bluuebunny/crossref_metadata_2025_split huggingface dataset:
1003 Outcomes of Patients With Nonalcoholic Steatohepatitis With Cirrhosis and Low Model for End Stage Liver Disease Score
Authors: Laderian Behnam , Murali Arvind R. , Sanchez Antonio J. 
Published: October 2019

INTRODUCTION:
Subsets of patients with cirrhosis from non-alcoholic steatohepatitis and low MELD scores have slow progression of their MELD score over time. These patients may succumb to progressive liver disease prior to receiving a transplant. Early identification of this subset of patients is crucial to improve outcomes.

METHODS:
We retrospectively studied patients with NASH cirrhosis seen at our large tertiary care center. We collected data on demographics, clinical and laboratory variables including MELD score at diagnosis, at decompensation and at death. We recorded mortality, cause of mortality, and liver transplantation if received. Patients with MELD score< 15 at the time of diagnosis were analyzed. We performed Kaplan-Meier survival analysis. Univariate logistic regression analysis was performed to identify factors predicting transplant-free survival in NASH patients with low MELD.

RESULTS:
Two hundred and six patients with NASH cirrhosis and MELD < 15 were identified. Mean age 57.8 (12), 62 (30%) were males. Median MELD was 8 (IQR 6-10). Eight five (41%) patients developed hepatic decompensation, 82 (40%) developed ascites. Median MELD at decompensation was 10 (IQR 8-12). At a mean follow up of 5.4 (4.0) years, 8 (4%) patients had progression of their MELD score and received liver transplantation. Eight (4%) patients died of whom 6 (75%) died of progressive liver disease. Median MELD at the time of death was 18 (IQR 15-21). Kaplan Meier survival of all NASH cirrhosis patients with MELD < 15 was 96% at 3 years, and 92% at 5 years. On univariate analysis, absence of ascites was the single most important predictor of transplant free survival in patients with MELD < 15. Age, sex, creatinine, total bilirubin, and MELD score, were not significant predictors of survival. Kaplan Meier survival of patients with NASH cirrhosis and MELD < 15 with and without ascites was 94% vs 98.9% at 3 years, and 88% vs 98.9% at 5 years respectively (P = 0.02).

CONCLUSION:
A significant proportion of patients (∼40%) with NASH cirrhosis have a low MELD score despite decompensation with ascites and have a poor outcome as compared to NASH patients with low MELD and without ascites. A subset of low MELD NASH cirrhosis patients with ascites die of progressive liver disease at a low MELD score before diseased donor liver transplant (DDLT) can become available. Patients with NASH cirrhosis with ascites and low MELD score should be considered for a living donor or high risk diseased donor liver transplant to improve outcomes.
1008 Diarrhea Is Common Both Early and Late After Liver Transplantation and Rates of C. diff. Remain Elevated
Authors: Young Christopher , Patel Samarth , Siddiqui Mohammad B. , Zhang Emily , Chandrakumaran Anchalia , Faridnia Masoud , Hernandez Jose Roman , Siddiqui Mohammad S. , Smallfield George B. 
Published: October 2019

INTRODUCTION:
Diarrhea is a common complication of liver transplant (LT) frequently attributed to immune suppressive therapy. However, there is a dearth of published literature with regards to etiology, management, and time course of diarrhea in LT recipients. The aim of this study was to describe and compare the etiology of diarrhea both in the first 12 months after transplant and in diarrhea arising later after LT.

METHODS:
This is a retrospective examination of 333 consecutive patients who underwent LT at author's institution. Diarrhea was defined as ≥3 loose bowel movements occurring within 24 hours. Charts were reviewed for diagnostic evaluation of diarrhea, causative agent, and management. Diarrhea was described at intervals of within 12 months post-LT, diarrhea occurring after 12 months post-LT, and diarrhea that occurred during both time intervals. Risk factors and etiology of diarrhea were analyzed and described.

RESULTS:
The mean age of the cohort was 52.4 years, 38.1% were female. Patients were followed for up to 5 years after transplantation. 162 patients (48.6%%) developed diarrhea within 5 years of LT. 80 patients (24%) developed diarrhea within 1 year after LT but did not have recurrent episode. 63 patients (18.9%%) first developed diarrhea more than 12 months after LT. 19 patients (5.7%) developed diarrhea both during the first year and after 1 year. Clostridium difficile (C. Diff) infection was the most common diagnosis in all 3 groups, with 23 (28.8%) occurrences in the early group, 16 (26.7%) in the late group, and 5 (26.3%) in the early and late group. Nearly half of those patients that developed diarrhea were admitted to the hospital. 37/80 (46.3%) patients with diarrhea within 12 months were admitted. 29/63 (46.0%) patients in the late group were also admitted. 9/19 (47.3%) patients with diarrhea both within 12 months and after required admission. No significant differences in etiology or admission rate between the groups were found.

CONCLUSION:
Diarrhea is common after liver transplant and occurs both early and late following LT. Hospital admissions are also common in both groups of patients. With the high rates of C. diff infection both early and late post-LT, further study of preventative measures are warranted.
1011 Comparable Response of Intradermal Hepatitis B Vaccination in Dialysis and General Population Non Repsonder to Intra-Muscular Route
Authors: Hanif Farina , Mehmood Nasir , Laeeq Syed Mudassir , Luck Nasir Hassan , Khan Shoaib Ahmed , Kumar Sandeep 
Published: October 2019

INTRODUCTION:
Hepatitis B vaccine is extremely potent, however, 5% of healthy population and around 50% of hemodialysis patients do not respond to its intramuscular administration. We aim to determine the effectiveness of intradermal Hepatitis B vaccine in both dialysis and general population, who previously were non responder to its intramuscular form.

METHODS:
All participants were enrolled from January 2010 to 2019, received 5 doses of 10 µgm Hepatitis B vaccine via intradermal route every 2 weeks. Hepatitis Bs antibody (HBsAb) titer were checked 6 weeks after the last dose. Participants were consider as responder if HBsAb titer was more than 10 IU/L and good responder if more than 100 IU/L.

RESULTS:
In 95 participants, majority were female (51.6%) with mean age of 39.0 ± 13.5 years. Forty nine participants (51.6 %) were on maintenance hemodialysis. The risk factors for hepatitis B included intramuscular/intravenous injection in 85 (89.5 %), blood transfusion in 56 (58.9 %) and surgical procedures in 45 (47.4%) subjects. The mean HBsAb titer level was 263.5 ± 350.1 IU/L. Overall, 72 (75.8%) participants responded to vaccination, 42 (44.2%) of which achieved good response. Similar vaccination response was noted between hemodialysis and general population i.e., 75.5% and 76.1%, respectively (P = 1.00). Although a good response was observed more in hemodialysis patients (49%) than in general population (39.1%) however, it was not statistically significant. (P = 0.41).

CONCLUSION:
Intradermal hepatitis vaccination showed good response in those previously unresponsive to intramuscular route. Study participants on maintenance hemodialysis showed a similar response rate as the general population.
1023 Early Treatment of Recurrent Hepatitis C Post-Liver Transplant
Authors: Thiyagarajan Abirami , Romano John , Guo Yuqi , Massoud Omar , Shoreibah Mohamed , Jones DeAnn 
Published: October 2019

INTRODUCTION:
The rate of hepatitis C virus (HCV) recurrence after liver transplant (LT) is greater than 95% and chronic recurrence is more aggressive in the setting of immunosuppressive therapy (IS) in LT patients. Sustained viral response (SVR) is associated with lower mortality rates related to hepatic and extrahepatic manifestations of HCV including renal disease. Currently, however, there are no clear guidelines for the timing of HCV treatment post LT. The goal of this study is to examine the effects of early HCV treatment post-LT on kidney function, liver function and IS.

METHODS:
This is a retrospective study of 38 LT patients who received HCV treatment within 1 year between 2015 and 2018. Renal function, hepatic function and immunosuppressive regimens were compared at HCV treatment initiation and when patients achieved SVR post treatment. 86% of patients received a Sofosbuvir based regimen.

RESULTS:
The study included 38 patients with recurrent HCV post LT. Patients were 79% male, 71% Caucasian, with mean age being 57 [range 33-73]. The mean number of days between LT and HCV treatment initiation was 129 days [range 15-321]. All patients were initiated on treatment within the first year of LT. SVR rate was 100% in patients that were compliant with the regimen. No serious side effects were reported. There was no significant difference in mean pre and post-HCV treatment creatinine or number of patients with GFR < 60-pre/post treatment. There was no significant difference between number of patients on Mycophenolate or Tacrolimus before and after treatment. There was no significant difference in the mean dose of steroids, Azathioprine, Mycophenolate or Tacrolimus before and after HCV treatment.

CONCLUSION:
In patients completing treatment for recurrent HCV within 1 year of LT as early as 15 days post LT, treatment was well tolerated and effective with 100% SVR rate. There was no significant change in number of patients with Cr < 60 before and after treatment and no significant change in the dose of IS. Further studies will help compare outcomes and effects of HCV treatment within one year post LT vs later particularly on renal function and IS therapy.
1027 Health Outcomes in Patients With Hepatic Encephalopathy Treated in Community Practice Using a Specialized Pharmacy Team
Authors: Guerrero Richard , Kim Jae , Ramirez Ruben , Mitchell Robert , Van Frank Timothy , Christensen Kimberley , Hinojosa Kim , Landaverde Carmen , Loo Nicole , Rodas Fabian , Wells Jennifer , Alkhouri Naim , Lawitz Eric , Pedicone Lisa D. , Poordad Fred 
Published: October 2019

INTRODUCTION:
The prevalence of cirrhosis is on the rise in the US and predisposes patients to multiple costly complications, including hepatic encephalopathy (HE). Hospital readmissions among patients with decompensated cirrhosis are common and ∼1/3 are due to recurrent HE. Recommended treatment of HE is lactulose +/- rifaximin; however, access to rifaximin is sometimes difficult to access due to formulary restrictions or cost. This study assesses health outcomes, the rifaximin approval process and compliance in patients with HE in community GI/hep practices that use a dedicated pharmacy team with expertise in liver disorders.

METHODS:
This IRB-approved, observational protocol captures long-term health outcomes and pharmacy support data every 6 months for up to 10 years. Patients have cirrhosis, at least stage 1 HE and are already receiving or newly starting rifaximin. The concomitant use of lactulose was allowed at the discretion of the physician. Patients from community practices across Texas were included in this patient cohort followed over the first 6 months.

RESULTS:
The first cohort of 744 patients received rifaximin with (45%) or without (55%) lactulose and were insured through Medicare (39%), private (36%) or Medicaid (24%). In this cohort, 99% of rifaximin prescriptions were accepted with the first prior auth request and the majority of patients started treatment <14 days of prescription submission. DDI assessment and dosing compliance were reviewed resulting in 94% medication compliance during Month 1. During the first 6 months, 17.4% had >1 ER/urgent care visit and 4.4% were hospitalized due to an HE-related event. Thirteen patients had a new HCC diagnosis and 9 patients underwent liver transplant. After 6 months, 73% remained on rifaximin, 14% no longer wanted to participate, 8% were lost to follow up and 5% died. Overall medical condition was stable/improved for 90% compared to 6 months prior.

CONCLUSION:
Patients with HE who are treated at community sites with a specialized pharmacy team can receive rifaximin in an expedited manner. Continued patient education and communication with the health care team can lead to high adherence rates which can minimize ER/urgent care visits and hospitalizations. HCV remains the most common underlying disease in this cohort. In spite of rigorous monitoring, a large % of patients with advanced liver disease die or are lost to follow up. Close monitoring through a chronic care management model can lead to early diagnosis and better patient management.
1029 The Utility of the Baveno VI Criteria in a Safety Net Hospital
Authors: Jacobs Jaclyn , Hamid Osama , Calderon Amy 
Published: October 2019

INTRODUCTION:
Patients with liver cirrhosis are at risk for life-threatening hemorrhage from esophageal varices. Variceal hemorrhage can be prevented with medical and endoscopic therapies, so identifying patients through a screening process is paramount. Traditionally, screening was offered to all patients with cirrhosis; however, not all patients with cirrhosis are at the same risk to develop variceal hemorrhage. Using the Baveno VI criteria, cirrhotic patients with low risk for esophageal varices can be identified and spared the risks associated with invasive endoscopic screening. Previous studies have not evaluated these criteria in a safety net hospital population.

METHODS:
We enrolled 75 patients with cirrhosis for a retrospective chart review. Inclusion criteria were F3-4 or F4 by transient elastography and esophagogastroduodenoscopy (EGD) within 12 months of the elastography procedure.

RESULTS:
Mean age was 58 years, 54.7% were male and 53% of patients identified as black, African-American, or Hispanic. 67% had hepatitis C, 16% had alcoholic liver disease, and 16% had non-alcoholic fatty liver disease. 42.6% of patients had obesity (BMI > 30) and 56% had metabolic syndrome. 21 patients met Baveno VI criteria and 12 had esophageal varices on upper endoscopy. 4 additional patients had esophageal varices, yet were not identified as a high risk patient per Baveno VI criteria. 16 patients in total had esophageal varices (21.3%). 11 had small esophageal varices (without high risk stigmata) and 5 had high risk varices requiring intervention (large varices or varices with high risk stigmata). For Baveno VI criteria predicting the presence of any varices, the sensitivity was 75% (12/16), specificity was 84.8% (50/59), positive predictive value was 57.1% (12/21), and the negative predictive value was 92.6% (50/54). Baveno VI criteria identified all patients with high risk varices (5/5).

CONCLUSION:
With a robust negative predictive value in a safety net hospital population, Baveno VI criteria seems to be an adequate method for identifying patients who can avoid screening endoscopy for esophageal varices.
1031 Social and Medical Determinants of NASH versus NAFLD Using Liver Histology: A Single Center Experience
Authors: Rastegari Sheila , John Elizabeth S. , Valle Selena , Acharya Priyanka , Mantry Parvez 
Published: October 2019

INTRODUCTION:
Non-alcoholic fatty liver disease (NAFLD) is pandemic across the world and has a wide spectrum of presentations. Both NAFLD and its most severe histopathologic subtype, non-alcoholic steatohepatitis (NASH), can progress to cirrhosis, making early diagnosis pivotal. Liver histology is critical for the diagnosis of NASH, however little is known about the association of social and medical factors with its histologic features. We are conducting a retrospective analysis of a large single center database of over 2000 patients with fatty liver disease proven by biopsy. Here we focus on one year of data collected at our institution.

METHODS:
We reviewed 653 liver biopsies from a one-year period at Methodist Liver Institute to identify subjects with NAFLD and NASH based on the NAFLD Activity Score (NAS). NASH was defined as NAS score = >3. Patients under the age of 18, documented significant alcohol use, and without steatosis were excluded. We then collected data on demographics (age, race, insurance, and median income), comorbid disease (diabetes mellitus, hypertension, hyperlipidemia, metabolic syndrome), and medication use (antihypertensives, oral antihyperglycemics, insulin, statins, opioids), and used univariate statistical analysis to compare subjects with and without NASH.

RESULTS:
Of 253 biopsies included, 118 had steatosis without NASH and 145 had steatosis with NASH. Subjects with NASH were significantly younger, and more likely to be of Caucasian race than African American race, have Medicaid than commercial insurance, and have diabetes mellitus with use of oral antihyperglycemics. There was no significant difference between NASH and no NASH groups with regards to BMI, hypertension, hyperlipidemia, metabolic syndrome, or use of antihypertensives, statins, insulin, or opioids (Table 1).

CONCLUSION:
Though histologic confirmation is the gold standard to distinguish NAFLD from NASH, there is a lack of data establishing prognostic factors that may predict the degree of fibrosis. In our analysis having diabetes mellitus or Medicaid instead of commercial insurance correlated with more severe histopathologic disease, suggesting that more aggressive screening and treatment should be promoted in this population. There was no significant difference in socioeconomic factors such as median income or metabolic syndrome. Our study was limited by small size, and data collection is ongoing to determine other factors that may contribute to worsening fibrosis and validate or refute these early findings.
1035 Hepatitis C Virus Screening Practices by Medical Residents in a Federally-Qualified Health Center
Authors: Zakarya Mohamed , Pose Alix , Fekredengel Tizita , Homayounrooz Forugh 
Published: October 2019

INTRODUCTION:
Hepatitis C virus (HCV) is the most common chronic blood-borne pathogen in the United States. Treatment for HCV infection is currently available, curative, and with few associated side effects, increasing the importance of identifying HCV-infected individuals. HCV screening guidelines recommend a 1-time screening for baby boomers (individuals born between 1945 and 1965). Baby boomers have a higher risk for HCV-related morbidity and mortality. As of 2015, less than 13% of this population has undergone screening for HCV infection. This study aims at quantifying the baseline screening rates amongst baby boomers in a medical residents’ community clinic and evaluating the impact of resident-targeted interventions on HCV screening rates.

METHODS:
A retrospective chart review of baby boomers seen by medical residents between 7/1/17 and 12/31/18 was performed. Patients had to be seen at least once for a physical exam by the medical resident during the study period, and not screened for HCV infection previously. Baseline screening rates were recorded. Interventions were implemented for a period of 4 months. These included an updated electronic medical record (EMR) reminder for screening based on birth year, an EMR HCV risk assessment tool to identify patients need testing before visit, a link to HCV screening indications and guidelines, and small group teaching sessions about testing and linking patients to appropriate posttest care. A second phase of data collection included a chart review of baby boomers seen between 2/1/19 and 5/31/19 and meeting same criteria. A paired comparison t-test is used to analyze results.

RESULTS:
This investigation includes 502 patients in the first phase and 164 patients in the second phase of data collection. Pre-intervention screening rate was 89/502 (17.7%) compared with 72/164 (43.9%) post-intervention (P value < 0.0001).

CONCLUSION:
This investigation shows the suboptimal baseline HCV screening rate in baby boomers in a residents’ community clinic. Our post-intervention findings highlight the impact of focused resident-targeted education and the effectiveness of integrating appropriate tools into clinic infrastructure to help improve the rate of screening. Subsequently, this can help identify individuals who are in need for medical attention, potentially reducing complications of HCV infection and providing good value for our health care dollar overall.
1037 Safety and Efficacy of Sofosbuvir Plus Ribavirin and Sofosbuvir Plus Daclatasvir With or Without Ribavirin Combinations in Children and Adolescents With Chronic Hepatitis C
Authors: Hassan Adil , Bughio Ubedullah , Bhatti Rehmatullah , Ali Mashooque , Jamali Laraib , Sadik Muhammad 
Published: October 2019

INTRODUCTION:
The combination of Sofosbuvir plus Ribavirin and Sofosbuvir plus Ledipasvir are recommended by American Association for the study of Liver Disease for treatment of Chronic Hepatitis C Virus (HCV) infection in adolescents; however, there is no clear recommendations for its use in children age < 12 years. The purpose of this study is to evaluate use of Sofosbuvir plus Ribavirin and Sofosbuvir plus Daclatasvir with or without Ribavirin in children and adolescents with Chronic HCV infection.

METHODS:
An observational (off-label), single-centre study was conducted from January 2016 to December 2018. All Chronic HCV RNA detected, aged between 3 to 17 years of either gender were included. Patients were offered one of two regimes; Sofosbuvir plus Ribavirin for 24 weeks (Regime 1) and Sofosbuvir plus Daclatasvir with or without Ribavirin for 12 weeks (Regime 2), according to their weight i.e. standard dose for patients >34kg, half of standard dose for patients weight between 17 to 34 kg and half of standard dose on alternate day for patients < 17 kg. Patients were closely monitored for any drug related adverse effects and very Rapid Virological Response (vRVR) i.e. undetectable serum HCV RNA by week 2 of treatment, then accordingly till Sustained Virological Response (SVR12) i.e. undetectable serum HCV RNA at 12 weeks after completion of treatment.

RESULTS:
Total 14 patients were included with mean age of 12.36 ± 5.43 years with 6 (42.9%) patients were less than 12 years and 8 (57.1%) were 12 years. Among these 9 (64.3%) were boys and 5 (35.7%) were girls. 13 (92.9%) patients were non-cirrhotic and 1 (7.1%) patient was compensated cirrhotic. 5 (35.7%) patients treated with Sofosbuvir plus Ribavirin (Regime 1) and 9 (64.7%) patients treated with Sofosbuvir plus Daclatasvir with or without Ribavirin (Regime 2). 13 (92.9%) patients achieved vRVR except 1 (7.1%) patient who achieved partial response in Regime 1. SVR12 achieved by all 14 (100%) patients. No any significant adverse effect was observed and normal growth was assessed with CDC Growth Charts.

CONCLUSION:
The combination of Sofosbuvir plus Daclatasvir with or without Ribavirin is not approved by the FDA or EMA for paediatric use, however, it is highly safe and effective in children and adolescents while Sofosbuvir plus Ribavirin combination showed good efficacy and comparable safety profile in age < 12 years.