilization of endoscopic ultrasound in the management of pancreatic cysts, suggesting that if worrisome features are not present, follow up can be determined by cyst size alone.
2944 The Effects of Liver Disease on Cardiovascular Mortality Among Patients With Cardiovascular Disease
Authors: Atem Ngum Kikah , Weerakoon Sitara M. , Olanipekun Titilope , Abe Temidayo , Atem Folefac
Published: October 2019

INTRODUCTION:

The mediating effect of liver disease on cardiac diseases has not been comprehensively outlined in the medical literature. Liver disease can increase your risk of heart disease which remains the leading cause of death in the United States. In this study, we looked at the overview of the mediating effect of liver disease on patients diagnosed with cardiovascular disease (CVD) and how this affects death due to cardiovascular disease.

METHODS:

We selected patients with a death record from the second-generation Framingham Heart Study database and performed descriptive and analytical tests. Unadjusted tests to understand the variables associated with cardiovascular death were based on t-test and chi-square test when appropriate. A mediation analysis was conducted with patients diagnosed with cardiovascular disease as the independent variable and patients diagnosed with liver disease as the mediator while controlling for possible confounders.

RESULTS:

Liver disease was not a significant mediator for death due to CVD among patients diagnosed with CVD (P = 0.5882) and only 0.13% of CVD death is attributed to the mediation of liver disease. However, the effect of those diagnosed with CVD on CVD death and the total effect of those diagnosed with CVD and liver disease on CVD death were both statistically significant (P < 0.0001 and P = 0.0017, respectively).

CONCLUSION:

Liver disease does not significantly mediate CVD death among patients diagnosed with CVD. However, our study is limited to death due to CVD. Furthermore, the death record only contains information on a single cause of death. Patients could have died from multiple complications, but the death records did not collect this data.
2950 Gastrostomy Tube Placement in Patients With Ascites: A National Inpatient Sample Analysis
Authors: Sohail Abdullah , Khan Ahamd , Gupta Kamesh , Goyal Hemant , Bansal Pardeep
Published: October 2019

INTRODUCTION:

As the treatment of liver diseases progress, patients with cirrhosis are living longer, and physicians are facing an increasing need for gastric feeding tube placement to provide enteral nutritional support to these patients. Cirrhotic patients are usually considered as a poor surgical risk candidates, making a surgically placed gastrostomy tube an undesirable option; thus, percutaneous endoscopic gastrostomy (PEG) is often considered to an alternate route to provide enteral nutrition. Cirrhotic patients with portal hypertension often have varices or ascites and are inherently more prone to procedural complications. There is limited data on the safety of the gastrostomy tube in patients with ascites. The aim of our study is to assess the outcomes of gastrostomy tube placement in patients with ascites.

METHODS:

We conducted a retrospective review of patients with ascites who underwent gastrostomy tube placement using the largest all-payer database, national inpatient sample (NIS) from 2007-2014 using validated ICD-9 codes. Primary and secondary outcomes included in-patient mortality, length of stay (LOS) and total hospital charges, respectively. We adjusted for confounding factors including age, gender, insurance, zip income, and hospital size and location by using multivariate regression.

RESULTS:

Out of total 2,603,539 hospitalizations for adult patients with ascites, 29,001 patients underwent gastrostomy tube on that hospitalization. Mean age of patients with ascites with gastrostomy 64 ± 2 years with male predominance (55% vs. 45%). The patients with ascites who had gastrostomy tube placed were more likely to die in the hospital (adjusted OR 1.84; 95% CI 1.7-1.9, P = 0.00) as compared to ascites patients without gastrostomy tube. Also, we found a significant increase in mean LOS (28.83 days vs 8.34 days) and mean total charges ($277,404.5 vs $71,874.73).

CONCLUSION:

Our study is the largest evaluation to date of cirrhotic patients who have undergone PEG. This study suggests that patients with ascites who undergo gastrostomy tube placement have increased mortality, length of stay, and hospital charges. The results of this study point towards caution for the use of PEG in patients with ascites.
2953 A Novel Tool to Estimate Early Insulin Resistance and Prevent Metabolic Syndrome and Non-Alcoholic Fatty Liver Disease: Retrospective Study in the Veteran Population
Authors: Houston Trevor , Makar Ranjit , Singh Ashok K. , Fayad Joseph
Published: October 2019

INTRODUCTION:

Previous studies such as the Homeostasis Model Assessment (HOMA) IR1 have been validated tools to estimate Insulin resistance and a predictor of metabolic syndrome (MS) and its related co morbidities such as Non-Alcoholic Fatty liver disease (NAFLD) and Cardiovascular disease (CVD). In the current obesity epidemic, we need simple validated tools to help detect early insulin resistance and curb the growing epidemic of NAFLD. Proinsulin was reported once and in patents as a marker of pancreatic exhaustion hence we propose a novel tool which take proinsulin into account to help predict risk of development of fatty liver disease.

AIM:

To study proinsulin as a predictor of progression to fatty liver disease in non-diabetic veteran population.

METHODS:

Single center retrospective chart review of 55 patients. Charts from the gastroenterology department at Las Vegas VA clinic were analyzed and data collected including liver enzymes, insulin, proinsulin, fasting blood sugar, HbA1C, albumin and lipid profile levels (Table 1). Using the data provided a logistic regression model was used to identify strong predictors of fatty liver disease. A novel statistical model called the Random Forrest method was also used to identify predictors of fatty liver disease.

RESULTS:

Using the logistic regression model, proinsulin and ratio of insulin to proinsulin were found to be significant in predicting fatty liver disease. The overall accuracy was 80%, with precision and recall for both categories ranging from 66.67% to 86.49% (Figure 2). When using the Random Forest methodology, factors such as total cholesterol, ALT, pro-insulin, triglycerides, insulin, ratio IP, and glucose were found to be the most important predictors of Fatty Liver disease (Figure 3).

CONCLUSION:

Early detection of insulin resistance in non-diabetic patient population and can help intervene with medical and dietary or other management to prevent the development and progression of Metabolic syndrome. Our study suggests that proinsulin should be routinely used in at risk patient population for early detection of insulin resistance and prevention of metabolic syndrome and related comorbidities such as NAFLD. Hence pro insulin is a strong predictor of insulin resistance and future prospective studies can help validate proinsulin as a predictor of NAFLD.
2954 Acute Pancreatitis Outcomes May Not Be Worse in Subjects Post-Liver Transplant
Authors: Wadhwa Vaibhav , Gupta Kapil , Gonzalez Adalberto , Castaneda Daniel , Garg Sushil , Bilal Mohammad , Castro Fernando , Lara Luis
Published: October 2019

INTRODUCTION:

The association of Acute Pancreatitis and Celiac Disease (CD) has been sparingly reported in the literature. CD is known to affect approximately 1% of the western population. A Swedish national database study reported a 3-fold increased risk of developing pancreatitis in patients with CD. The exact mechanism of this is unknown, but it could be related to an untreated celiac disease affecting the major papilla causing stenosis or exocrine pancreatic insufficiency that has been reported previously. This study aimed to look at the association between acute pancreatitis and celiac disease. We also looked at whether there was any association between chronic pancreatitis and celiac disease.

METHODS:

We performed a retrospective cross-sectional cohort study using the 2013 National Inpatient Sample (NIS) database. We included all patients who were hospitalized with either acute pancreatitis (ICD Code 577.0) or Chronic Pancreatitis (577.1). Patients who had diagnoses of both acute and chronic pancreatitis were considered to have acute on chronic pancreatitis and combined with the chronic pancreatitis group. We then analyzed both groups for the presence or absence of celiac disease. Continuous variables were compared using t-tests, and categorical variables were compared using Rao-Scott chi-square tests. All analyses were performed using SAS Survey Procedures (version 9.4, The SAS Institute, Cary, NC).

RESULTS:

We analyzed more than 35 million hospitalizations in 2013 out of which 378,715 had a primary discharge diagnosis of acute pancreatitis and 155,130 had a primary discharge diagnosis of chronic pancreatitis. The mean age in the acute pancreatitis group was 53.3 yrs and in chronic pancreatitis group was 51.7 yrs. There were more males in chronic pancreatitis group (55.1%) than females (44.9%). There was significantly higher prevalence of acute pancreatitis in CD (2.3%) than non-CD patients (1.2%) (Figure 1, P = 0.001). Similarly, there was higher prevalence of chronic pancreatitis (1.2%) than the control group (0.43%) (Figure 1, P < 0.001).

CONCLUSION:

There is a higher prevalence of acute pancreatitis in patients with CD. Patients were also found to have much higher prevalence of chronic pancreatitis in CD. This could be related to recurrent acute pancreatitis episodes in CD patients. Further studies are needed to validate these findings.
2955 Nearly One-Half of Patients With Recurrence of Hepatocellular Carcinoma Did Not Receive Any HCC-Directed Surgical Therapies: An Analysis of the 1973-2015 Surveillance Epidemiology and End Results Cancer Database
Authors: Zhang Julia A. , Hirode Grishma , Wong Robert
Published: October 2019

INTRODUCTION:

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality with high rates of recurrence despite treatment. The characteristics and outcomes of HCC recurrence are not well studied. We utilize a national cancer registry to evaluate predictors of overall survival in recurrent HCC.

METHODS:

Using National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) cancer registry, we retrospectively evaluated U.S. adults with recurrence of HCC from 1973-2015. HCC tumor stage was assessed with the SEER historic staging system (localized, regional, distant) and HCC treatment was assessed using SEER's site-specific surgery variable (no treatment, locoregional therapy, surgical resection, and liver transplantation (LT)). Overall survival was evaluated using Kaplan Meier and Cox proportional hazards models.

RESULTS:

Among 275 patients with recurrence of HCC (76.7% male, mean age at initial HCC diagnosis 61 ± 11 years, 48.7% non-Hispanic white, 14.9% Hispanic, 7.6% African American, 27.6% Asian/Pacific Islanders), the majority of patients had localized stage at initial HCC diagnosis (76.4%). At time of HCC recurrence, the proportion of patients with distant/advanced stage was 4 times higher than at initial diagnosis (8.7% vs. 2.2%, P < 0.01). At initial HCC diagnosis, 24.6% did not receive any HCC-directed surgical therapies. At the time of recurrence, overall treatment rates were significantly lower, with 46.6% not receiving any HCC-directed surgical therapies and only 28.7% receiving surgical resection or LT. Median survival was 98 months (95% CI 85-118) after initial HCC diagnosis and 36 months (95% CI 31-48) after HCC recurrence. Significantly higher risk of death was associated with increasing age at time of HCC diagnosis (HR 1.02, 95% CI 1.01–1.04, P < 0.01) and distant stage at diagnosis of recurrence compared to localized stage (HR 2.11, 95% CI 1.26-3.53, P < 0.01). There was a trend towards lower risk of death in Asians compared to non-Hispanic whites (HR 0.67, 95% CI 0.44-1.03, P = 0.07). Receipt of any HCC-directed surgical therapy either for the initial HCC or HCC recurrence was associated with significantly lower risk of death.

CONCLUSION:

Among U.S. adults who developed recurrence of HCC, nearly half did not receive any HCC-directed surgical therapy at time of HCC recurrence. Older age and more advanced tumor stage at recurrence were associated with significantly higher risk of death despite HCC treatment.
2957 Retrospective Review of Patients With Chronic Hepatitis B in Las Vegas, Nevada
Authors: Fajardo Noel R. , Cremonini Filippo , Lapasaran Alex , Dela Cruz-Acupan Jasmine
Published: October 2019

INTRODUCTION:

The estimated annual incidence of clearance of Hepatitis B surface antigen (HBsAg) is 1–2% in Asian populations. The spontaneous seroclearance of HBsAg in patients with chronic Hepatitis B infection in the Western world is seldomly reported. HBsAg loss is a relatively rare outcome in the natural history of chronic Hepatitis B. Aim of this study was to assess the incidence of spontaneous seroconversion of Hepatitis B surface antigen and the natural development of immunity to HBV virus as evidenced by development of Hepatitis B surface antibody (HBsAb) in a US-based outpatient population.

METHODS:

Electronic medical records from January 2010 to May 2019 at a large outpatient community-based Gastroenterology practice were retrospectively reviewed. Seroconversion of HBsAg and appearance of HBsAb were recorded. Serologic markers for Hepatitis B infection, AST, ALT, and alpha fetoprotein levels were also recorded.

RESULTS:

A total of 263 charts were reviewed. One hundred seventy nine (179/263; 68%) of these patients had a positive HBsAg upon referral. Fifty five had a history of Hep B treatment; 124 (124/179; 69%) were treatment-naïve. Forty six (46/179; 26%) had chronic active Hepatitis B, and seventy three (73/179; 40%) were lost to follow up. Five (5/179; 2.7%) patients seroconverted to negative HBsAg. Four of these patients subsequently developed immunity as evidenced by the appearance of HBsAb (4/179; 2.2%). Sixty seven (67/263; 25.5%) of all referred patients had immunity to Hepatitis B through natural infection. Thirteen (13/263; 4.9%) patients had incomplete serologies; 4 (4/263; 1.5%) patients were caught in the “window period” with both negative HBsAg and HBsAb. All four patients who had a documented loss of HBsAg were male, Asians (Filipino), aged 48-65 years. The average time from referral to HBsAg clearance was 8-9 years. None of the 4 patients had a positive Hepatitis delta agent, concomitant infection with Hepatitis C, or elevated AFP.

CONCLUSION:

Chronic HBV infection poses a significant socio-economic burden specially among immigrant communities from endemic geographic regions. Continued adherence to CDC guidelines for HBV screening should be encouraged among high risk patient populations. Further race/ethnicity and community based studies on the natural history of chronic HBV infection will further increase knowledge of disease prevention and cure.
2958 Assessing the Association Between Psoriasis and Nonalcoholic Liver Disease
Authors: Sarmini Muhammad Talal , Asfari Mohammad Maysara , Fahad Hamna , Alomari Mohammad , Al-Khadra Yasser , Dasarathy Srinivasan , McCullough Arthur J.
Published: October 2019

INTRODUCTION:

Psoriasis is an inflammatory disorder that is associated with increased risk for multiple comorbidities. It is reported in the literature that psoriasis can increase the risk for nonalcoholic fatty liver disease (NAFLD) which is the most common liver disease in the United States (US). We aimed in this study to assess the risk for NAFLD in psoriasis patients using large database.

METHODS:

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

RESULTS:

The total population was comprised of 101,137,145 patients, of which 274,491 (0.271%) were diagnosed with psoriasis. These patients with psoriasis were older (60 vs 48) and less likely to be females (49.1% vs 58.4%) and African American (6% vs 14.3%) (P < 0.001). In addition, psoriasis patients had more diabetes mellitus with or without complications (4.7% vs 3.2%) and (22.5% vs 14.1%) respectively (P < 0.001 for all). Furthermore, the psoriasis patients had more hypertension (HTN) (54.4% vs 36.4%), hyperlipidemia (HLD) (23.3% vs 13.4%), obesity (16.4% vs 6.9%) and hypothyroidism (12.2% vs 7.8%) (P < 0.001 for all). Using Multivariate logistic regression, and after adjusting for potential cofounding factors including: (age, race, gender, HTN, HLD, DM, hypothyroidism and obesity), psoriasis patients had a statistically significant higher rate of NAFLD (Odds Ratio [OR], 2.13, 95% confidence interval [CI], 2.05-2.22, P < 0.001).

CONCLUSION:

Based on these data, patients with psoriasis are twice more likely to have NAFLD which is known to increases the risk for cardiovascular disease and diabetes mellitus. Early recognition and appropriate treatment which includes mainly life style modifications and controlling risk factors for NAFLD are essential in preventing progression of NAFLD in these patients.
2959 How Does the FibroScan® Agree With the Liver Biopsy With Respect to Hepatic Steatosis and Fibrosis?
Authors: Lopez Carmen , Rao Shanti , Faruqui Saamia , Howard Elizabeth , Moehlen Martin
Published: October 2019

INTRODUCTION:

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease in Western countries. Liver biopsy is the current gold standard to diagnose, grade, and stage NAFLD; however, it is invasive, costly, and prone to sampling error. Fibroscan® (FS) is an FDA approved noninvasive test that employs vibration-controlled transient elastography to estimate liver fibrosis. FS also has a “controlled attenuation parameter” (CAP) that measures the degree of attenuation by hepatic fat. Many non-U.S. based studies have supported the use of CAP in the estimation of hepatic steatosis. Due to Louisiana's unique biodiversity, there is a theoretical conundrum that generalizability of outside data on CAP may not be reliable on local subjects. Therefore, we aim to assess the agreement of these tools in our patient population.

METHODS:

A retrospective chart review was performed that identified patients using ICD-10 and CPT codes from Tulane Hospital with fatty liver who had both a FS and liver biopsy performed within one year of each other. Between April 2018 and January 2019, 36 eligible patients were identified. The data collected was de-identified and then analyzed using SAS version 9.4. Using accepted cut-offs, we categorized the FS stiffness data into Metavir fibrosis stages and the CAP scores into steatosis grades. We tested the agreement between the FS and the liver biopsy by calculating kappa values.

RESULTS:

The figures show the association between FS findings and liver biopsy as it pertains to fibrosis and steatosis, respectively. We dichotomized and compared the presence or absence of hepatic steatosis and cirrhosis by FS and liver biopsy. While there was no difference between the two tests for either steatosis or fibrosis (P = 0.71 and P = 0.16), they were only reproducible 25% and 22% of the time, respectively.

CONCLUSION:

Our study represents a unique sample of a busy liver practice where both a liver biopsy and FS were performed. We found fair agreement of presence/absence of steatosis or cirrhosis between FS and liver biopsy; however, our sample was too small to see agreement for precise grading and staging between these modalities. Limitations are small population size and the potential change in grading that may occur between the time of biopsy and FS. Lastly, our study may be prone to a selection bias, as liver biopsy is often obtained after an incongruent noninvasive test and clinical. Despite these limitations, this study demonstrates fair agreement between FS and liver biopsy.
2964 Real World Evidence Demonstrates a Difference in the Presenting Characteristics of Cirrhotic Patients Who Received Albumin Compared to Those Who Received Only Crystalloids
Authors: Davis E. Anne , Kim W. Ray , Sindhwani Navreet S. , Telang Santosh , Runken M. Chris , Lodaya Kunal , Raghunathan Karthik
Published: October 2019

INTRODUCTION:

Cirrhosis affects over 633,000 adults in the US with recent mortality rates increasing by 3.4% annually. Readmission rates have also been shown to be high. These patients may be resuscitated with albumin, crystalloids, or both.

METHODS:

This study used real-world data to examine differences in the burden of disease among adults admitted with cirrhosis who were treated with albumin (<24 hours (early) versus >24 hours (late) after admission) versus crystalloids alone, between January 1, 2009, and December 31, 2016. We used a nationwide Electronic Health Record database (Cerner Health Facts®) and compared Model for End-stage Liver Disease Sodium (MELD-Na) score and Elixhauser Comorbidity Index across the fluid resuscitation groups.

RESULTS:

We identified 86,432 patients admitted with cirrhosis. The mean age was 59.2 years and the majority (55.4%) were male. Patients who received albumin (n = 26,835) had higher MELD-Na scores at presentation (mean score 22.0 in patients treated early and mean score 19.5 in patients treated late), versus patients who received only crystalloids (n = 59,597; mean score 14.1). Additionally, at presentation, patients who received albumin had a higher Elixhauser Comorbidity Index (mean 18.8 and 19.9 in patients receiving albumin early versus late respectively) versus patients who received crystalloids alone (mean 16.3).

CONCLUSION:

Cirrhotic patients who were treated with albumin had, at presentation, a higher MELD-Na score and Elixhauser Index, which represents a greater burden of disease compared to patients treated with only crystalloids. Further research is needed to examine differences in clinical and economic outcomes, including complications of cirrhosis such as acute kidney injury, spontaneous bacterial peritonitis, ascites, and procedures of large volume paracentesis, following different fluid resuscitation regimens.
2966 A Sub-Analysis of Puerto Rican Hepatitis C Infected Patients Enrolled in the Phase 2 and 3 Glecaprevir-Pibrentasvir Clinical Program
Authors: Sepúlveda-Arzola Gladys , Rosado-Carrión Barbara , Lovell Sandra , Bugarin Gabriela , Aponte Fernando , Crown Eric D. , Rodríguez-Pérez Federico
Published: October 2019

INTRODUCTION:

Chronic hepatitis C virus (HCV) infection is a leading cause of cirrhosis and advanced liver disease, and viral clearance is associated with reduced risk of developing cirrhosis, hepatic decompensation, and death. Glecaprevir (NS3/4A protease inhibitor) and pibrentasvir (NS5A inhibitor) are direct-acting antivirals (DAAs) co-formulated as a once-daily, fixed-dose combination regimen (G/P) to treat genotype (GT) 1‒6 HCV infection. G/P has been licensed in the United States and Europe, supported by a phase 2/3 global clinical trial program demonstrating high efficacy with a favorable safety profile. The objective of this study was to describe the clinical characteristics and virologic response to G/P in Puerto Rican (PR) patients included in the G/P clinical program.

METHODS:

Data were pooled from 14 phase 2, 3, and 3b clinical trials conducted in 32 countries and representing 3,233 treatment-naive and treatment-experienced patients with chronic HCV GT1–6 infection who received G/P once-daily for 8, 12, or 16 weeks. The primary endpoints were percentage of patients with sustained virologic response 12 weeks after treatment (SVR12) and percentage with treatment-emergent adverse events (AEs).

RESULTS:

From the 3,233 patients included in the G/P clinical program, this sub-analysis included 79 (2%) patients from sites in Puerto Rico. Overall, 52 (66%) were male, 64 (81%) were white race and the median age was 56 years (range: 29–78). Most patients were infected with HCV GT1 (n = 69; 87%), of whom 71% (49/69) had GT1a infection, and overall, 63 (80%) were treatment-naïve. Additionally, 39 (53%) patients had baseline fibrosis stage F0–F1, while 25 (34%) had stage F4. The overall SVR12 rate was 97.5% (77/79), with two patients not achieving SVR12 due to non-virologic reasons (both missing SVR12 data). AEs occurred in 38 (48%) patients, with none leading to discontinuation. Serious AEs occurred in 4 (5%) patients but none were deemed by investigators to be related to DAAs. There were 4 (5%) grade ≥3 laboratory abnormalities, and none were deemed clinically meaningful.

CONCLUSION:

G/P achieved high SVR12 rates and was well-tolerated in Puerto Rican patients enrolled in the G/P clinical trial program. The efficacy and safety profile of G/P in Puerto Rican patients was comparable to the overall patient population in the G/P registrational trial program, and SVR12 rates were comparable to real-world studies of G/P.
2969 Implementation of a Proper Inoculation and Transport Technique for Ascitic Fluid in Patients With Suspected Spontaneous Bacterial Peritonitis: A Quality Improvement Project
Authors: Williams Mary-Jane O. , Akhondi Hossein A. , Ayutyanont Napatkamon , Faris Frank
Published: October 2019

INTRODUCTION:

Spontaneous bacterial peritonitis (SBP) is a fatal complication of cirrhosis. Abdominal paracentesis needs to be performed to collect ascitic fluid for analysis with a good technique. In our hospital, we routinely collected the ascitic fluid in general purpose test tubes. To maximize the yield, we implemented a quality improvement (QI) project to use blood culture bottles for this matter. This is because SBP is a low-colony-count mono-microbial infection similar to bacteremia and the low concentration of bacteria in infected ascites and small volume obtained by conventional methods provides minimal sensitivities and very low yields.

METHODS:

For baseline, pre-implementation yield rate, the charts for all the patients age 18-85 years old who underwent paracentesis from 2011-2017 in our center were reviewed. All these patients had cirrhosis, abdominal tenderness and identified as having SBP using the ICD diagnostic criteria. Patients with use of antibiotics within the previous week were excluded. Their ascitic fluid was collected in the conventional test tube bottles and results of the fluid analysis were based on these samples. For QI implementation, we created an order set in our electronic medical record to use blood culture bottles for ascitic fluid collection. Appropriate handling of the ascitic fluid was taught to laboratory technicians. For post-implementation yield rate, data from patients who were tested with the new protocol will be evaluated and compared to that of pre-implementation.

RESULTS:

Data from 60 patients with SBP was tabulated. Baseline positivity rate for the samples collected with regular test tubes was calculated (as determined by PMN >250 cells/mm3). 60% of the samples were positive and 40% negative. Post-implementation data will be determined and final results will be provided during the conference in October.

CONCLUSION:

SBP can occur through bacteremic seeding, translocation of gut bacteria, or decreased intestinal motility in cirrhotic patients who are presumed to be malnourished and immunocompromised. Ascitic fluid collected with a suboptimal technique with delays and use of standard test tubes leads to falsely negative results and sub-standard treatment of patients. Immediate inoculation of fluid into blood culture bottles will likely increase the yield and direct the treatments.
2970 Non-Cirrhotic Portal Hypertension in Myeloproliferative Disease: Left and Right-Sided Component of Portal Hypertension
Authors: Sharma Mithun , Rao Padaki N. , Reddy Duvurr N.
Published: October 2019

INTRODUCTION:

NCPH is the presence of portal hypertension (PH) in the absence of cirrhosis. While Schistosomiasis is the commonest cause in West, myeloproliferative diseases (MPD) characterized by cellular proliferation of one or more hematologic cell lines resulting in extra-medullary hematopoiesis predominantly in the spleen and occasionally in liver may cause PH. Pathogenesis of NCPH in MPD revolves around the concept of left sided portal hypertension. This study presents a cohort of Indian patients of NCPH with MPD.

METHODS:

260 patients with NCPH were evaluated and 9 MPD was diagnosed based on 2008 WHO-criteria. Cirrhosis was ruled out by fibroscan and liver biopsy. All patients underwent a pro coagulant screen which included protein-C, protein-S, factor-V leiden, antithrombin D, anti phospholipid antibody, prothrombin gene deficiency and Jak-2 mutation study. Routine PH evaluation and Fibroscan and liver biopsy was done in all cases.

RESULTS:

Out of 9 patients 4 (44.4%) each had polycythemia-rubra-vera (PRV) and myelofibrosis while 1 had essential thrombocytosis. Median age was 50 ± 7 yrs with 8 male and 1 female patient. 5 (55.5%) presented with symptomatic splenomegaly, 1 (11.1%) with ascites and 3 (33%) with GI bleed and comprised of 64.3% in PRV. Splenomegaly was universally present and hepatomegaly in 44.4%. Isolated gastric varices was present in 3 and gastroesophageal varices in 4 and isolated esophageal varices in 2 patients. Except for Jak-2 mutation found positive in 100% cases of PRV and 66.7% cases of MF, none of the other markers were positive. None, except 1 patient on liver biopsy showed sinusoidal deposits. 8/9 patients underwent endoscopic therapy for varices and were given prophylaxis with carvedilol. Mean follow up was 40 months and none had recurrent bleed or worsening of liver function due to PH.

CONCLUSION:

True incidence MPD causing PH is under-recognised. Our results are similar to other studies from Asia. Unlike other studies, we did not find portal vein thrombosis. MPD patients had huge splenomegaly leading to increased blood flow through the splenic vein leading to left sided portal hypertension. Myeloid metaplasia in liver can also leading to right-sided PH. Whether beta blockers would help as primary or secondary prophylaxis without this component is inconclusive. However, in our cohort of patient they were helpful. Rescue therapy like splenectomy, JAK 2 inhibitors, TIPS etc may be reserved for the refractory cases.
2973 Can BE3A Score Predict Improved Outcomes in Patients With Decompensated Cirrhosis Receiving Direct-Acting Antiviral Therapy for Hepatitis C Virus Infection?
Authors: Nawaz Arif , Riaz Saherish , Iqbal Haseeb , Khan Zohaib , Ali Bushra , Chowdhry Asad , Farooq Abdul , Nawaz Shahmeer , Chaudhry Hafsa , Arshad Abru , Arif Ayesha
Published: October 2019

INTRODUCTION:

Hepatitis C virus (HCV) treatment is now recommended in all patients, except those with a shortened life expectancy that cannot be altered by viral eradication. Treatment with direct-acting antiviral (DAA) agents can reduce Model for End-Stage Liver Disease and Child-Pugh-Turcotte (CPT) scores in patients with decompensated HCV cirrhosis caused. To assist decision making a scoring system known as BE3A had been devised to predict the outcome of these patients treated with DAAs.

METHODS:

This was a retrospective study of 44 patients with Child Pugh class B and C cirrhosis undergoing Sofosbuvir based therapy in combination with Daclatasvir ± Ribavirin. Baseline parameters of the BE3A score including BMI, Encephalopathy, Albumin, Ascites and ALT were recorded. Inclusion criteria was age 18-65 years, chronic HCV infection, with detectable HCV plasma RNA, and decompensated cirrhosis (CPT B or C). Patients with Hepatocellular carcinoma, Post liver transplant CHC, eGFR <30 ml/min and not on sofobuvir based regime were excluded. The patients were followed up for 36 weeks and patients were reassessed for their CTP class and MELD score. Data was analyzed using SPSS.

RESULTS:

Data was collected on 44 patients with SVR12 on DAA therapy. 42/44 patients were alive at 36 weeks with one patient each dying with BE3A scores of 1 and 3 respectively (one with score of 3 had several co-morbidities). 7%, 52%, 33% and 7% patients had scores of 1, 2, 3 and 4 respectively. Majority of the patients with scores of 3 and 4 had improved outcomes as evidenced by a reduction in their MELD scores but no patient had a change of their CTP class to A.

CONCLUSION:

Our study provides us real life data on the ability of the BE3A score to predict outcomes in patients with decompensated liver cirrhosis undergoing DAA therapy. It does predict improved outcome in terms of an improved MELD and CTP scores but this treatment does not lead to a change in the CTP class in our patients. We feel that a longer term follow up may result in this improved outcome. This ability to predict treatment outcomes is particularly relevant in resource constrained countries like Pakistan in order to prioritize treatment for the patients most likely to benefit from treatment. In addition Sofosbuvir/Daclatasvir ± Ribavirin based combination is very economical as compared to the other regimens and may be used in resource poor countries with acceptable results.
2988 Development of the Celiac-Provider Education Guideline Support (Celiac-PEGS) Website
Authors: Crozier Louise A. , Crowe Sheila E.
Published: October 2019

INTRODUCTION:

Celiac disease is an autoimmune disease that affects about 1% of a genetically susceptible population. Approximately 3 million individuals in the United States have celiac disease (CD) and are required to eat a gluten-free diet (GFD) to prevent severe health issues. Poor dietary management and lack of comprehensive care can lead to increased significant co-morbid conditions. Current literature suggests a significant lack of provider knowledge and implementation of CD guidelines may negatively affect management and care of adult patients with CD. Poor dietary management of CD, in addition to the lack of comprehensive care, can lead to daily symptoms, significant co-morbid conditions and decreased quality-of-life in patients with CD. There is an increased need for improving awareness, knowledge, and accessible treatment guidelines for providers who manage the care of adult patients with CD.

METHODS:

The emphasis of this project has been on the development of a web-based program to assist providers in the implementation of the current complex CD guidelines for management of adult patients with CD. Grounding of this web-based program is with currently published guidelines including the American College of Gastroenterology “Diagnosis and Management of CD” guidelines (2013), the British Society of Gastroenterology “Diagnosis and Management of Adult Coeliac Disease: Guidelines” (2014), the American College of Physicians “In the Clinic” celiac guidelines (2011), and the World Gastroenterology Organization Global CD Guidelines (2016). This project translates current evidence-based practice guidelines into an organized system that will guide providers as well as increase their knowledge and confidence to successfully direct care and guide patients with CD.

RESULTS:

A usability study conducted in 2018 involving 15 GI providers from California and New Mexico evaluated ease of use of the new Celiac- Provider Education Guideline Supportweb-based program, which showed above average usability and this information, was previously presented at DDW 2019.

CONCLUSION:

We have developed a web-based program for providers of adult patients with CD, which is easy to use. The goals of this innovative website are to improve awareness, education, and management support that will result in comprehensive implementation of current adult CD guidelines. Ultimately, we believe that this web-based program once nationally disseminated, will especially support providers in primary care and in rural areas.
2989 To Determine the Frequency of Helicobacter pylori in Patients With Gastric Cancer
Authors: Adnan Muhammad , Adnan Nida
Published: October 2019

INTRODUCTION:

Around the world, particularly in Asia and Eastern Europe, gastric disease remains a main source of malignant growth demise. A higher danger of advancement of gastric malignancy has been accounted for in patients with positive serologic tests for H pylori. This investigation is a push to demonstrate a relationship of H pylori as a cancer-causing agent and the seriousness of harm it is related with. H. pylori is perceived as a reason for constant gastritis, which might be viewed as the initial phase in a grouping of changes to the gastric mucosa perhaps bringing about malignancy. In this manner, the present examination investigated the presence of H. pylori disease in people with gastric malignant growth at tertiary consideration healing center.

METHODS:

The two year cross section study screened fifty cases of carcinoma stomach for H. pylori infection. The inclusion criteria were patients with carcinoma stomach confirmed by endoscopy and histopathology while the exclusion criteria patients received anti H pylori treatment within 6 months and the patients not willing/refuse to give consent for the study. All patients who presented with upper GI symptoms and suspected to have carcinoma stomach investigated in the form of complete blood count, ultrasound and upper gastrointestinal endoscopy. On endoscopy patient who had growth in the stomach biopsy was taken from and around the growth and subjected to Rapid urease test and histopathologic examination along with serology test for antibobies to H. pylori. The frequency/percentages (%) and means ± SD computed for study variables.

RESULTS:

During two year study period total fifty patients were explored for H. pylori infection. The frequency for male and female population was 32 (64%) and 18 (36%) with mean ± SD for age of male and female individuals was 55.83 ± 9.62 and 58.21 ± 8.72 respectively. The H. Pylori infection was positive in 30 (60%) patients while the growth exists in antrum 25 (50%), antrum and body 10 (20%), body 08 (16%), body and fundus 04 (8%), fundus 03 (6%) while regarding the histopathology well differentiated carcinoma 07 (14%), moderately differentiated carcinoma 10 (20%), poorly differentiated carcinoma 33 (66%).

CONCLUSION:

The existence of H. pylori observed in gastric carcinoma cases may lead to a spread of H. pylori in histologic sections and might describe the variation in H. pylori infection rates reported for patients with gastric cancer.
2990 Helicobacter pylori in Chronic Spontaneous Urticaria: An Interim Analysis of a Case-Control Study in Nepalese Population
Authors: Poudyal Yogesh , Paudel Mukesh , Pathak Nandu , Mandal Amrendra
Published: October 2019

INTRODUCTION:

Chronic spontaneous urticaria (CSU) is defined as the spontaneous appearance of wheals, angioedema or both for more than six weeks due to known or unknown causes. Infections like helicobacter pylori have been implicated as causes of CSU. In this study, we aimed to determine an association of H. pylori infection with CSU.

METHODS:

This was a case-control study conducted in Lumbini city Hospital, Butwal, Nepal. Study duration was from March to May 2019. Sample size was calculated to be 83 participants in each group. Participants fulfilling the diagnosis of CSU were enrolled. They underwent 14C -Urea Breath Test (UBT) by a standard protocol, for noninvasive detection of H. pylori. HUBT-20P model of the analyzer from Shenzhen, China was used. A value of less than 150 DPM (disintegration per minute) was considered to be negative. We excluded the following from the study: pregnant individuals, participants with recently used of antibiotics and bismuth compounds (<4 weeks), participants with recent use of proton pump inhibitors (<2 weeks), less than two years age, those with previous gastric surgery and those suspected of having coexisting inducible urticaria. The results were compared with age and sex-matched controls.

RESULTS:

We included 29 patients with CSU and 29 controls in this study. The average age of participants was 25.8 ± 8.69 years. Sixteen (55.17%) patients with CSU were females and 13 (44.82%) were males. Twenty-six (89.65%) patients with CSU tested positive for H. pyloriwith UBT; only 10 (34.48%) participants from the control group tested positive. The distribution of H. pylori by 14-C urea breath test in cases and controls is shown in Table 1.

CONCLUSION:

In this interim analysis of 29 cases and controls, majority of participants were females with an average age of 25.8 years. In a study of 673 adults with CSU, majority (72%) were reported to be females. Chronic urticaria is sometimes associated with other autoimmune conditions and hence its increased prevalence in females may be indirect evidence of the autoimmune nature of this disease. Most of the participants with CSU tested positive for H. pylori with UBT as compared to the age and sex-matched controls and this difference was statistically significant (P < 0.0001).