bluuebunny/crossref_metadata_2025_split huggingface dataset:
1092 Referral Trends Show Low Linkage-to-Care of NAFLD Patients at a Tertiary Care Academic Center in Northern California
Authors: Leung Marcia , Piao Cindy , Frank Darren M. , Kuo Alexander , Sarkar Souvik 
Published: October 2019

INTRODUCTION:
Non-alcoholic fatty liver disease (NAFLD) has emerged as the most common cause of chronic liver disease. NAFLD affects ∼1/3rd of the US population, with ∼70% prevalence in diabetics of whom 4-5% have advanced fibrosis. Despite its prevalence, NAFLD is under-recognized by physicians. Defining at-risk NAFLD patients is a cost-effective strategy. There is limited data on the referral process of NAFLD patients to help incorporate changes within health systems. In this study we queried referral trends for NAFLD, with specific focus on diabetes patients and non-invasive fibrosis score.

METHODS:
This is a retrospective analysis of referrals to gastroenterology at a tertiary care referral center for a large part of Northern California, for fatty liver disease between Jan 1, 2017 – December 31, 2018. Demographics, laboratory data, imaging (Fibroscan, MR elastography), comorbidities and liver biopsy, if available, were recorded. Well-validated FIB-4 score was calculated.

RESULTS:
Of 435,739 active patients at the center, 31,934 (7%) were diabetics. In 2 years, 188 referrals were made for NAFLD of whom 23% had diabetes, 67% did not have diabetes, 8% were unknown. Primary care providers made 86% referrals; there were no referrals from endocrinology. Approximately half of referrals (46%) had elevated ALT. Among them, 40% were referred for chief complaint of abnormal labs. As noted in the Table 1, FIB-4 >2.67 was seen in 14% of diabetics and 12% non-diabetics, while FIB-4< 1.3 was 39% and 57% of diabetics and non-diabetics. Nearly half of the referred patients underwent fibroscan, MRE or liver biopsy with the tests primarily in those with higher FIB-4 (66% of those with FIB-4≥1.3). Based on biopsy and/or imaging, 45% had stage 0-1 fibrosis while 24% and 6% were stages 2-3 or 4, respectively. Of those with FIB-4< 1.3, 84% had fibrosis 0-1 on further imaging/biopsy, while in those with FIB-4 1.3- 2.67 or >2.67 had stage 2-4 fibrosis in 29% and 54%, respectively.

CONCLUSION:
In the span of two years, only a handful of diabetic patients with NAFLD have been linked to care, with a notable lack of referrals from endocrinology. Majority of the referrals were for those with low FIB-4 scores, potentially missing a large percentage of advanced fibrosis patients. Our data shows a significant need for systems change and provider education to link-to-care patients at high risk of advanced NAFLD, with FIB-4 as a starting point.
1095 Presence of Acute Kidney Injury (AKI) at Admission in Severe Alcoholic Hepatitis (SAH) Patients Predicts Mortality: A Single Centre Experience
Authors: Singh Shivaram Prasad , Khatua Chitta Ranjan , Barik Rakesh Kumar , Sahu Saroj Kanta , Pradhan Subhasis , Meher Dinesh , Nath Gautam 
Published: October 2019

INTRODUCTION:
Severe Alcoholic Hepatitis (SAH) is a life-threatening condition. There are different models to prognosticate patients with SAH. However, the impact of presence of acute kidney injury (AKI), defined as per AKIN criteria in patients with SAH has not been assessed for this region of Asia. Hence we performed a prospective study to evaluate the spectrum of SAH including outcome in hospitalized patients and the impact of AKI on outcome of patients with SAH.

METHODS:
This study was conducted on consecutive alcoholic hepatitis (AH) patients hospitalised in Gastroenterology Department, SCB Medical College, Cuttack, India between October 2016 and October 2018. On diagnosis of AH, modified Maddrey discriminant function (mDF) was used to detect SAH (mDF score ≥32).Demographic, clinical and laboratory parameters were recorded and survival was compared between patients with and without AKI (as per AKIN criteria) during hospitalisation and also at 28 days and 90 days.

RESULTS:
339 patients of AH were included in the study. Out of them, 236 (70%) patients had SAH (DF ≥ 32) and 103 patients (30%) had DF < 32.All patients with SAH were males. 164 (69%) patients with SAH had AKI and72 (31%) did not have AKI at hospitalisation. On comparison between SAH patients with or without AKI, age was comparable between the two groups. However, patients with SAH and AKI had higher MELD UNOS (28.69 ± 8.36 vs 19.50 ± 3.83; P < 0.001), MELD Na+ (30.44 ± 7.56 vs 22.97 ± 4.56; P < 0.001), CTP score (12.46 ± 1.84 vs 11.93 ± 1.50; P = 0.033), DF ((71.18 vs 53.24,IQR; P < 0.001) and ABIC score (3.37 ± 1.47 vs 2.26 ± 0.61; P < 0.001). Furthermore, they had increased prevalence of ACLF as per CANONIC study criteria (73.2% vs 34.7%; P < 0.001), increased duration of hospitalisation (5days vs 4days,IQR; P < 0.001) and decreased survival both at 28days (57.9% vs 80.6%; P < 0.001) and 90days (36% vs 55.6%; P = 0.005). Kaplan–Meier survival curves showed significant differencesin survival between patients with and without AKI both at 28 days (log rank P value < 0.001) and 90 days (log rank P value < 0.001) (Figure 1).

CONCLUSION:
In our institution, over three fourth of alcoholic liver disease patients had severe AH and three fourth of them had AKI at admission. Patients with AH and AKI had increased proportion of ACLF, longer hospital stay, and decreased survival both at day 28 and 90.
1102 Direct Oral Anticoagulants May Be Used in the Treatment of Portal Vein Thrombosis in Patients With Cirrhosis: A Systematic Review and Comparative Meta-Analysis
Authors: Mohan Babu P. , Khan Shahab R. , Aravamudan Veeraraghavan Meyyur , Trakroo Sushrut , Garg Rajat , Ponnada Suresh , Asokkumar Ravishankar , Adler Douglas G. 
Published: October 2019

INTRODUCTION:
Well-defined guidelines for the treatment of portal vein thrombosis (PVT) in patients with cirrhosis do not exist due to lack in robust data. Treatment options include low molecular weight heparin (LMWH), vitamin K antagonists (VKAs), and the newer direct anticoagulants (DOACs). Anticoagulation safety has been an issue in patients with cirrhosis, and the best choice of anticoagulation is unknown.

METHODS:
We conducted a comprehensive search of multiple databases and conference proceedings (through November 2018) to identify studies that reported on the use of LMWH, VKAs, and DOACs in the treatment of PVT in patients with cirrhosis. Goals were to evaluate the pooled rate of treatment success and bleeding with LMWH, VKAs, and DOACs, and indirectly compare the outcomes.

RESULTS:
From a total of 744 patients (17 studies), 648 were treated with some form of anticoagulation and 96 were control. 155, 315, and 70 patients were treated with LMWH, VKAs, and DOACs respectively. Baseline characteristics were comparable among the groups. Age ranged from 41 to 71 years with a predominantly male population. 144 patients were Childs A, 182 Childs B, and 121 Childs C. Pooled rate of treatment responders with anticoagulation was 66.7% (95% CI 58.3-74.1, I2 = 72.7) and with control was 26% (95% CI 14.2-42.7, I2 = 36.7). The difference was statistically significant, P = 0.001. Pooled rate of bleeding was similar between these two groups (7.8%, 95% CI 4.5-13.3 and 15.4%, 95% CI 4.3-42.7, P = 0.33). Pooled rates of treatment success and bleeding events were comparable between LMWH, VKAs, and DOACs (Table 1). On meta-regression analysis, Child-Pugh classification did not seem to affect the treatment success and/ or the bleeding outcomes. The calculated 2-sided P-value of intercept was 0.39, Childs A was 0.15, Childs B was 0.11, and Childs C was 0.15.

CONCLUSION:
Our study demonstrates that anticoagulation is effective and safe in the treatment of PVT in patients with cirrhosis. Bleeding is not increased in treatment group compared to control group. Due to their similar and comparable outcomes, DOACs may be offered as a first line treatment based on patient preferences. Limitations of our study were the comparatively small sample size of patients on DOACs, heterogeneity, and indirect comparison. Well-conducted studies are warranted to ascertain the role of DOACs in the treatment of PVT in patients with cirrhosis.
1103 Can Non-invasive Markers of Liver Histology for Non-Alcoholic Fatty Liver Disease (NAFLD) Help Predict Cardiovascular Risk by Application of the Framingham Scoring System?
Authors: Malik Fahad , Kim Marina , Heldon Alec , Vaze Reema , Golpanian Daniel , Mohanty Smruti R. 
Published: October 2019

INTRODUCTION:
Non-alcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease in developed countries with a prevalence of 25%-30%. Independent of cardiovascular and metabolic risk factors, NAFLD is associated with the progression of coronary atherosclerosis. The Framingham risk score (FRS) is useful in identifying patients at higher 10-year coronary heart disease risk. We aim to creative a simple, safe, cost-effective and non-invasive method for diagnosing NAFLD and assigning a cardiovascular risk.

METHODS:
In this retrospective analysis, 1038 adult patients who underwent a liver biopsy between the years of 2009 – 2016 were examined. NAFLD was diagnosed on the basis of histology after the exclusion of alcohol, viral, metabolic and autoimmune liver disease by chart review. Clinical and laboratory data was collected from the time of the liver biopsy. The NAFLD Activity Score was used to histologically classify our patients into different degrees of steatohepatitis. From the initial 1038 patients, 276 patients were identified to have steatosis on histology (< 5% steatosis excluded). We calculated the FRS score based on a standard score sheet that is gender specific and includes the following variables: age, blood pressure, total cholesterol, HDL-cholesterol, smoking history and history of diabetes. To conform to the FRS, we included only patients between 30-74 years old. Non-invasive scores for liver fibrosis such as AST platelet ratio index, BARD, Fibrosis-4 index, and NAFLD fibrosis score were calculated for the remaining 50 patients and compared to the liver histology graded by the NAFLD Activity Score and to the FRS.

RESULTS:
Regression of our variables showed a positive association between AST platelet ratio index with the FRS, 2.71 (P = 0.0162), and a negative association between the BARD score and FRS 1.38 (P = 0.0189). The remaining non-invasive scores (FIB-4, NFS) did not show a statistically significant association with the FRS. Finally, the NAS score did not show a statistically significant association with the FRS score.

CONCLUSION:
The APRI score can accurately predict the degree of liver fibrosis in a patient with NAFLD and the FRS can readily be calculated in NAFLD patients that may be at highest risk of CHD outcomes and could benefit from an intervention. Our study was limited due to a small sample size, which may attribute to the lack of statistical significant association between FIB4, NFS, and the NAS to the FRS and the 10 year risk of coronary heart disease.
1109 Ethnic and Geographic Variations for NAFLD-Related Hospitalizations
Authors: Tawadros Augustine , Bhurwal Abhishek , Rustgi Vinod K. , Pioppo Lauren , Reja Debashis 
Published: October 2019

INTRODUCTION:
Non-Alcoholic fatty liver disease (NAFLD) is increasingly being recognized as an epidemic in the United States. We analyzed geographic patterns of hospitalized patients with NAFLD. Multiple factors are involved in NAFLD/NASH including genetic factors such as has been shown with GWAS studies identifying the PNPLA3 polymorphism which is increased in the Hispanic population.

METHODS:
This was a retrospective cohort study using the 2016 Nationwide Inpatient Sample (NIS) utilizing International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10 CM). All patients greater than 18 years of age with principal or secondary discharge diagnoses of NAFLD were included in the cohort. Comparisons were made between four geographic regions (northeast, south, Midwest and east) and between ethnicities (Caucasian, African American, Hispanics). Outcomes included incidence of NAFLD-related admissions, in-hospital mortality, length of stay (LOS) and total hospitalization charges. Proportions were compared using fisher’s exact test and continuous variables using student t-test. Multivariable and Poisson regressions were performed for length of stay and hospitalization charges. All statistics were performed utilizing STATA software.

RESULTS:
A total of 109,634 discharges had principal or secondary diagnoses of NAFLD for the year 2016. Of these, 19,815 (18%) were in the Northeast, 18,340 (16.7%) in the Midwest, 46,214 (42.15%) were noted in the South, whereas 25,264 (23%) were identified in the East as shown in Table 1. 62% were Caucasians, 10% were African Americans, while 18% were Hispanics. Table 2 shows ethnic differences. The Hispanic population was significantly younger with an increased predominance in males and was disproportionately present in all four regions. Diabetes Mellitus was more significantly associated with NAFLD in the South and African-Americans. The length of stay was significantly shorter in the East (3.03 days vs 3.53 days in Northeast, P < 0.001. These findings persisted after adjustment for confounders.

CONCLUSION:
Our study does show differences in hospitalization related to NAFLD during the year 2016 in terms of cost and length of stay. NAFLD-related hospitalizations were more common in the South. Further studies are needed to elucidate the reasons for the predominance of NAFLD in the South and the Hispanic population.
1110 The Use of Four-Factor Prothrombin Complex Concentrate versus Fresh Frozen Plasma in Patients With Cirrhosis
Authors: Mandel Julie , Ahmad Samrah , Lee Susan , Bernstein David 
Published: October 2019

INTRODUCTION:
Cirrhotic patients (pts) are at increased risk for bleeding due to alterations in hemostasis. Fresh frozen plasma (FFP) is the most common agent used for reversal of coagulopathy. However, four-factor prothrombin complex concentrate (4F-PCC) usage has increased as it has a lower infusion volume and shorter administration time. The objective of this study was to evaluate the efficacy of 4F-PCC compared to FFP in correcting INR for treatment and prophylaxis of bleeding in pts with cirrhosis undergoing urgent procedures.

METHODS:
A retrospective chart review of cirrhotic pts who received at least one dose of 4F-PCC or FFP during the defined study period of January 2016 through March 2019 was performed. Pts were identified in the Allscripts EMR. Cirrhosis was identified by the presence of one or more of seven pre-determined diagnostic codes. Pts were excluded if they received both agents within 24 hours or had no documented INRs. Data collected included: age, sex, race, etiology of liver disease, baseline anticoagulant and antiplatelet use, reversal agent administered, baseline and subsequent INR values,, thromboembolic events, mortality, and length of stay (LOS). All data was recorded confidentially and de-identified. The primary outcome was time to INR reversal, defined as an INR of less than 1.5 ULN. Secondary outcomes included thromboembolic event occurrence, all-cause mortality and hospital length of stay. Appropriate statistical analysis was performed.

RESULTS:
39 pts were included in the study with 43 reversal agents administered, 29 FFP and 14 4F-PCC. There was no statistical difference in baseline characteristics between groups. A majority of pts had Child’s C cirrhosis. Reversal of INR was observed in 4 FFP pts (14%), and 8 4F-PCC pts (57%). The median time to reversal in the 4F-PCC group was 267.5 minutes (P = 0.035). The reduction in INR from baseline to nadir was 0.5 units (20.5%) in the FFP group and 1.2 units (44%) in the 4F-PCC group (P < 0.001). There was no observed thromboembolic events and mortality rates did not differ between groups (44% vs 30%, P = 0.70). Mean hospital (LOS) was 20.7 days in the FFP group and 12.8 days in the 4F-PCC group (P = 0.67).

CONCLUSION:
4F-PCC was associated with significantly 1) improved time to INR reversal, 2)improved extent of INR correction and 3)decreased hospital LOS compared to FFP. Cirrhotic pts with an abnormal INR who present with bleeding may benefit from the administration of 4F-PCC prior to procedural intervention.
1112 Hepatitis C Virus Infection in Young Adults - A Re-Emerging Problem
Authors: Nagaraj Savitha V. , Lin Kyawzaw , Etienne Denzil , Reddy Madhavi 
Published: October 2019

INTRODUCTION:
Hepatitis C virus (HCV) infection is a major cause of life-threatening liver diseases worldwide. People born between 1945-1965 have been known to have high incidence of HCV. In recent years, increased rate of HCV infection is noted in the younger populations. This has been attributed to injection drug use, opioid addiction and perinatal transmission. It is paramount to understand the pattern of HCV transmission, disease severity and treatment rates in the young adults which can enable us to provide timely intervention and prevent detrimental liver complications.

METHODS:
Retrospective observational study including patients between 18 to 40 years who tested positive for HCV antibody between 2016-2017. Descriptive and statistical analyses were performed to evaluate prevalence of HCV, treatment rates and disease severity. Liver disease severity was calculated using Model of End Stage Liver Disease (MELD) and Child-Pugh Turcot (CTP) scores.

RESULTS:
A total of 507 patients who tested positive for HCV antibodies between 2016-2017 was evaluated. Of these, 83 (n = 83) patients between 18 to 40 years were included in this study. Prevalence of HCV was noted to be 16.4%. Majority of the population were African American (66%). An almost equal number of males and females (53% and 47%) were present. The incidence of smoking, alcohol use and IV drug use were 12%, 25% and 19% respectively. Majority had CTP score of 5-6 (87%) and rest had CTP score 7-9 (13%). Majority also had MELD < 9 (60%) followed by MELD 10-19 (23%) and MELD 20-29 (17%). The MELD and CTP scores were lower compared to patients >40 years of age with HCV. A small population had decompensated cirrhotic features of hepatic encephalopathy and ascites (7% and 2% respectively). A very low number of them Hepatitis B surface Ab positive (1%) and majority had not received treatment for HCV infection (90%).

CONCLUSION:
In this study we noted a high number of young adults between 18-40years of age infected with HCV, majority were HCV treatment naïve and had less advanced liver disease with low rates of liver cirrhosis, hepatic encephalopathy and low MELD and CTP scores. IVDU was low in our population in contrary to other data. Very low HBV vaccination rate was noted, indicating the high risk for HBV infection in this population. In conclusion, HCV in young adults is a growing problem and it is pivotal to increase awareness and study the disease and transmission patterns to adequately manage this issue and prevent liver complications.
1118 Transplantation of Human Adipose Tissue Derived-SVF Enhance Liver Function in Fibrotic Liver Through High Hepatogenic and Anti-Fibrotic Capabilities
Authors: Choi Ja Sung , Kim Sung-Whan 
Published: October 2019

INTRODUCTION:
Although human adipose tissue-derived stromal vascular fraction (SVF) has been considered a promising source of stem cells, its characteristics relevant to treatment of a damaged liver have not been fully elucidated. In the present study, we sought to characterize the hepatogenic and anti-fibrogenic property of human SVF and determine the therapeutic utility of SVF in the liver cirrhosis model.

METHODS:
We performed microarray, quantitative (q)-PCR experiments, and in vivo therapeutic assays using a liver cirrhotic mouse model.

RESULTS:
q-PCR results revealed that the well-known hepatogenic or anti-inflammatory factors hepatocyte growth factor (HGF), vascular endothelial growth factor (VEGF)-A, Interleukin (IL)-10 and microRNA(miR)-146 were more highly upregulated in SVF than in human adipose-derived mesenchymal stem cells (ASCs). The SVF culture medium (CM) inhibited the activation of hepatic stellate cells in vitro. Injection of SVF significantly suppressed TAA-induced liver fibrosis and repaired liver function by inhibition of infiltrating inflammatory cells and induction of capillary/hepatocyte regeneration in vivo.

CONCLUSION:
Our data indicate that SVF has a high therapeutic potential for treating fibrotic liver diseases through their hepatogenic and anti-fibrogenic properties. Therefore, SVF might be a novel therapeutic alternative for the treatment of liver cirrhosis in clinical settings.
1125 Body Fatness over the Life Course and the Risk of High-Risk Serrated Polyps and Advanced Conventional Adenomas
Authors: Lo Chun-Han , He Xiaosheng , Hang Dong , Wu Kana , Onigo Shuji , Chan Andrew , Giovannucci Edward , Song Mingyang 
Published: October 2019

INTRODUCTION:
Obesity is an established risk factor for colorectal cancer. Serrated polyp (SP) and conventional adenoma (CA) represent two distinct groups of colorectal premalignancy. In contrast to the well-documented effect of adulthood obesity, the influence of early-life body fatness on the risk of developing SPs and CAs remains unclear.

METHODS:
This prospective study within the Nurses’ Health Study (1990-2012), the Nurses’ Health Study 2 (1991-2013), and the Health Professional Follow-up Study (1990-2010) collected detailed information on body fatness at different ages and the diagnosis of SPs and CAs. We individually examined the risk of high-risk SPs (≥10 mm or proximal SPs) and advanced CAs (≥10 mm or advanced histology) in relation to body fatness in early childhood (age 5), late childhood (age 10), early adulthood (age 18 for women and 21 for men), middle adulthood (baseline) and weight change from early adulthood to middle adulthood. Multivariable-adjusted logistic regression for clustered data was used to calculate the odds ratios (OR) and 95% confidence intervals (CI).

RESULTS:
Among 29221 men and 132546 women in the three cohorts who had undergone at least one lower bowel endoscopy during 18-20 years of follow-up, we documented 3119 cases of high-risk SP and 3299 cases of advanced CA. The ORs of high-risk SPs and advanced CAs ranged from 1.12 (95% CI, 1.02-1.23) to 1.25 (95% CI, 1.10-1.42) in women who were obese in early and late childhood. The associations were attenuated after adjusting for adulthood BMI. Body fatness in middle adulthood showed a strong positive relationship with the risk of both types of CRC precursor lesion in men and women. Weight change from early adulthood to middle adulthood was associated with greater risk of high-risk SPs in women (OR comparing weight gain ≥20.0 kg to gain or loss < 2.0 kg, 1.39; 95% CI, 1.22-1.58) and men (OR, 1.40; 95% CI, 1.01-1.29), and advanced CAs in both women (OR, 1.14; 95% CI, 1.07-1.82) and men (OR, 1.21; 95% CI, 1.03-1.42). The associations were stronger for high-risk SPs than for advanced CAs in women (P
heterogeneity = 0.01 for adulthood BMI, 0.004 for weight change).

CONCLUSION:
Weight gain during early adulthood and attained adiposity are associated with increased risk of high-risk SPs and advanced CAs in both men and women. There is heterogeneity in the associations among different types of colorectal precursor lesions in women but not in men. Body fatness in childhood is also associated with an increased risk in women.