bluuebunny/crossref_metadata_2025 huggingface dataset:
1065 Thirty-Day Readmissions in Patients Admitted With Hepatic Encephalopathy Between 2010-2015: A Study From the Nationwide Readmission Database
Authors: Elkafrawy Ahmed A. , Kaddourah Osama , Kennedy Kevin F. , Likhitsup Alisa
Published: October 2019

INTRODUCTION:

Hepatic encephalopathy (HE) is a common diagnosis of hospital admissions. Our aim in this study is to identify trends, causes and predictors of 30-day readmissions in patients admitted with HE.

METHODS:

The Nationwide Readmissions Database (NRD) was queried to identify index admissions with HE between 2010-2015 using the ICD-9 code 572.2. All the patients non-electively admitted within 30 days of Index admission were included. We excluded patients who died during their index admission or left against medical advice. Chi-Square, Fisher’s Exact and Student-t tests were used for statistical analysis to compare baseline characteristics among patients with and without 30-day readmission. Multivariate logistic regression models were used to predict factors associated with readmissions. All analyses were performed with SAS 9.4 (Cary, NC).

RESULTS:

We identified 196,730 eligible index admissions. The 30-day readmission rate was 29.4% and stable over time (Figure 1). Median (IQR) age was 60 (52, 68) years, 42% were female and the median length of stay was 5 (3, 10) days. Among patients with 30-day readmission, there is a higher proportion of patients with Medicaid (23.5 vs 20%, P < 0.001), residing in the metro area (32.3 vs 29.5%, P < 0.001), being discharged from metro-teaching hospital (P < 0.001). The hospital bed size and ownership setting were similar between the groups. The proportion of patient readmitted to the hospital was lower among patients who were discharged to a skilled facility (24 vs 27%, P < 0.001) but higher among patients who were discharged to home with self-care (53 vs 50%, P < 0.001). The main reason for 30-day readmission was liver disease-related complications (37.6%), followed by sepsis, mental health or substance use disorder (Figure 2). Multivariate analysis showed Metro-teaching hospital, presence of diabetes, renal failure, presence of ascites, required paracentesis, presence of portal hypertension were predictive factors associated with 30-day readmissions (Table 1).

CONCLUSION:

Approximately a third of patients admitted with HE were readmitted to the hospital, and the trend has been stable over a 6-year period. From our study, health-care provider education in the metro-teaching hospitals regarding cirrhosis, renal failure, and ascites management will likely improve 30-day readmission rate among patients with HE.
1067 Use of Obeticholic Acid in Patients With Primary Biliary Cholangitis: A Systematic Review and Meta-Analysis
Authors: Anugwom Chimaobi , Dirweesh Ahmed , Singh Dupinder , Levy Cynthia , Sultan Shahnaz
Published: October 2019

INTRODUCTION:

Obeticholic acid (OCA), a farnesoid-X receptor agonist, has been approved for the management of PBC since 2016. It has been shown to significantly decrease serum alkaline phosphatase (ALP) and total bilirubin levels in patients with primary biliary cholangitis (PBC), either alone or in combination with ursodiol. Data on the efficacy of OCA in PBC is limited. We conducted a systematic review and meta-analysis to evaluate the efficacy of OCA in patients with PBC.

METHODS:

We searched PubMed, Cochrane and Embase databases for randomized control trials (RCTs) comparing OCA to placebo in the management of PBC through 2019. The Cochrane Risk of Bias tool was used to assess the quality of the RCTs. We estimated odds ratio (OR) with 95% confidence interval (CI) for each outcome using a random effects model. The quality of the evidence was assessed using the GRADE approach.

RESULTS:

A total of 3 randomized controlled trials including 440 patients were identified. The mean age of patients was 54 and follow up ranged from 3-12 months. The studies varied with respect to whether OCA was used as monotherapy or added to standard of care (ursodiol). Compared to placebo, OCA resulted in reduction of ALP to < 1.67X the ULN with an OR of 5.92 (CI 2.98 – 11.94, P < 0.00001); and 1.76X the ULN with an OR of 5.95 (CI 3.25 – 10.93; P < 0.00001). Across the three studies, patients on OCA experienced higher rates of pruritus as compared with placebo. The overall certainty of evidence was moderate. Data on clinical endpoints such as quality of life, progression to cirrhosis or liver transplantation, and mortality were lacking.

CONCLUSION:

Obeticholic acid is superior to placebo in reducing ALP in patients with PBC. An important limitation in these studies is the lack of data on clinical endpoints however, ALP levels have been shown to correlate with risk of liver transplantation and death. More RCT data with longer follow up is needed to fully assess the net benefits and harms of OCA in patients with PBC.
1069 Overutilization of CT Scan of the Brain in the Diagnosis of Hepatic Encephalopathy: Choosing Wisely
Authors: Khan Ahmad , Sohail Abdullah , Cipriani Allison , McDaniel Bryce A. , Farooq Junaid , Chowdhry Monica , Singh Shailendra
Published: October 2019

INTRODUCTION:

Hepatic encephalopathy (HE) is a clinical diagnosis and rarely requires neuroimaging. Hepatic encephalopathy (HE) is the most common diagnosis for patients with cirrhotic patients presenting with altered mental status (AMS). It is a clinical diagnosis, and computed tomography (CT) of the brain does not contribute to the diagnostic or grading information. However, patients with cirrhosis are at increased risk of intracerebral hemorrhage, and therefore, CT scans are usually performed to rule out other etiologies of AMS, which may lead to overutilization of CT scans. There is limited data on the magnitude and yield of CT scan utility in the workup for HE. This study aims to assess the magnitude and yield of CT scan for the workup of HE in a large tertiary care hospital.

METHODS:

An electronic medical query for adult patients discharged from our center between September 2016 to June 2019 with ICD-10 codes for liver cirrhosis and its complications was made. A total of 300 patient charts were randomly selected for detailed review. Patients with an established diagnosis of advanced dementia, stroke, intracranial tumor, or bleed were excluded. We collected patient demographics, admission records, readmissions, laboratory values, and imaging records.

RESULTS:

A total of 214 patients met our search criteria. Out of these, 64 patients admitted with a complaint of AMS were included in the final analysis. The mean age of these patients was 61 ± 9 years, and 54% were males. A total of 152 HE-related hospitalizations were recorded for these 64 patients (an average of 2.3 admissions per patient). In the study duration, a total of 178 brain CT scans were performed for 152 hospitalizations. Out of the total 178 scans, only 2 CT (1.1%) scans revealed intracranial bleed leading to change in diagnosis or management. Notably, 12 (18.75%) patients had multiple CT scans during a single hospitalization.

CONCLUSION:

The yield of CT scan brain in patients with an established diagnosis of hepatic encephalopathy is low (1%) and usually does not influence the diagnosis or management. CT scans are likely overutilized, leading to unnecessary excessive radiation exposure to the patients and increases the total costs of hospitalization. Institutional efforts should be implied for the judicious use of CT scans in patients with HE. Further large multicenter studies are needed.
1073 Integration of Cirrhosis Best Practices Into Electronic Medical Record Associated With Reduction in 30-Day Mortality
Authors: Sherman Zachary , Wahid Nabeel , Soltani Amin K. , Wagner Michael , Jesudian Arun
Published: October 2019

INTRODUCTION:

Hospital admissions for patients with cirrhosis continue to increase. In New York City, 25-30% of hospitalized cirrhotics are readmitted within 30 days. Re-hospitalization is associated with increased mortality, poor quality of life, and financial burden to patients, hospitals, and payers. Preventable readmissions are partially accounted for by a well documented quality gap between evidence based guidelines for cirrhosis management and real world adherence to these recommendations.

METHODS:

We performed a prospective cohort study that compared outcomes among cirrhotic patients admitted to four internal medicine teams over a 6-month period. An electronic medical record (EMR) note template that outlined best practice measures for cirrhotics was developed. Inpatient providers on two teams were instructed to include it in daily progress notes and discharge summaries. The recommended practices included diagnostic paracentesis and diuretics for ascites, rifaximin and lactulose for hepatic encephalopathy, beta blockers for esophageal varices, and antibiotic prophylaxis for spontaneous bacterial peritonitis. The remaining two teams continued standard of care of cirrhotic patients. The primary outcome was 30-day readmissions. Secondary outcomes included in-hospital mortality, 30-day mortality, length of stay, and adherence to best practice guidelines.

RESULTS:

Over a 6-month period, 108 cirrhotic patients were admitted, 83 in the interventional group and 25 in the control group. MELD-Na scores on admission did not differ between the groups (20.1 v 21.1, P = 0.57). Thirty-day readmissions were not significantly different between the interventional and control groups (19.3% v 24%, P = 0.61). However, 30-day mortality was significantly lower in the interventional group (7.2% v 24%, P = 0.02). There was no difference between the two groups in in-hospital mortality (3.6% v 0%, P = 0.34) or length of stay (10.2 days v 12.6 days, P = 0.34). Adherence to best practice metrics was similar between the groups, except for rates of diagnostic paracentesis, which were higher in the interventional group (98% v 80%, P = 0.01).

CONCLUSION:

Implementation of an EMR note template with cirrhosis best practices was associated with lower 30-day mortality and higher rates of diagnostic paracentesis among admitted patients with cirrhosis. These findings suggest that integration of best practice measures into the EMR may improve outcomes in hospitalized cirrhotic patients. Larger studies are required to validate these findings.
1079 Advanced HCC Management in Clinical Practice Evolves Beyond BCLC Guideline
Authors: Al-Omary Ahmed , Cheng Robert
Published: October 2019

INTRODUCTION:

Hepatocellular carcinoma (HCC) represents 90% of all primary liver cancer and is the fifth commonest malignancy. BCLC staging and treatment recommendations have been adopted worldwide as standard of care for HCC management. Hence, Australian practice was reviewed over heterogeneous period of time in two main tertiary centres; Royal Prince Alfred Hospital (RPA) and Westmead Hospital (WM).

METHODS:

After obtaining ethics approval, 838 patients underwent active HCC surveillance, with 597 being followed-up at WM and 241 being followed-up at RPA. Cirrhosis staging and HCC staging were recorded as well as treatment received and survival outcomes of the 95 patients who developed HCC.

RESULTS:

More than half of the HCC patients (61%) were BCLC stage 0 or A at diagnosis when they are eligible for curative treatments. BCLC-0 patients were appropriately treated with liver resection or locoregional therapy (LRT). All achieved adequate disease control without requiring further therapy. BCLC-A patients were treated with liver resection, liver transplant (LT) and LRT at a rate of 24%, 9% and 63% respectively. Half of the liver resection patients had HCC recurrence and required LRT, but eventually went on to have sorafenib. Two patients from the LRT primary treatment group (7% of this subgroup) went on to have sorafenib. Deviating from BCLC guideline, one patient (8%) from the BCLC-B group received liver transplant and continued to enjoy cancer-free survival. Two patients (17%) from BCLC-B group had liver resection; one of them had HCC recurrence and received sorafenib as salvage therapy. Only a quarter of BCLC-C patients received sorafenib as primary therapy in accordance with BCLC guideline. The other 75% of BCLC-C patients received LRT first, and eventually went on to have sorafenib as secondary treatment. Most surprisingly, as primary treatment two of the 17 BCLC-D patients (12%) received sorafenib and 7 (17%)received LRT. Only 8 of them (47%) were managed according to BCLC guideline and received palliative care first.

CONCLUSION:

In this multi-centre HCC cohort, BCLC-0 and A patients were treated in accordance with BCLC guideline. However, some of our BCLC-B patients also received LT or liver resection and enjoyed positive survival outcome. Interestingly, the majority of BCLC-C and 17% of BCLC-D patients received LRT. The difference in practice may be attributed to increasingly published data on survival benefits of giving LRT to BCLC late stage patients.
1085 The Use of the Molecular Adsorbent Recirculating System (MARS) in Treatment of Cholestatic Drug Induced Liver Injury
Authors: Rapaka Babusai , Vora Ravi , Flynn Mary , Subramanian Ram
Published: October 2019

INTRODUCTION:

Cholestatic drug induced liver injury (DILI) is a subtype of DILI defined by elevated alkaline phosphatase (ALP) or bilirubin levels from exposure to a drug causing cholestasis. It is a challenging diagnosis with limited treatment options. The molecular adsorbent recirculating system (MARS) allows for hemofiltration of albumin-bound substances that can improve cholestatic hepatitis, pruritus, and hepatic encephalopathy (HE). Here we report six cases of acute cholestatic DILI treated with MARS.

METHODS:

Patients with cholestatic DILI who underwent MARS were identified at a single institution. Pre-MARS, post-MARS and post hospitalization data on ALP, bilirubin, INR and HE were collected. Completion of MARS therapy was defined as continuous therapy for three to five days.

RESULTS:

Six cases were identified, one of which progressed to acute liver failure (ALF). Hepatotoxic medications included acetaminophen, phentermine, methimazole, OxyElite and two cases of the anabolic steroid Methyl-1-etiocholenololepietiocholanolone. Mean total bilirubin prior to MARS was 34.5 mg/dl. Over the course of therapy, patients had significant improvement with an average bilirubin of 13.4 mg/dl at completion of MARS and 2.4 mg/dl at follow up. Coagulopathy was seen in the case of ALF from acetaminophen with pre-MARS INR of 1.9 and post-MARS INR of 1.7. This patient also had grade 4 HE prior to MARS with improvement to grade 0 post-MARS. ALP levels were not abnormal and did not change. Clinical improvement in pruritis and jaundice was seen in all cases.

CONCLUSION:

This case series highlights six patients with cholestatic DILI who had significant improvement in bilirubin, pruritis and jaundice with MARS. This improvement in cholestasis was thought to be due to filtration of bilirubin. Removal of bilirubin also improved jaundice. In conjunction with medical therapy and withdrawal of the offending agent, there was sustained improvement in bilirubin that continued even on outpatient follow up. There was also improvement in pruritis that was refractory to maximal medical therapy. It is unclear which substance is the principal pruritogen associated with cholestasis. However, MARS provided significant symptomatic relief that persisted. In the one case of cholestatic DILI causing acute liver failure, MARS resulted in resolution of HE and served as a bridge to spontaneous hepatic recovery. Our case series shows that MARS is a viable option in treating acute cholestatic liver injury refractory to medical therapy.
1089 Hypophosphatemia in Patients With Alcoholic Hepatitis
Authors: Chiang Ryan S. , Farooq Ahmad , Parish Alice , Niedzwiecki Donna , Kappus Matthew R. , Patel Yuval , Liddle Rodger A. , Muir Andrew J.
Published: October 2019

INTRODUCTION:

Patients with alcoholic hepatitis suffer from high rates of malnutrition and are at risk for hypophosphatemia due to poor dietary intake, renal wasting, and refeeding syndrome. The aim of this study was to assess phosphate monitoring and supplementation practices in patients with alcoholic hepatitis, and to determine if phosphorous levels are associated with increased risk of morbidity and mortality in patients with alcoholic hepatitis.

METHODS:

A retrospective analysis was performed on a cohort identified through the use of an electronic health record query tool for an academic health system. Study population was defined as 18 years or older with hospital admission 8/1/12 to 9/30/18. Alcoholic hepatitis was defined using ICD-9/10 codes 571.1, K70.10, or K70.11. Patients also met the National Institute on Alcohol Abuse and Alcoholism criteria for alcoholic hepatitis. Patients were excluded if other etiologies of liver disease were present.

RESULTS:

64 admissions met study criteria, and phosphate measurements occurred at least once during admission in 45/64 (70%). Patients with serum phosphorous data measured had higher serum creatinine. They also had higher Maddrey’s discriminant function and MELD scores, although not statistically significant (Table 1). Hypophosphatemia was noted in 18/45 (40%) patients at initial measurement, while 6/45 (13%) had hyperphosphatemia. Phosphate supplementation did not occur in 5/18 (28%) patients with hypophosphatemia. Of the 6 patients with hyperphosphatemia, 5 died with multi-system organ failure. There were 7 ICU admissions in the normal phosphate group, of which 6 had a reduction in phosphorous levels during the admission. Among the normal phosphorous group, phosphorous measurements were not repeated routinely during the admission. All 4 deaths in the normal phosphorous group experienced reduction in their phosphorous level during the admission; 2 did not receive any form of supplementation despite follow-up phosphorous levels below the normal range.

CONCLUSION:

Many patients with alcoholic hepatitis did not receive routine phosphorus measurement. Patients with phosphorus measurements had higher creatinine levels, suggesting that renal dysfunction prompted measurement. Among patients with normal initial phosphorous levels, all 4 deaths and 6 of 7 ICU admissions experienced evidence of refeeding syndrome. These findings reiterate the importance of phosphorus monitoring and supplementation for patients with alcoholic hepatitis.
1094 A Study of the Characteristics of Hepatic Blood Flow Ex Vivo Using a Cardio-Emulation Arterial Pump Perfusion System
Authors: Lake-Bakaar Gerond V. , Aardema Charles , Cronin David C. , Robertson John
Published: October 2019

INTRODUCTION:

The CAVESWave® organ perfusion system provides cardio-emulated systolic and diastolic pressure waves to the hepatic artery HA, as well as variable pressure to the portal vein PV, replicating in vivo hepatic perfusion conditions. This allows a unique opportunity to study the interaction between HA and PV flow patterns in the autoregulation of hepatic venous HV outflow. The conditions exclude artefacts generated from cardiac pulsations.

METHODS:

Ten freshly procured porcine livers were perfused on the CAVESWave® system for four hours. At the two-hour midpoint, the temperature of the perfusate was increased from 15°C to 30°C and the flow variation associated with the temperature change documented. Flow rates in the HA, PV and HV were captured using flow sensors in the perfusion circuit. The distribution of perfusate was documented using Infra-red thermography (IRT), which measured surface liver temperature to a depth of 3 mm.

RESULTS:

Both IRT and the flow sensor measurements demonstrated stable, steady-state values after target perfusate temperatures were reached. Pulsatile waves reflecting cardio-emulated systolic and diastolic pressure waves were present in both HA (Figure 1) and PV (Figure 2). The only possible source of pulsations in the PV was transmission from the HA. Pulsatile waves were significantly attenuated or absent in the HV (Figure 3). The flow at 150 C in the HA (630.1 + 239.9; ml/min M + SD) was significantly greater than in the PV (316.2 + 90; P < 0.004). As expected, flow in the HV (904 + 292.8) approximated the sum of HA and PV flow. Increasing the temperature of the perfusate to 300 C significantly increased flow in all three circuits: HA (761.5 + 220; P < 0.014); PV flow (375.0 + 139.1; P < 0.007) and HV (1016.1 + 302.4; P < 0.007). The flow in the HA increased by 116.75 + 140.9 ml/min; the increase was 56.7 + 80.3 in the PV and 111.8 + 100.8 in the HV. The time for this change was significantly shorter for HA (18.9 + 13.5 mins) than for PV (26.4 + 18.1; P < 0.05). The significance of the delay in the PV flow is unclear. It likely reflects greater capacitance within the venous circuit. PV flow was inversely correlated with HA flow at all temperatures, correlation coefficient, -0.26. This suggests compensation or buffering between the arterial and venous circuits.

CONCLUSION:

Autoregulation of flow in response to temperature change is maintained in the ex vivo perfused liver. The inverse correlation between HA and PV flow, suggests a Hepatic Artery Buffering Response, HABR in this model.
1097 Are There Demographic Variations Between Obese and Non-Obese (Lean) Patients With Non-alcoholic Steatohepatitis?
Authors: Ismail Mohamed S. , Sanchez Javier , Hassan Manal , Abdullah Khalid , Jalal Prasun , Egwim Chukwuma , Ankomasey Victor
Published: October 2019

INTRODUCTION:

Non-alcoholic steatohepatitis (NASH) in the absence of overweight and/or obesity is designated as non-obese (lean) NASH. Several studies suggested that lean NASH is a variant phenotype of NASH, where its features metabolically resemble obese NASH individuals with insulin resistance, and metabolic syndrome plays the pathogenetic role in both phenotypes. Limited data suggested that Asians have propensity to develop NASH at a comparatively lower BMI, mostly due to body composition and fat distribution. We aimed at assessing baseline demographic variations between obese and non-obese (lean) patients with NASH.

METHODS:

Based on fibroscan reports with CAP and fibrosis scores, 124 patients with NAFLD had been identified between 09/2018 and 05/2019 at the Liver Associates of Texas Hepatology Clinics in Houston. Standardized fibroscan report (steatosis, and fibrosis stage) was determined by expert clinicians. Demographic information, chronic infection with hepatitis B virus (HBV) and hepatitis C virus (HCV), baseline body mass index (BMI), presence of major comorbidities and metabolic syndrome were recorded for all patients. For continuous variables, we used the Student’s t test to compare differences in the mean values. The chi-squared test was used to compare the proportions of risk factors between groups.

RESULTS:

According to the baseline body mass index, patients were classified into obese (BMI ≥30) and non-obese (BMI < 30). With the consideration of presence and absence of NASH and obesity, participants were further classified into four groups as seen in Table 1. Our data indicated that Asians (47.1%) especially men (57.1%), P = .06 are more likely to be classified as non-obese/NASH. No significant variation between all groups, however, with respect to age at diagnosis or gender distribution.

CONCLUSION:

No significant difference between obese and lean patients with NASH regarding age, gender or ethnicity. NASH should be considered in the differential diagnosis of unexplained liver disease even in presence of normal BMI. Management strategy, and surveillance protocol for NASH should be evaluated and validated in non-obese (lean) NASH subjects.
1100 Outcomes of Cholecystostomy With and Without Follow-Up Cholecystectomy in Patients With Cirrhosis
Authors: Vedachalam Srikanth , Porter Kyle , Li Na , Kelly Sean , Conteh Lanla , Hanje James , Michaels Anthony , Black Sylvester , Mumtaz Khalid
Published: October 2019

INTRODUCTION:

Cirrhotic patients are twice as likely as the general population to form gallstones and are therefore at increased risk for acute cholecystitis. Cholecystectomy (CCY) is currently the definitive therapy for cholecystitis, but cirrhotic patients have been shown to have dramatically higher mortality rates during CCY in previous studies. Percutaneous cholecystostomy tube (PCT) placement is therefore an alternative to CCY in cirrhosis. Subsequently these patients require CCY. However, data on PCT and subsequent CCY cirrhotics are not reported. We studied the trends and outcomes of PCT with and without follow-up CCY in cirrhotic patients.

METHODS:

The National Readmissions Database (NRD), using pre-validated ICD-9 codes was queried to study the patients with acute calculous cholecystitis between the years of 2010-2014 who underwent either CCY or PCT with or without follow-up CCY. Study groups included non-cirrhotics (NC), compensated cirrhotics (CC) and decompensated cirrhotics (DC). DC patients were classified using Baveno IV criteria. Variables included were patient and hospital characteristics, Elixhauser co-morbidities, rates of CCY, rates of PCT with or without follow-up CCY, and approach to CCY- open vs closed. Primary outcomes included 30-day readmission rates, plus index and calendar year mortality. Secondary outcomes were rates of PCT placement, rates of CCY after PCT, length of stay and cost.

RESULTS:

PCT are more commonly placed in cirrhotics (3.7%) compared to non-cirrhotics with acute cholecystitis (1.4%). Within cirrhotics, DC (7.7%) received far more PCT than CC (2.9%). Inversely, NC underwent more CCY vs CC and DC (98.9%, 97.4% and 92.9%, respectively). Predictors of PCT were DC (P < 0.001), but not CC (P = 0.23) compared to NC. PCT was followed by CCY less in cirrhotics than NC with DC having the lowest rates (NC: 39.9%, CC: 28.6%, and DC: 16.1%). Presence of CC and DC were predictors of not receiving CCY after PCT ((OR: 0.57; CI: 0.35-0.92) and (OR:0.29; CI:0.14-0.60), respectively). Finally, outcomes of CCY after PCT were shown to be similar between NC vs all cirrhotics with all comparisons not being statistically significant.

CONCLUSION:

Cirrhosis was seen as a risk factor for PCT without subsequent CCY with DC having the lowest rates. However, while CC and DC had lower rates of CCY after PCT, their outcomes were similar to NC. Allowing time for medical optimization with PCT tubes, especially in CC, may result in similar surgical outcomes to NC undergoing follow-up CCY.
1106 Impact of Splanchnic Vasoconstrictors on Sodium Level in Inpatient Cirrhotics With Hyponatremia: A Retrospective Cohort Study
Authors: Ismail Bahaaeldeen , Alkhairi Baker , Benrajab Karim , Ali Saad Emhmed , Castro Fernando
Published: October 2019

INTRODUCTION:

Hyponatremia (hypoNa) in cirrhosis represents another consequence of splanchnic vasodilation. Splanchnic vasoconstrictors are currently used in hepatorenal syndrome (HRS) which has similar pathogenesis, however their role in hypoNa has not been fully investigated. Aim of the study is to evaluate the effect of octreotide ± midodrine on hypoNa in cirrhotics.

METHODS:

We retrospectively included adult cirrhotics admitted to the Cleveland Clinic hospitals between 10/1/2011 and 10/1/2015, who had Na < 133 at or during admission. We excluded subjects with less than 5 days of follow up, those who received potent vasoconstrictors as norepinephrine or received hypertonic saline, tolvaptan or renal replacement therapy during admission. Population was divided into those who received octreotide versus those who did not. Outcomes were Na level at days 5, 7 and 10 after starting octreotide. Secondary outcome was determination of predictors of change of Na at day 5 using a multivariate model that included variables with P < 0.1 on univariate analysis. We then performed a subgroup analysis for only those with baseline Na < 125 (as this is the correction threshold for many transplant centers).

RESULTS:

Patients in the octreotide group were younger, had higher Model for End-Stage Liver Disease score, more patients had ascites and varices compared to controls [Table 1]. The octreotide group had lower baseline Na, but the Na levels at 5,7 and 10 days after octreotide were significantly higher [Figure 1]. The two predictors of higher Na at 5 days were having a lower baseline Na and receiving both octreotide and midodrine Table 2]. When analysis was restricted to the subgroup with baseline Na < 125, 97% of those who received octreotide had Na ≥125 by day 5 (compared to 77% of controls, P = 0.03). In this subgroup, the only predictor of reaching Na ≥125 by day 5 (multivariate logistic regression model) was receiving octreotide; OR 11.2 (1.16- 109), P = 0.04.

CONCLUSION:

Cirrhotics with hypoNa that received octreotide had a significantly higher rise in Na. On a multivariate analysis accounting for the potential confounders, octreotide remained a significant predictor only when combined with midodrine, suggesting a synergistic effect (similar to HRS). To our knowledge, this is the largest study evaluating the effect of splanchnic vasoconstrictors on sodium level in cirrhotics with hypoNa compared to controls. Prospective studies are needed with matched controls and longer follow up.
1108 Alkaline Phosphatase Levels Are Negatively Correlated With the Severity of Hepatic Steatosis in Patients With Primary Sclerosing Cholangitis
Authors: Motowski Hayley , Senter-Zapata Michael , Ciorba Matthew A. , Deepak Parakkal , McHenry Scott
Published: October 2019

INTRODUCTION:

Primary Sclerosing Cholangitis (PSC) is a chronic, immune-mediated cholestatic liver disease with a strong association with Inflammatory Bowel Disease (IBD), including Crohn’s disease (CD). Our group has shown that patients with CD have twice the risk of hepatic steatosis compared to the general population. We have also shown that there is a robust protective effect of ileal-inflammation and hepatic steatosis in CD. Conversely, we found active perianal disease increases the risk of hepatic steatosis. These findings suggest that inflammation directed through the portal vein is protective against hepatic steatosis. In this study, we aimed to demonstrate if an analogous inflammatory marker in PSC, alkaline phosphatase, is protective against hepatic steatosis.

METHODS:

This is a single-center, retrospective cohort study between 1/1/2013 through 12/31/2018. Adult patients with a clinical diagnosis of PSC that had undergone magnetic resonance cholangiopancreatography (MRCP) were included. Patients with an alternative etiology of liver disease (e.g. chronic viral hepatitis, greater than moderate alcohol use) were excluded. All MRCP protocols had been modified to allow liver fat quantification by the proton density fat fraction (PDFF) method. The primary outcome was the nonparametric, Spearman’s correlation (Rs) between PDFF and alkaline phosphatase. Secondary analysis was performed using a linear regression model for the natural log (Ln) transformation of PDFF.

RESULTS:

There were 112 PSC patients (80% with Ulcerative colitis, median age at enrollment 48 years, median age at PSC diagnosis 39 years). The median PDFF was 2.3% and the median body-mass index (BMI) was 27 kg/m2. There was a negative-linear relationship between PDFF and alkaline phosphatase with a Rs = 0.4 (P < 0.001). This negative-linear relationship between alkaline phosphatase and PDFF persisted after adjusting for BMI in the linear regression model (P < 0.001).

CONCLUSION:

We demonstrated that alkaline phosphatase, the surrogate for PSC-associated cholestasis and hepatic inflammation, demonstrates a negative-linear relationship with liver fat even after adjusting for BMI. This supports the hypothesis that acute inflammation in the portal circulation is protective against hepatic steatosis. Future directions include clarifying the role of the enterohepatic circulation and non-immunologic enterokines in liver-fat handling.
1121 Impact of Weight Parameters on Colorectal Cancer Survival: A Systematic Review and Meta-Analysis
Authors: Jaspan Vita , Lin Kevin , Wilder Evan , Chang Steven , Popov Violeta
Published: October 2019

INTRODUCTION:

Metabolic risk factors have been implicated in the incidence of colorectal cancer (CRC); however, less is known about the relationship between obesity and CRC outcomes. We hypothesized that obesity would be associated with worse outcomes compared to normal weight, but with better outcomes compared to underweight individuals.

METHODS:

A systematic review of electronic databases was performed through May 2019, including NCBI, Embase, Cochrane, and Web of Science. Screening was performed independently by two authors using Covidence. Inclusion criteria were retrospective and prospective cohort studies reporting CRC outcomes at least 60 months after CRC diagnosis. The primary outcome analyzed was CRC mortality in obese compared to normal body mass index (BMI). Secondary outcomes included overall mortality, disease free survival (DFS) and CRC mortality by BMI category (underweight, normal, overweight, and obese), and high vs. normal waist circumference (WC). Odds ratios (OR) and 95% confidence intervals (95% CI) are reported. Random effects analysis was performed for all outcomes, with heterogeneity assessed by the I2 statistic and meta-regression by area of origin (East vs. West).

RESULTS:

484 relevant citations were identified and 17 were included in the final analysis. Fifteen studies analyzed CRC outcome data in terms of BMI, and 2 in terms of WC. These studies comprised 251,347 patients, with a median age range of 61.8-71 years and follow-up time range of 60-192 months. Obesity was associated with significantly increased CRC-specific mortality compared to normal BMI (Figure 1). Interestingly, study origin (East vs. West) explained 53% of the heterogeneity in these results, R2 = 0.53 (Figure 2). Underweight patients had increased CRC mortality compared to both normal and overweight patients, but not significantly different from obese patients. High WC was also associated with increased CRC mortality compared to normal WC (Table 1). Obese and underweight patients both had increased OM compared to normal weight patients; underweight patients had increased OM compared to obese patients. Significant effects of BMI on DFS were only observed in Eastern studies, where underweight patients had worse DFS than normal weight and obese.

CONCLUSION:

Overweight and obesity as well as underweight are risk factors for CRC-specific mortality. Underweight patients had poorer prognosis than overweight patients, but not significantly different from obese patients.
1136 Weight to Height Ratio Is a Better Predictor of Non-Alcoholic Fatty Liver Disease in Both Genders in South Asian Population
Authors: Kumar Sandeep , Hanif Farina , Majid Zain , Luck Nasir Hassan , Khan Shoaib Ahmed , Laeeq Syed Mudassir , Mehmood Nasir
Published: October 2019

INTRODUCTION:

Various obesity indices have been reported to predict non-alcoholic fatty liver disease (NAFLD). We aimed at evaluating these indices based upon anthropometric measures including waist to height ratio (WHtR), waist circumferences (WC), body mass index (BMI) and fatty liver index (FLI) and used it to determine the discriminatory ability of these indices in diagnosing NAFLD.

METHODS:

In this cross sectional study, NAFLD was diagnosed via abdominal ultrasound. Height (in), weight(cm), WC (cm), BMI, WHtR and FLI was calculated in all the participants .FLI comprising of BMI,WC, triglyceride and gamma glutamyl transferase was calculated by using an online scoring tool.1 The Receiver operating characteristic analysis was then conducted to determine the discriminatory ability and related cut-off points of indices. P value of ≤0.05 was taken as significant.

RESULTS:

In total of 300 participants, the prevalence of NAFLD was 44.8% in men and 54.8% in women. Univariate analysis reported statistical significant association of NAFLD with all of the applied indices (P = 0.00). The WHtR (AUC = 0.87, 95% CI:0.77-0.97) showed slight better performance as compared to FLI (AUC = 0.86, 95% CI:0.76-0.97) in diagnosing NAFLD. Regression analysis reported stronger association of WHtR (OR = 9.3, P = 0.00) compared to FLI (OR = 6.0, P = 0.02) with NAFLD. Moreover, the performance of WHtR was similar between men and women (AUC = 0.89) while different in FLI i.e., AUC of 0.88 in men and AUC of 0.85 in female.

CONCLUSION:

We reported a stronger association of WHtR in prediction of NAFLD and a similar discrimatory ability regardless of gender. WHtR is simple and easily performable modality for NAFLD prediction.
1142 Regional Variation in the Intestinal Microbiome of Pediatric Patients With Crohn’s Disease
Authors: Shah Rajesh , Hoffman Kristi , Kellermayer Richard
Published: October 2019

INTRODUCTION:

Numerous studies have described microbiome alterations in patients with Crohn’s disease (CD), but no studies have examined the influence of geography on these changes. Therefore, the aim of this study was to examine the effect of geography on microbiome composition in pediatric patients with CD and to develop a machine learning model to differentiate patients from healthy controls.

METHODS:

We performed a cross sectional study of pediatric patients with newly diagnosed CD from the RISK cohort. The RISK cohort was a multicenter study that enrolled patients with CD throughout the United States. Ileal, rectal and stool samples were analyzed using 16S rDNA sequencing prior to initiation of therapy. Age at diagnosis, sex, ethnicity, disease phenotype and center were reviewed. Centers were grouped into 3 regions based on geography (Northeast, South and West). Patients were compared by regions using richness, alpha and beta diversity and taxonomy. A random forest model was trained in the Northeast and tested in the South and West to discriminate patients from controls using the R package randomForest.

RESULTS:

We included 227 patients with CD and 165 controls. The mean ages were 12.2 and 12.1 for patients and controls, respectively. 58.6% of patients were male and 78.9% were Caucasian. 182 patients were in the Northeast region, 33 in the South and 12 in the West. No significant differences were found between richness or alpha and beta diversity between patients from biopsies. However, unweighted and weighted PCoA plots of stool samples revealed significant differences. In the South, patients had an increase in Fusobacteria and Bacteroidetes with a decrease in Actinobacteria and Firmicutes. This corresponded to an increase in the genera Bacteroidesand Fusobacteriumwith a decrease in Bifidobacteriumand Lactobacillus. The random forest models performed well in the Northeast and South, with decreased performance in the West. In the models, ileum and rectum shared OTUs discriminating CD, which included Lachnospiraceae, Clostridiaceae and Blautia. Additionally, ileal biopsies and stool samples shared OTUs for Erysipelotrichaceae and Haemophilus.

CONCLUSION:

The stool microbiome of pediatric patients with CD varies slightly between geographic regions. A random forest model effectively discriminates patients from healthy controls. Within North America, regional variation does not seem to significantly influence microbiome composition in pediatric patients with CD.
1147 Long-Term Efficacy of Vedolizumab in Pediatric Inflammatory Bowel Disease
Authors: Sarles Harry E. , Whitney Annette E. , Kuten Samantha A. , Van Anglen Lucinda J.
Published: October 2019

INTRODUCTION:

Pediatric patients (pts) with inflammatory bowel disease (IBD) who have failed anti-TNF therapy have limited treatment options. Vedolizumab (VDZ) has proven to be safe and effective for adults with refractory IBD. While short-term data (≤30 weeks) of VDZ in pediatric IBD pts are promising, long-term outcomes have not been reported.

METHODS:

We performed a retrospective study of IBD pts ≤18 years who received VDZ for at least 12 months. Data collection included demographics, disease characteristics, therapy, and adverse events (AEs). Disease activity scores were assessed at baseline, 14 weeks, 6, 12, and 24 months using the short pediatric Crohn’s disease (CD) activity index (shPCDAI) and pediatric ulcerative colitis (UC) activity index (PUCAI). Clinical remission was defined by shPCDAI score less than 15 or PUCAI score less than 10.

RESULTS:

A total of 29 pediatric IBD pts treated with VDZ since drug approval in 2014 were identified. Baseline demographics were as follows: mean age 14 ± 3.2 years, male 17 (59%), CD 16 (55%), UC 13 (45%). All were previously treated with an anti-TNF agent. Median VDZ treatment duration was 21.3 months (IQR 13.8-39.1). VDZ was discontinued in 5 pts for primary non-response (< 6 months) and in 5 pts for secondary non-response (12-24 months). Efficacy data is presented for 24 pts treated with VDZ for 1 year and 14 pts for 2 years. Significant reductions in shPCDAI and PUCAI scores compared to baseline were observed at all time points, as shown in Figure 1. Clinical remission was achieved at 1 year in 8 of 13 (62%) CD pts and 5 of 11 (45%) UC pts. Remission was sustained at 2 years in 8 of 9 (89%) CD pts and 3 of 5 (60%) UC pts [Figure 2]. The most commonly reported AEs were headache and fatigue; no drug discontinuations occurred due to AEs. There was one IBD-related ED visit and three IBD-related hospitalizations, with two resulting in surgery.

CONCLUSION:

Our data suggest that VDZ is effective in achieving clinical remission in pediatric IBD pts with prior anti-TNF failure, with minimal safety concerns. We observed early and sustained remission rates in both UC and CD pts, with CD pts experiencing higher rates than previously reported in literature. Additional studies are warranted to determine the role of VDZ in the treatment of pediatric IBD.
1155 Temporal Trends of Discordant Recommendations in Gastroenterology Guidelines Over the Last 5 Years
Authors: Numan Laith , Shah Raj , Chauhan Mahak , Chandar Apoorva K. , Maruggi Chiara , Alabdulwahhab Motib , Davitkov Perica , Falck-Ytter Yngve , Sultan Shahnaz
Published: October 2019

INTRODUCTION:

Within the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework, recommendations are accompanied by a strength of recommendation (strong/conditional) along with an assessment of the certainty of evidence (high/moderate/low/very low). Strong recommendations based on lower certainty evidence are termed “discordant recommendations.” While generally not considered appropriate, within GRADE there are 5 situations in which such recommendations may be warranted: Strong recommendations FOR an intervention can be made when there is 1) only low/very low certainty of benefit but you have a life-threatening problem, 2) low/very low certainty of equivalence in benefit of two interventions but one is associated with less harm. Strong recommendations AGAINST the intervention can be made when there is 1) low/very low certainty of harm but the harm is catastrophic and 2) high certainty of similar benefits of two alternatives but one is less harmful, and 3)low/very low certainty of benefit but one is more harmful. We strived to assess the prevalence of GRADE recommendations and temporal trends of discordant recommendations (DR).

METHODS:

Guidelines produced by AASLD, ACG, AGA, and ASGE from 2013 to October 15, 2018 that used GRADE, were reviewed. Across all guidelines, we identified the prevalence of and temporal trends of DRs.

RESULTS:

A total of 87 guidelines were identified and of these 78 (89.6%) were based on the GRADE framework. Across these 78 guidelines a total of 1,443 recommendation statements were generated. The number of DRs that did not fit the 5 paradigmatic scenarios above by year were as follows: 2013 = 12.7 % (45/353), 2014 = 15.9 % (50/313), 2015 = 19.5 % (60/307), 2016 = 29.3% (54/184), 2017 = 17.9% (32/178), 2018 = 17.5% (19/108) [Figure 1].

CONCLUSION:

Discordant recommendations are discouraged because when either the benefits or harms of an intervention are uncertain, one cannot be confident that an intervention does more good than harm. Over the last 5 years, the number of DRs in gastroenterology guidelines increased until 2016 and then started to downtrend. Further investigations should explore the etiology of why discordant recommendations are made as they may contribute to patients receiving suboptimal care.
1162 Choosing Wisely: The Evidence Behind Gastroenterology Recommendations
Authors: Thakur Kshitij , Pekez Marijeta
Published: October 2019

INTRODUCTION:

Choosing wisely initiative of the ABIM foundation seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures. We live in a society where medical bills are the number one cause of bankruptcy and social determinants of health play a crucial role in the care we provide to our patient. The Choosing wisely recommendations promote conversations between clinicians and patients by helping choose care that is evidenced bases, free from harm and truly necessary.

METHODS:

Our aim was to review the evidence supporting the recommendations related to gastroenterology. We listed all the gastroenterology (GI) related recommendations from different societies by using the topic area filter as “Gastroenterology” in the Choosing wisely website. We got a list of 26 recommendations from 11 different societies and extracted all the references cited by these recommendations. We excluded 2 specific recommendations related to use of PEG tubes due to duplication. All recommendations were categorized by the highest level of evidence strength cited.

RESULTS:

Among all GI recommendations, 70.9% cited Clinical practice guidelines, while 29.1% cited primary research (16.6% systematic review and 12.6%observational studies). None of the recommendations cited case series, review articles or other lower quality data as their highest evidence.

CONCLUSION:

These findings suggest that all GI related Choosing wisely recommendations are from high quality evidence. These recommendations should be used in daily practice to help with decision making. These recommendations also provides a valuable resource to educate trainees about evidence based medicine.