bluuebunny/crossref_metadata_2025 huggingface dataset:
925 Incremental Value of Endoscopic Ultrasound in Detecting Pancreatic Lesions in Patients With MEN1
Authors: Ahmed Osman , Cazacu Irina , Weston Brian , Ross William , Lee Jeffrey , Bhutani Manoop S.
Published: October 2019

INTRODUCTION:

Multiple endocrine neoplasia type 1 is an inherited disorder that affects the endocrine glands caused by a mutation in the MEN1 gene. MEN1 is associated with pituitary, parathyroid and pancreatic lesions (specifically tumors of islet cells and neuroendocrine tumors) and the prevalence of pancreatic lesions can range as high as 75%. Currently, CT and MRI are used to investigate pancreatic lesions in MEN1. Endoscopic ultrasound can also be used to assess the pancreas and also allows for tissue sampling. The main disadvantage of EUS is that it is invasive and requires an endoscopy with anesthesia to perform. In this study, we examine the incremental value of performing EUS in patients with MEN1 who were referred after CT or MRI.

METHODS:

This was a retrospective study of all patients with a mutation-proven MEN1 diagnosis who underwent EUS between 2009 and 2018. Patients who had previous resection for pancreatic lesions were excluded. The cross-sectional image closest to the date of the EUS was used as a comparison. Relevant data including lesion characteristics were extracted. The location of the lesions were also recorded as multiple locations could affect future treatment options.

RESULTS:

A total of 42 patients with MEN1 underwent EUS for pancreatic lesions. The mean age was 51.9 years (SD +/- 13.7) and 24 (57%) patients were female. A total of 31 patients had a CT while 11 patients had an MRI to compare to EUS. For patients who underwent CT followed by EUS, CT showed 45 lesions (1.5 lesions per procedure) while EUS showed 78 pancreatic lesions (2.5) (P < 0.05). The mean size of the largest lesion was 22.4 mm (SD 14) with EUS, and 16.7 mm (SD 17). In 14 cases, EUS saw a lesion in an area of the pancreas that was not seen on CT, while only in 3 cases the CT saw a lesion in a location not seen on EUS. Twenty-five (81%) of patients in the CT group underwent FNA to obtain cytology. For patients who underwent MRI followed by EUS, MRI showed 19 lesions while EUS showed 48 lesions (P < 0.05). The mean size of the largest lesion was 14.3 (SD 10.5) with EUS, and 6.9 with MRI (SD 7.8). In 8 cases, EUS saw a lesion in a territory that was not seen in on MRI. Six (55%) patients in the MRI comparison underwent FNA. Overall, no complications were noted from performing EUS or FNA.

CONCLUSION:

Despite advances in imaging by CT and MRI, EUS continues to play an important incremental role in detecting and mapping pancreatic lesions in patients with MEN1.
926 POEM Is a Safe and Effective Treatment for Achalasia: A Large Single Center Experience
Authors: Moosvi Zain , Abadir Alexander , Cao Vicky , Samarasena Jason , Chang Kenneth J.
Published: October 2019

INTRODUCTION:

Achalasia is a primary motility disorder characterized by aperistalsis and failure of lower esophageal sphincter relaxation. Traditionally, treatment modalities have consisted of drug therapy, botulinum toxin injections, laparoscopic Heller myotomy, and balloon pneumatic dilatation. However, in the past several years, the novel technique peroral endoscopic myotomy (POEM) has gained popularity, as prior studies have suggested that it offers excellent short-term outcomes. In this study, we analyze the efficacy of POEM with a focus on both short-term and long-term outcomes.

METHODS:

This retrospective study utilized collected data at our tertiary referral center. A total of 71 patients underwent POEM. 18 patients were lost to follow-up post-procedure. 47 patients were included in the short-term assessment, defined as less than 6 months removed from the procedure, while 15 patients were included in the long-term assessment, defined as greater than or equal to 6 months removed from the procedure. Eckhardt score was assessed before POEM and afterwards for short-term follow-up and long-term follow-up.

RESULTS:

Mean age was 56.5 years old. 54% of patients were female. Mean short term follow-up time was 2.96 months. Mean long-term follow-up time was 13.0 (8-27) months. The mean pre-POEM Eckhardt score was 7.6. The mean short-term post-POEM Eckhardt score was 1.2 (P < 0.001) while the mean long-term post-POEM Eckhardt score was 1.8 (P < 0.001). There was no significant difference between short-term and long-term Eckhardt scores. Additionally, there were no adverse outcomes or effects in any of the 65 POEM cases.

CONCLUSION:

This study was one of the largest single-center studies that examining the efficacy and safety of POEM . Eckhardt scores decreased significantly after POEM, remained significantly decreased at longer-term follow-up, and there were no adverse outcomes. In short, this study supports that POEM is a safe, effective, and durable option for the treatment of achalasia.
928 Efficacy and Safety of Endoscopic Full Thickness Resection (EFTR) of Colorectal Neoplasms Using the Full Thickness Resection Device (FTRD): A Systematic Review and Pooled Analysis
Authors: Dasari Chandra S. , Nutalapati Venkat , Duvvuri Abhiram , Chandrasekar Viveksandeep Thoguluva , Malik Afeerah , Kohli Divyanshoo , Sharma Prateek
Published: October 2019

INTRODUCTION:

Endoscopic full thickness resection (EFTR) using the Full Thickness Resection Device (FTRD) is being increasingly used for the resection of colorectal lesions not amenable to conventional endoscopic resection. We conducted a systematic review and pooled analysis to assess the efficacy and safety of this device for resection of colorectal lesions.

METHODS:

An electronic database search was conducted in PubMed/MEDLINE, Embase, Google Scholar and Cochrane databases to identify studies that used EFTR for colorectal lesions using the over the scope FTRD. The primary outcome was the rate of technical success and R0 resection. Secondary outcomes included complications (bleeding, perforation and post polypectomy syndrome) and the total procedure time. Pooled rates were reported with 95% Confidence Interval (CI) with heterogeneity (I2). We used a random effects model to calculate pooled rates and used the I-square statistic to quantify heterogeneity.

RESULTS:

A total of 7 studies were included in the final analysis - 559 patients with 563 lesions removed using FTRD; mean age 67 years, males 59.3% and mean lesion size of 15.7 mm. Mean follow up of the studies was 4.0 months. The colorectal lesions resected by EFTR included: 32% cancers, 0.01% neuroendocrine tumors and 67% adenomas. The pooled overall technical success was 91% (95% CI 88% - 93%, I2 = 0%) (Figure 1) with a R0 resection rate of 81% (95% CI 74% -86%, I2 = 62%) (Figure 2). The pooled rates of immediate bleeding, perforation, and post polypectomy syndrome were 5% 3% and 2% respectively. The overall combined rate of any complication (bleeding, perforation and post polypectomy syndrome) was 9.2% (6.1%-13.5%). The mean total procedure time was 47.76 min (95%CI 40-55, I2 = 84%) (Figure 3).

CONCLUSION:

Endoscopic full thickness resection (EFTR) using over the scope Full Thickness Resection Device (FTRD) appears to be a effective and safe technique for the resection of non-lifting colorectal lesions, with a >90% technical success rate, R0 resection rate of >80% and an overall complication rate of < 10%.
938 Positive Results From REGENERATE: A Phase 3 International, Randomized, Placebo-Controlled Study Evaluating Obeticholic Acid Treatment for NASH
Authors: Younossi Zobair , Ratziu Vlad , Loomba Rohit , Rinella Mary , Anstee Quentin M. , Goodman Zachary , Bedossa Pierre , Geier Andreas , Beckebaum Susanne , Newsome Philip , Sheridan David , Trotter James , Knapple Whitfield , Lawitz Eric , Kowdley Kris , Montano-Loza Aldo , Boursier Jerome , Mathurin Philippe , Bugianesi Elisabetta , Mazzella Giuseppe , Olveira Antonio , Cortez-Pinto Helena , Graupera Isabel , Orr David , Gluud Lise Lotte , Dufour Jean-Francois , Shapiro David , Campagna Jason , Zaru Luna , MacConell Leigh , Shringarpure Reshma , Harrison Stephen , Sanyal Arun
Published: October 2019

INTRODUCTION:

Obeticholic acid (OCA), an FXR agonist, improved both fibrosis and histologic features of nonalcoholic steatohepatitis (NASH) in the Ph2 FLINT study. This Month 18 pre-specified interim analysis of the Ph3 REGENERATE study evaluated the effect of OCA on liver histology in patients (pts) with biopsy-confirmed NASH1.

METHODS:

Pts with NASH and fibrosis stages F2-3 (ITT), and an exploratory group of F1 pts with metabolic syndrome, were randomized to placebo (PBO), OCA 10 mg, or OCA 25 mg QD. Primary endpoints were fibrosis improvement (≥1 stage) with no worsening of NASH, or NASH resolution with no worsening of liver fibrosis per liver biopsy. The safety population included all randomized and dosed pts (F1-3, N = 1968). Clinical outcomes will be evaluated at the end-of-study.

RESULTS:

The ITT population included 931 pts (PBO [n = 311], OCA 10mg [n = 312] or OCA 25mg [n = 308]), comprised of 44% F2 and 56% F3. Baseline characteristics were well-balanced across groups. Results in Table 1. The primary fibrosis endpoint was met by 11.9% PBO, 17.6% OCA 10 mg (P = 0.0446 vs PBO), and 23.1% OCA 25 mg (P = 0.0002 vs PBO) pts (ITT). The primary NASH endpoint was not statistically significant (ITT); however significantly more pts on OCA 25 mg showed improvements in hepatocellular ballooning (P = 0.0011 vs PBO) and lobular inflammation (P = 0.0322 vs PBO). Dose-dependent reductions in ALT, AST and GGT were observed. Pruritus was the most common AE (19% PBO, 28% OCA 10mg, 51% OCA 25 mg) and was predominantly mild to moderate in severity (severe pruritus: < 1% PBO, < 1% OCA 10mg, 5% OCA 25 mg). SAEs occurred in 11% PBO, 11% OCA 10 mg and 14% OCA 25 mg pts. Increases in LDLc with OCA were observed by Week 4, but approached baseline by Month 18 (OCA 25mg: LS mean change Wk4 +22.6 mg/dL, M18 + 4.0 mg/dL). Three deaths occurred; none were considered treatment-related (PBO n = 2; OCA 25 mg n = 1).

CONCLUSION:

Treatment with OCA 25mg improved liver fibrosis, key histologic features of steatohepatitis and liver biochemistry, demonstrating consistent efficacy with an overall AE profile similar to previous studies.
1

Interim analysis results at 18 months are based on surrogate endpoints and impact on clinical outcomes has not been confirmed. The REGENERATE study is ongoing to confirm the clinical benefit of OCA.
942 Low Incidence of Bleeding Complications in Patients With Cirrhosis Undergoing Transesophageal Echocardiography: A Systematic Review and Meta-Analysis
Authors: Odewole Mobolaji , Sen Ahana , Mufti Arjmand R. , Agrawal Deepak , Nguyen Anh D. , Singal Amit G. , Rich Nicole E.
Published: October 2019

INTRODUCTION:

The presence of esophageal varices is considered a relative contraindication to transesophageal echocardiography (TEE) by some professional societies, so gastroenterologists are often consulted to perform upper endoscopy prior to TEE in patients with cirrhosis. Our study’s aim was to perform a systematic review and meta-analysis to quantify the risk of bleeding complications in cirrhosis patients following TEE.

METHODS:

Two reviewers searched MEDLINE and EMBASE databases from January 1992 to January 2019 for studies reporting bleeding complications following TEE in patients with cirrhosis. Data was extracted by two authors using standardized forms. The pooled incidence rate was calculated using the DerSimonian and Laird method for a random-effects model. The modified Newcastle-Ottawa Scale (NOS) was used to assess study quality. This study was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines.

RESULTS:

We identified 16 studies meeting inclusion criteria comprising 3415 unique cirrhosis patients. Nine studies (n = 3009) assessed risk of intraoperative TEE during LT and 7 studies (n = 406) included cirrhosis patients undergoing TEE for other indications; upper endoscopy was performed prior to TEE in 3 out of 9 and 7 out of 7 of those studies, respectively. The pooled risk of bleeding complications post-TEE was 1.0% (95%CI 0.0 – 2.0%) across all studies. The proportion of patients with bleeding complications was similar among patients undergoing intraoperative TEE during LT compared to those undergoing TEE for other reasons (1.1% vs 2.2%, P = 0.06). Further, bleeding rates were similar among patients in the subgroup of studies with mean MELD > 18 compared to studies with mean MELD < 18 (1.9% vs 1.3%, P = 0.31). Three studies had NOS quality scores < 5, 6 had a score of 5–7, and 7 studies had quality scores >7. Overall, the cohorts were representative and included patients with various etiologies of cirrhosis, though most were retrospective in design and lacked a control group. Detailed data on patient-level factors impacting bleeding complications (including degree of liver dysfunction and coagulopathy) were inconsistently reported and limited across studies.

CONCLUSION:

There is a low risk of bleeding complications in cirrhosis patients following TEE, suggesting TEE is safe and risk stratification with upper endoscopy may not be necessary.
943 A Step-Wise Approach to Non-Invasive Diagnosis of Advanced Fibrotic Disease in NAFLD
Authors: Fahad Hamna , Mitchell Brittany , Sarmini Talal , Singh Tavankit , McCullough Arthur J.
Published: October 2019

INTRODUCTION:

The accurate diagnosis of advanced fibrosis using non-invasive methods remains a challenge in patients with nonalcoholic fatty liver disease (NAFLD). Recently, improved accuracy has been suggested with a new approach which uses a two-step model to diagnose advance fibrosis; first classifying patients based on NAFLD Fibrosis Score (NFS) and then, based on the Liver Stiffness Measurements (LSM) as measured by the Fibroscan®. Our study examines the usefulness of this approach in reducing the number of liver biopsies needed in NAFLD patients.

METHODS:

Patients were included if they had Fibroscan® and liver biopsy done within 6 months of each other during 2017 and 2018 at a large tertiary center. The NFS, LSM and Fibrosis (F) score on biopsy were assessed. LSM cut offs of 10 and 15 kPa were derived from the Baveno IV consensus. First, patients were divided into three groups based on NFS score: low risk (< -1.455), intermediate (-1.455-0.675) and high risk (>0.675). A Fibroscan® was then performed in each group. Patients with an NFS >-1.455, LSM > 10kPA and/or a combination of both were thought to qualify for a liver biopsy. We then compared the accuracy of using NFS alone, LSM alone or a Step-Wise Approach (SWA) to the biopsy result. Descriptive statistics analyzed the data.

RESULTS:

98 patients met our inclusion criteria and underwent analysis. By being classified as intermediate or high risk using NFS alone, LSM alone, or SWA; 64, 64, and 48 patients qualified for liver biopsies, respectively. For low risk categories, using NFS, LSM and SWA, we classified 34, 34 and 50 patients respectively as having no significant fibrosis, 3,0,3 of them were misclassified respectively. The sensitivity, specificity, positive predictive value and negative predictive value for SWA were 88%, 64.4%, 45.8%, and 94%. SWA had the highest diagnostic accuracy.

CONCLUSION:

SWA has a high specificity and negative predictive value and accurately prevented 16 biopsies. We propose that SWA is beneficial in clinical practice to decrease the number of liver biopsies needed for NAFLD patients as shown in Figure 1. Furthermore, our results show that patients with NFS < -1.455 gain little benefit from subsequent LSM to rule out advanced fibrosis. Conversely, patients with high risk NFS and high risk LSM may have the biopsy deferred and be treated as compensated cirrhosis unless indicated otherwise.
946 Factors Leading to Discordance Between Vibration-Controlled Transient Elastography and Liver Biopsy in Patients With Non-Alcoholic Fatty Liver Disease
Authors: Fahad Hamna , Mitchell Brittany , Sarmini Talal , Singh Tavankit , McCullough Arthur J.
Published: October 2019

INTRODUCTION:

Vibration-Controlled Transient Elastography (VCTE) or Fibroscan® is used for the non-invasive assessment of liver fibrosis. However, liver biopsy remains the gold standard for diagnosis due to potential inaccuracies of VCTE including, the patient's body mass index and interobserver variance. Therefore, we examined simple lab parameters and patient related factors that might contribute to this discordance, in patients with Non-Alcoholic Fatty Liver Disease (NAFLD).

METHODS:

Patients were identified using appropriate ICD 9 and 10 coding for NAFLD. We included patients 18 years and older who underwent a VCTE (both the M and XL probe) and liver biopsy within 6 months of each other. Electronic medical records were reviewed manually to extract data. Variables of interest included VCTE liver stiffness measurement (LSM), VCTE fibrosis score and biopsy fibrosis stage according to the NASH CRN Scoring System. Only valid VCTE results (IQR < 30 and with 10 valid readings) were included. Discordance was defined a difference of more than 2 fibrosis stages between VCTE and biopsy results. Mann-Whitney U test was used to compare continuous variables, Fischer’s exact test to compare categorical variables and multivariate analysis for logistic regression.

RESULTS:

109 patients with fatty liver on imaging and elevated transaminases without other types of liver disease underwent a Fibroscan and a subsequent biopsy. In 52% of patients (57/109) the Fibroscan overestimated fibrosis by 2 stages. In univariate analysis, discordance was associated with BMI (36 vs 32.9), ALT (45 vs 72), Fibroscan IQR (17.24 vs 13.5), FIB-4 Score (1.65 v/s 2.25), and NAFLD Activity Score (2.33 vs 3.36), (P value < 0.05 for all). In multivariate analysis, BMI was the only factor independently associated with discordance (P < 0.05).

CONCLUSION:

Although multiple factors may lead to discordant results for the stage of fibrosis between VCTE and liver biopsy, our results indicate that a higher BMI is the major factor for this discordance with the XL probe. These data also suggest that a stepwise approach combining a noninvasive scoring system and VCTE should be explored as an alternative approach to improve the accuracy of noninvasive methods and minimize the need for liver biopsy in NAFLD patients.
949 National Trends in the Epidemiology of Drug Use in Patients With Hepatitis B and C Infections
Authors: Alomari Mohammad , Hader Ismail , Al Momani Laith , Nusairat Leen , El Kurdi Bara , Khazaaleh Shrouq , Young Mark , Romero-Marrero Carlos
Published: October 2019

INTRODUCTION:

Hepatitis B and C are the main causes of liver failure worldwide. Drug use places people at particular risk for contracting viral hepatitis. Therefore, we conducted this study to evaluate the incidence rate and trend of these infections over fifteen successive years between 2002 and 2016 the united states.

METHODS:

This is a retrospective epidemiological study that included patients diagnosed with hepatitis B and hepatitis C from the National Inpatient Sample Registry between 2002-2016. We excluded those with missing information, age < 18 years old and hospital transfers based on the ICD-9 and 10 codes. (Figure 1) Data were then stratified based on drug use status. Poisson regression with robust estimator was used to assess the trend of drug use, as well as the association with age, sex, race, and region.

RESULTS:

A total of 9,475,105 hospitalizations with hepatitis B or C were included. Of them, 2,532,542 patients had a drug use diagnosis. The incidence of drug use in hepatitis increased from 22.7% (2002) to 30.6% (2016) (Figure 2), with an adjusted annual percent change of 3.4%. Male sex (PR 1.237, 95% CI 1.234-1.240) and younger age (0.963, 0.963-0.963), were associated with higher drug use. Compared to the white race, the black race had a higher prevalence of drug use (1.143, 1.139-1.146), while Hispanics (0.981, 0.978-0.985) and other races (0.581, 0.577-0.584) were associated with lower drug use prevalence ratios. Furthermore, the highest drug use prevalence ratio was in the Northeast, followed by the West (0.820, 0.817-0.822), the Midwest 0.735 (0.732-0.738), and finally, the South (0.654, 0.652-0.656) (Table 1).

CONCLUSION:

Drug use in patients with hepatitis B and C is rising at an alarming rate in the United States. This emphasizes on the need for more efforts to combat drug use through known effective methods which will have a significant consequence on these individuals and, subsequently, our communities.
952 Outcomes of Glecaprevir-Pibrentasvir Treatment for Chronic Hepatitis C of Any Genotype (1-6, Mixed) in Patients With Compensated Cirrhosis: Real World Results From a Safety Net Hospital
Authors: Sehmbey Gurbir , Quigley Gerard , Bowie Tessa , Bellapravalu Sharad , Nadir Abdul , Chuang Keng-Yu
Published: October 2019

INTRODUCTION:

Glecaprevir-Pibrentasvir (G/P) is pan-genotypic direct-acting antiviral agent (DAA) which has achieved 99% success rate in the treatment of chronic Hepatitis C (HCV) genotypes (GTs) 2, 4, 5, or 6 infection, and 95% in genotype (GT) 1 and 3 infections in clinical trials. Real world data in the compensated cirrhotic population is lacking.

METHODS:

A retrospective study of patients treated for chronic HCV of any GT using G/P between January 2018 through January 2019. A successful G/P treatment is defined as an undetectable Hepatitis C Viral Load at 12 weeks post-treatment (SVR12). The percentage of successful G/P treatments will be calculated for two groups of patients: patients with chronic HCV without cirrhosis and patients with chronic HCV with compensated cirrhosis. The proportion of successfully treated patients from the two groups will be compared to evaluate whether the performance of the G/P treatment is similar between compensated cirrhotic and non-cirrhotic groups of patients. Wilcoxon Rank Sum test and Chi-square/ Fisher’ Exact tests were used to calculate continuous and categorical variables, respectively. P-value of 0.05 was considered statistically significant.

RESULTS:

A total of 187 subjects were eligible for inclusion in the study: 76 (40.64%) were Hispanic, 111 (59.36%) were non-Hispanic. 126 (67.38%) were male, 61 (32.62%) were female. 17.5% of subjects were diabetic, and 33% had hypertension. 28.3% (53) of subjects had compensated cirrhosis, 68.5% (128) were non-cirrhotic. 129 subjects had GT1 infection, 19 had GT2 infection, 25 had GT3 infection, 3 had mixed GT1 and GT2 infection, 2 had GT4 infection, and one subject was of unknown GT. Cirrhotic subjects had a mean age of 55.1 years, mean age of non-cirrhotics was 48.7 years. Of the 53 cirrhotic subjects, 26 achieved documented SVR, 27 were lost to follow-up (50.9%). Of the 128 non-cirrhotic subjects, 58 achieved documented SVR, 70 were lost to follow-up (54.6%). 20 were excluded from the study: 6 for unwillingness to proceed with initial workup, and 14 started their therapy after the cut-off date.

CONCLUSION:

Our study suggests achieving a documented SVR in the setting of treatment based in a safety-net hospital system is difficult due to challenges with patient follow-up. Data suggest an overall improvement in hepatic measurements: APRI, FIB-4, Metavir, and Elastography. However, due to poor patient follow-up, there was insufficient data to complete an accurate evaluation of overall hepatic health post G/P treatment.
955 Epidemiology and Outcomes of Bacterial Infections in Patients With Cirrhosis: A Single Centre Experience
Authors: Khatua Chitta Ranjan , Sahu Saroj Kanta , Barik Rakesh Kumar , Pradhan Subhasis , Nath Gautam , Meher Dinesh , Singh Shivaram Prasad
Published: October 2019

INTRODUCTION:

Bacterial infection is a life-threatening condition in patients with cirrhosis, and by inducing an inflammatory state, it can precipitate acute on chronic liver failure (ACLF). However, the epidemiology and the outcome of bacterial infections are poorly understood from this resource constrained region of Asia. So we performed a prospective study to evaluate the spectrum of bacterial infections in cirrhosis patients and their outcome in hospitalized patients.

METHODS:

This study was conducted in consecutive decompensated cirrhosis patients hospitalised in Gastroenterology Department, SCB Medical College, Cuttack, India between October 2016 and October 2018. Demographic, clinical, laboratory and microbiological parameters were recorded in all cirrhotics and survival was compared between patients with and without infection during hospitalisation and also at 28 days and 90 days.

RESULTS:

274 (47.6%) out of 576 patients had infection, of which 28.8% (n = 166) had urinary tract infection (UTI), 10.9% (n = 63) respiratory infection, 7.6% (n = 44) spontaneous bacterial peritonitis (SBP) and 3.6 % (n = 21) had skin and soft tissue infection. Culture positivity was seen in 17.5 % (n = 29) of UTI and 5 patients (11.36%) of SBP. E.coli was the commonest organism isolated from urine and ascitic fluid. Cirrhotics with bacterial infection had increased prevalence of ACLF as per CANONIC study criteria (56.9% vs 25.2%; P < 0.001). Furthermore, they had increased duration of hospitalisation (5 days vs 4 days, IQR; P < 0.001), increased hospital death (17.5% vs 5%; P < 0.001), decreased survival both at 28 days (68.6% vs 84.1%; P < 0.001) and 90 days (48.2% vs 67.9%; P < 0.001).

CONCLUSION:

In our institution, about half of decompensated cirrhosis patients had associated infection at the time of hospitalisation. Urinary and respiratory infections were common followed by spontaneous bacterial infection. Patients with AKI had increased proportion of ACLF, longer hospital stay, increased in hospital mortality and decreased survival both at day 28 and 90.
969 Perfluorooctanoate Exposure and Risk of Non-Alcoholic Fatty Liver Disease and Advanced Fibrosis in U.S. Adults: A Population-Based Study
Authors: Reja Debashis , Visaria Aayush , Pioppo Lauren , Tawadros Augustine , Bhurwal Abhishek , Rustgi Vinod K.
Published: October 2019

INTRODUCTION:

Industrial chemical exposure is an increasingly recognized entity in NAFLD and NASH. Perfluorooctanoate (PFOA) has been widely used in industrial manufacturing, and is linked to cardiovascular, thyroid, oncologic, and liver disease. This study examines its association with NAFLD and Advanced Fibrosis using U.S. nationally representative data.

METHODS:

A population of 2,833 non-pregnant individuals ages 18-74 were included in this secondary analysis of NHANES 2011-2016. Exclusion criteria: AST/ALT > 500 IU/L, alcohol > 10 drinks/week (females)/ >20 drinks/week (males), transferrin saturation > 50%, positive hepatitis B and C serology. NAFLD was defined by Fatty Liver Index score > 60. Advanced fibrosis was defined by National Fibrosis Score > 0.676. Student’s T-test was used for continuous and Rao-Scott Chi-Square test for categorical variables. Comparison across quartiles were done with simple linear regression for continuous, Rao-Scott Chi-Square test for categorical variables. Demographics and patient confounders were adjusted using multivariate logistic regression (SAS 9.4) for odds of NAFLD/Advanced Fibrosis with respect to PFOA quartile.

RESULTS:

NAFLD compared to non-NAFLD cohort were significantly more likely to be older, male, less educated, obese, have higher HbA1C, rates of diabetes, hypertension, insulin resistance, more likely Latino, and have higher total cholesterol (see Table 1). For NAFLD, adjusted regression analysis show a positive trend for NAFLD with increased PFOA quartile (Q3, OR 1.16, 95% CI 0.60–2.22), (Q4, OR 1.63, 95% CI 0.88–3.03), and on stratification the association was significant for BMI >30 (Q4 OR 3.25, 95% C.I. 1.33–7.95). Unadjusted regression analysis, participants with increased PFOA exposure were more likely to have Advanced Fibrosis (Q4 OR 1.74, 95% CI 1.03–2.98), and this association was seen particularly in females, smokers, and the obese with advanced fibrosis (Q4 OR 2.99, 95% CI 1.90–4.72), (Q4 OR 2.71, 95% CI 1.30–5.68), (Q4 OR 2.09, 95% CI 1.17–3.72), but was attenuated after adjustment.

CONCLUSION:

Our findings show a significant association for NAFLD in obese patients with increased PFOA exposure. Both NAFLD and Advanced fibrosis show a positive trend with increased PFOA exposure. This study highlights that PFOA, an established carcinogen and toxic industrial contaminant, may play a role in NAFLD and related comorbidities in the US population. Further studies are needed for confirmation.
984 Non-Invasive Predictors of Moderate-Large Esophageal Varices in Compensated Cirrhotic Patients
Authors: Hasan Irsan , Sulaiman Andri S. , Jasirwan Chyntia O. , Loho Imelda M. , Zulkifly Steven , Sardjan Jordan , Handayu Anugrah D.
Published: October 2019

INTRODUCTION:

Esophageal variceal hemorrhage (EVH) is a severe complication of liver cirrhosis with a high mortality rate. Esophagogastroduodenoscopy (EGD) screening to detect esophageal varices (EV) is currently recommended for all newly diagnosed cirrhotic patients. However, many patients who undergo EGD do not have varices, especially in compensated cirrhotic patients. Furthermore, EGD is an expensive and invasive procedure. The aim of the study is to identify a non-invasive and low-cost scoring system that could predict the presence of moderate–large EV in compensated cirrhotic patients.

METHODS:

A cross-sectional study was conducted in newly diagnosed patients with non-Child-Pugh (CP) C liver cirrhosis, without a history of variceal bleeding. Demographic, clinical, biochemical, and ultrasonographic parameters will be recorded. Presence and degree of esophageal varices will be determined during EGD. In order to identify independent predictors for the presence of esophageal varices, univariate and multivariate logistic regression will be analyzed.

RESULTS:

EV was found in 47 from 80 patients (58.8%) that were enrolled in this study. Of 47 patients, moderate-large varices was detected in 20/34 (58.8%) and 12/13 (92.3%) patients with CP-A and CP-B class, respectively. In univariate analysis, low platelet count (≤100 000/μL), increased bipolar spleen diameter (≥135 mm), and platelet count/bipolar spleen diameter ratio ≤ 847 were associated with the presence of moderate-large EV. Only platelet count/bipolar spleen diameter ratio was associated in multivariate analysis. The AUC, sensitivity and specificity of platelet count/bipolar spleen diameter ratio ≤ 847 is 0.77, 90.6% and 58.3%, respectively.

CONCLUSION:

Low platelet count is commonly found in liver cirrhotic patients and easily obtained in resource-limited setting. The enlarged spleen is often observed in patients with liver cirrhosis and associated with a higher risk of complications. The ratio of low platelet count/spleen bipolar diameter has been used to predict the presence of EV in cirrhotic patients, however, the previous studies included the patients with compensated and decompensated cirrhosis. For the implementation in daily clinical practice with resource-limited setting, a patient with compensated liver cirrhosis and platelet count/bipolar spleen diameter ratio ≤ 847 is highly recommended to undergo EGD screening procedure.
995 Lost to Follow-Up: Patients Diagnosed With Hepatitis C Virus During Pregnancy May Not Seek Postpartum Treatment
Authors: Goff Sara , Daitch Zachary , Briscoe Jessica , Langworthy James , Chamarthy Padma , Kataria Rahul , Orthey Perry , Gotfried Jonathan
Published: October 2019

INTRODUCTION:

Patients diagnosed with hepatitis C virus (HCV) during pregnancy represent a unique treatment challenge; direct acting antiviral agents are not currently approved for use during pregnancy. Treatment is delayed until postpartum that may lead to ‘leakage’ of patients ultimately resulting in persistent, untreated infection. We sought to determine the rate of persistent infection in patients diagnosed with HCV during pregnancy in obstetrics (OB) clinics across our health system and determine reasons for non-treatment following pregnancy.

METHODS:

We queried our health system’s EHR to identify patients with positive HCV antibody and/or RNA who were initially tested during prenatal testing in OB clinics between 2011–2018. We obtained demographic data, liver imaging and fibrosis scores, and determined level of postpartum engagement in health care for HCV treatment.

RESULTS:

A total of 110 patients were identified who were diagnosed in OB clinic during pregnancy and remained untreated. Ninety-two (84%) patients had follow-up in the first 6 months with any care provider but only 28 (25%) patients presented for follow up in GI clinic. The average time for presentation to GI clinic was 14 weeks after initial diagnosis. Of the patients assessed in GI clinic, 3 patients (11%) were prescribed therapy but did not have evidence of initiating therapy or achieving SVR. There were 12 patients (43%) who were assessed for therapy and required more testing and subsequently lost to follow up. Patients were not offered treatment in 21% (6/28) of cases due to lack of evidence for advanced fibrosis/cirrhosis at time of diagnosis. 25% of patients were evaluated in GI clinic prior to delivery (7/28) but did not present for follow up in the post postpartum period. For the entire cohort, there was no evidence of HIV or HBV co-infection. Only two patients had evidence of steatosis of liver US and no patients had evidence of advanced fibrosis (Fibrosure 0-1; low FIB-4 score).

CONCLUSION:

Patients diagnosed with HCV during pregnancy are at risk for ‘leakage’ from care in the postpartum period. Our study found a minority of patients presented for follow up in GI clinic for treatment and the vast majority of those patients did not receive treatment. Developing linkage to care programs to retrospectively reengage untreated patients and develop prospective protocols for close monitoring and outreach for future cases may help decrease this gap in care.
997 Nadir Mean Arterial Blood Pressure During the First Day of Admission to the Intensive Care Unit (ICU) Is Associated With ICU Mortality
Authors: Peng Jennifer L. , Russell Sarah M. , Shamseddeen Hani , Kettler Carla D. , Buckley Caitriona A. , Ghabril Marwan S. , Orman Eric S. , Desai Archita P. , Gomez Eduardo V. , Nephew Lauren D. , Chalasani Naga P. , Patidar Kavish R.
Published: October 2019

INTRODUCTION:

Current consensus guidelines endorsed by the American Society of Transplantation, American Society of Transplant Surgeons, and the European Association for the Study of the Liver recommend maintaining a mean arterial pressure (MAP) ≥ 60 mmHg to maintain organ perfusion in critically ill cirrhotics admitted to the intensive care unit (ICU). However, the associations between MAP and ICU-mortality, particularly during the first day of admission to the ICU, in critically ill cirrhotics remains unclear.

AIM:

To evaluate the association of nadir MAP during the first day of ICU admission and ICU-mortality in critically ill cirrhotics.

METHODS:

Cirrhotics admitted to the ICU at two academic tertiary care referral centers in 2017 were retrospectively analyzed. Nadir MAP one day after admission to the ICU was captured. Multivariable logistic regression analysis was performed to determine the association of day-1 nadir MAP with ICU-mortality. The Youden index was used to determine the optimal day-1 nadir MAP cut-off for discriminating risk for ICU-mortality. Kaplan-Meier (KM) survival curve was created with the optimal MAP cut-off for time to ICU-mortality.

RESULTS:

183 cirrhotics were included [59 yrs, 56% male, 32% alcohol and 28% non-alcoholic in etiology, Model for End-Stage Liver Disease-Sodium (MELD-Na) score of 25]. Mean day-1 nadir MAP was significantly lower in patients who died in the ICU compared to those who did not (53 mmHg vs 65mmHg, P < 0.0001). After adjusting for potential confounding admission variables (vasopressor use, hemodialysis, mechanical ventilation, MELD-Na, and stage 3/4 hepatic encephalopathy), day-1 nadir MAP was independently associated with ICU-mortality with an OR of 1.13 (for 1 mmHg decrease, 95%CI 1.05, 1.22, P = 0.001). The optimal cut-off for day-1 nadir MAP was determined to be 60 mmHg. Forty-three percent of patients with a day-1 nadir MAP < 60 mmHg died during their ICU stay compared to 7% with a MAP > 60 mmHg. On KM analysis, time to ICU-mortality was significantly lower in patients with a MAP < 60 mmHg [P = 0.018 (Figure)].

CONCLUSION:

In our preliminary analysis, we found nadir MAP during the first day of admission to the ICU to be independently associated with ICU-mortality. A cut-off of <60 mmHg may identify patients at risk for ICU-mortality, though larger studies at various time points are needed to substantiate this finding.
1010 Risk Factors for Recurrent Primary Sclerosing Cholangitis (rPSC) After Orthotopic Liver Transplant
Authors: Schoech Michael , Sherman Kenneth
Published: October 2019

INTRODUCTION:

Recurrent primary sclerosing cholangitis after liver transplantation occurs in approximately 10-25% of patients. rPSC is the leading cause of graft loss and mortality and significantly increases the need for retransplantation. Prior studies have suggested that Inflammatory bowel disease (IBD) with an intact colon is risk factor for the development of rPSC. Our aim was to evaluate whether IBD with or without a colectomy significantly affected the development of rPSC, identify other risk factors for recurrence, and define the overall recurrence rate.

METHODS:

In this ongoing single center, retrospective cohort, 1086 transplants were performed at University of Cincinnati between 2003 to 2019. rPSC was defined using the Mayo Clinic criteria. A total of sixteen risk factors were considered including: age, gender, type of anastomosis, type of transplant, hepatic artery thrombosis, acute cellular rejection, IBD, type of IBD, colectomy, timing of colectomy, cholangiocarcinoma, MELD score, cold ischemic time, hepatitis B core antibody donor status, and smoking. Data were analyzed using Statistix 10.0 with an alpha = 0.05.

RESULTS:

53/1086 liver transplants (4.9%) were performed in 48 patients for primary sclerosing cholangitis (PSC). Within the PSC group, the median age at transplant was 49 years with 72.5% male. The median MELD at transplant was 22, median cold ischemic time of 363 minutes, and a median follow-up of 47.5 months. 35 patients (68.6%) had IBD including 20 (57.1%) with ulcerative colitis. 9 patients (18.4%) developed rPSC in a median of 65 months. Among these, 67% developed subsequent graft loss from rPSC and 33% underwent retransplant (P < 0.03). As anticipated, HAT was a negative predictor for development of rPSC. There were no statistically significant risk factors for the development of rPSC, but rPSC patients were slightly younger (P < 0.06). In rPSC, graft loss (P < 0.004) and time to death (P < 0.007) occurred significantly later (107 and 102 months respectively) than in patients without rPSC.

CONCLUSION:

The overall recurrence rate of PSC (18.4%) is similar to prior studies without any discernable risk factors in this cohort. IBD and colectomy did not significantly reduce the rate of rPSC. rPSC leads to delayed graft loss and mortality with a high rate of retransplantation indicating an insidious disease process. Longer follow-up may increase the rate of rPSC, graft loss and mortality as a subset of individuals in the cohort were transplanted prior to the median recurrence time.
1017 HEP C: Helping Everyone Provide a Cure
Authors: Burke Sean M. , Bhavsar Indira , Dowdell Kimberly , Argo Curtis
Published: October 2019

INTRODUCTION:

The incidence of chronic liver disease in the United States is increasing and leading to a disproportionate number of patients for every gastroenterologist and a growing coverage gap in care. Electronic consultation (eConsult) is an asynchronous, text-based question-response between provider and consultant without consultant-patient contact that may improve access to hepatitis C virus (HCV) treatment. The purpose of this study is to assess treatment and referral patterns of HCV infections among primary care physicians and to further assess the role of eConsults in the treatment of chronic hepatitis C (CHC).

METHODS:

Primary care physicians (PCPs) associated with a large tertiary teaching hospital with a robust eConsult program were surveyed via an optional online questionnaire. Responses from urban, suburban, and rural resident and attending practitioners were anonymously recorded over a three month time spanning from March 1, 2019 to June 1, 2019 with regard to their current evaluation and management of patients with CHC.

RESULTS:

Fifty nine responses to the survey were generated. Of those surveyed, 0 providers treated HCV without referral to a specialist. The top three issues identified as barriers to treatment included “not enough information on protocol”, “not enough volume of patients to make it worth learning”, and “administrative hurdles.” 83% of those surveyed would be more open to treating HCV if they were provided administrative assistance and indicated that a centralized eConsult for HCV treatment provided adequate administrative support. 41% of physicians surveyed reported that less than half of their patients referred for treatment are ultimately linked to specialty care. Only 22% of providers felt that patient satisfaction would be negatively impacted without a subspecialty consult to manage HCV treatment.

CONCLUSION:

Our results indicate that PCPs do not routinely treat CHC infection though the vast majority of them would be interested in doing so given the percentage of their patients left without linkage to specialty care. This study identifies eConsults as a modality for expanding treatment of CHC by task-shifting treatment of the disease to PCPs through a uniform and stream-lined eConsult model, which would ultimately improve access to care, improve healthcare expenditures, and limit the direct burden placed on patients to see multiple providers.
1021 Regional Disparities and Trends of Liver Cancer in the USA: Shedding Lights on Potential Preventable Lethal Disease
Authors: Raed Anas , Bhagatwala Jigar , Sherid Muhammed , Rassameehiran Supannee , Sifuentes Humberto , Sharma Amol , Sridhar Subbaramiah
Published: October 2019

INTRODUCTION:

Liver and intrahepatic bile duct cancer are the second aggressive cancer with 5-year survival rate of 18%. Also, they are the fourth most common cause of GI malignancy, and there incidence has tripled since 1980. Hence, our objectives were to study incidence trends of liver cancer (LC) by geographic location, specifically by regions and states.

METHODS:

Data was extracted from National Program of Cancer Registries (NPCR) and Surveillance, Epidemiology and End Results (SEER) for the period 2001-2015. Age-adjusted incidence and annual percent change (APC) were calculated in a step-wise manner to examine the trends among each of four US regions, followed by 13 individual SEER-reported states. SEER Stat software was used to analyze this data.

RESULTS:

The incidence rates of LC in population younger than 50 years have been trending in all US regions. When reporting incidence rates of LC in population younger than 50 years by states, the rates have been trending down in all US states except state of Kentucky and Iowa which rates have been increasing with APC of 2.8 (CI: 0.7, 5.0), 2.7 (CI: 0.2, 5.3), respectively (Table 2). The incidence rates of LC in population 50 years or older have been increasing the in all US regions with highest rates in South with APC of 5.2 (CI: 4.8, 5.6) (Table 1). When reporting incidence rates of LC in population 50 years or older by states, the rates was the highest in state of Utah and Kentucky with APC of 7.1 (CI: 5.9, 8.4) and 6.6 (CI: 5.8, 7.3), respectively.

CONCLUSION:

This epidemiological data shows the disparities of LC by geographic location. Our outcomes of geographical variation of incidence rates of LC may help to initiate programs to target high risk regions and states.
1022 Regional Variations and Trends in the Gallbladder Cancer in the USA
Authors: Raed Anas , Bhagatwala Jigar , Sherid Muhammed , Sifuentes Humberto , Sridhar Subbaramiah , Sharma Amol
Published: October 2019

INTRODUCTION:

Gallbladder cancer (GBC) is the most common malignancy of the biliary tract. The regional and interstate variations in the US are unknown but are of high importance for epidemiology and preventive strategies. We investigated the regional and state-specific incidence and annual percent change (APC) of various histologic types of in the US over last 15 years.

METHODS:

Data was extracted from National Program of Cancer Registries (NPCR) for the period 2001-2015 and Surveillance, Epidemiology and End Results (SEER) for the period 2000-2015. Age-adjusted incidence and APC were calculated in a stepwise manner to examine the trends among each of four US regions, followed by 13 individual SEER-reported states. SEER Stat software was used to analysis.

RESULTS:

There were 54,224 GBC cases from 2001 to 2015. The incidence of GBC remained unchanged in four regions of the US between 2001-2015. However, a significant increase in the incidence rate of other-type of GBC histology was noted compared to the rest of the histologies with APC of 1.9% in the South (CI: 1.1, 2.8%). A rising but non-significant increase in APC of GBC was noted in the West, Northeast, Midwest with APC of 1.1% (CI: 0.0, 2.2%), 0.6% (CI: -0.3, 1.4%), 0.2% (-0.8, 1.3%), respectively (Table 1). Corresponding to NPCR data, all 13 SEER-reported states showed mixed pattern of increase and decrease in the APC of GBC incidence rate. When we noticed an upward trend of GBC incidence rate, it was mainly due to other histology such as California and New Jersey with APC 2.2% (CI: 1.1, 3.4%), 1.7% (CI: 0.0, 3.4%), respectively (Table 2). The only exception was Washington where the trend was mainly due to adenocarcinoma 2.3 (0.1, 4.6).

CONCLUSION:

The GBC incidence appears to be disproportionately higher in some states, predominantly the “other” histological type. Further public health initiatives need to investigate any potential causes for the regional disparities of increasing EAC incidence.