bluuebunny/crossref_metadata_2025_split huggingface dataset:
943 A Step-Wise Approach to Non-Invasive Diagnosis of Advanced Fibrotic Disease in NAFLD
Authors: Fahad Hamna , Mitchell Brittany , Sarmini Talal , Singh Tavankit , McCullough Arthur J. 
Published: October 2019

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CONCLUSION:
In our preliminary analysis, we found nadir MAP during the first day of admission to the ICU to be independently associated with ICU-mortality. A cut-off of <60 mmHg may identify patients at risk for ICU-mortality, though larger studies at various time points are needed to substantiate this finding.