bluuebunny/crossref_metadata_2025_split huggingface dataset:
1070 Hip Fractures in Celiac Disease Patients: A Nationwide Analysis
Authors: Khan Ahmad , Gupta Kamesh , Sohail Abdullah , Goyal Hemant 
Published: October 2019

INTRODUCTION:
Autoimmunity associated with Celiac disease (CD) has previously shown to be associated with bone health and hip fracture risk. Literature also supports supplementation of Vitamin D in celiac disease patients to increase bone mineral density. Currently, there is no US national-level study to show the risk of hip fractures in CD patients.

METHODS:
We conducted a cross-sectional study using the National Inpatient Sample (2008 to 2014). We identified patients with a primary diagnosis of HP using diagnosis codes for the neck of femur, intertrochanteric and subtrochanteric fractures or procedure codes for interventions for hip fractures including total hip replacement. The primary outcome was the total number of hospitalizations with secondary outcomes including mortality, length of stay (LOS) and total hospitalization charges. We adjusted outcomes for confounding factors such as age, gender, race, and comorbidities by the univariate and multivariate regression model.

RESULTS:
From 2008-2012, a total of 32,96,442 hospitalizations were identified for hip fractures, of which 3614 (0.1%) had associated celiac disease. CD subgroup had significantly increased number of females, Caucasians, and elderly patients but no differences were noted in the total number of comorbidities. CD + HP was more common in hospitals situated in the northeastern states than only HP group but there were no differences noted in the teaching vs nonteaching hospitals or urban vs rural hospitals. Multivariate analysis with confounding factors showed that patients with CD were more likely to have HP with OR 1.08 (95%CI: 1.003-1.18; P = 0.041). There was no significant difference in mortality or mean length of stay. Patients with CD and hip fractures had higher incidence and odds ratio of osteoporosis than non-CD patients (29% vs 13.1%, OR: 3.71, P = 0.00).

CONCLUSION:
Our study showed that patients with CD are more likely to get hip fractures which is further supported by increased prevalence of osteoporosis in these patients. However, there is no difference in terms of in-hospital mortality and hospital resources utilization in comparison to patients without CD. Our study reinforces the necessity of addressing risk of osteoporosis risk in CD patients with Vitamin D and calcium supplementation, which can likely prevent a gravely morbid event like a hip fracture.
1075 Primary Care and Specialty Physician Perspectives on Non-Alcoholic Fatty Liver Disease (NAFLD) Screening, Diagnosis, and Referral
Authors: Saeed Naba , Tincopa Monica , Mahmood Asadullah , Habbal Heba , Sengstock David , Glass Lisa 
Published: October 2019

INTRODUCTION:
Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease in the developed world. It is associated with cardiovascular risks, malignancy and poor health-related quality of life. It is often under-recognized and undertreated by primary care providers (PCPs), leading to increased morbidity and mortality. Our study aims to assess PCP awareness of NAFLD risk factors, diagnosis and treatments, as well as their referral patterns to specialty care.

METHODS:
An anonymous provider survey was developed by 2 hepatologists, to assess PCPs’ perspectives on NAFLD disease knowledge, diagnosis, management, and referral of patients to sub-specialty care. Primary care and sub-specialty providers from Internal Medicine, Medicine-Pediatrics, Family Medicine, Geriatrics, Cardiology and Endocrinology, who spend >25% of their time in adult clinical care, were included. Descriptive statistics (means for continuous data, percentages for categorical data) were used.

RESULTS:
A total of 438 physicians completed the survey: 83 Michigan Medicine, 18 Beaumont Health and 337 ACP physicians. 99.5% physicians reported most/some of their patients likely have NAFLD, while 19% strongly agreed to the role of screening for NAFLD. Most common associated comorbidities identified by PCPs were diabetes, obesity and hyperlipidemia. Comorbidities prompting screening most often were NAFLD family history, diabetes, and obesity. Hepatic function tests and liver ultrasound were the most frequently used screening tools. Only 22.6% of providers used non-invasive serum-based staging, and 23% used fibroscan. 67% providers referred few/none of their patients to specialists, with mainly advanced fibrosis/cirrhosis patients being referred. Most common barriers to PCP NAFLD evaluation and treatment included uncertainty of NAFLD treatments (47.3%) and low priority (30.8%). 74% providers reported no change in statin prescription.

CONCLUSION:
Despite the high rates of NAFLD in primary care, the rate of NAFLD screening and referral to specialty care is surprisingly low. Additionally, non-invasive tests for staging hepatic fibrosis are underutilized, which means that high-risk NAFLD patients with advanced fibrosis are likely overlooked. Important barriers to be addressed include improving NAFLD recognition, as well as disease assessment and knowledge of NAFLD treatment. Emphasis should be placed on early referral before patients reach advanced cirrhosis.
1077 Liver Cancer in Ethiopia: Presentation, Prognosis, and Therapy
Authors: Sultan Amir , Campos Marilia , Wondifraw Zerihun , Braimoh Grace , Bane Abate , Debes Jose D. 
Published: October 2019

INTRODUCTION:
Sub-Saharan Africa exposes one of the largest burdens of morbidity and mortality from Hepatocellular carcinoma (HCC). However, there is little information about HCC presentation and outcomes form the region. In this study we describe clinical characteristics and therapeutic approach to HCC in a single center in Ethiopia.

METHODS:
We retrospectively evaluated clinical charts of individuals that presented with HCC at a major referral clinic in Addis Ababa, Ethiopia from 2016 to 2018. Diagnosis of HCC was performed via biopsy or imaging criteria as established by AASLD guidelines. Survival was determined as date of last visit, and calculated in days from initial diagnosis visit. Those individuals with initial and last visit of less than seven days were removed from survival analysis. Mann-Whitney test was used for survival assessment.

RESULTS:
Forty-six cases are reported. The median age was 54 years (IQR 45-62) and 50% were females. Forty-one percent of individuals had hepatitis B (HBV) as underlying liver disease, 45% had hepatitis C (HCV) and the rest were classified as “other”. There was no association between region of origin and HBV-related HCC. Seventy-eight percent (N:36) of cases had evidence cirrhosis on presentation. Median age of HCC diagnosis was 54 years (IQR 45-62) in all patients and 48 years (IQR 19-38) in those infected with HBV. Median tumor size was 6.5cm (IQR 4.5-6.9) and median MELD score was 12 (IQR 8-17). The median survival in the entire cohort was 68 days (IQR 17-334). The most common treatment modalities were trans-arterial chemoembolization (TACE, 16%), Sorafenib (18%) and Palliative care (31%), with median survival being 351, 94 and 27 days, respectively. There was no correlation between MELD score and survival at 6 months. Twenty percent of all individuals were treated with sorafenib (N:9). Median survival in this group was 92 days (IQR 24-121), despite almost all of them having AFP >400ng/ml. Interestingly, a neutrophil-to-lymphocyte ratio (NLR) of < 2.5 correlated with better survival (109 days vs 68 days for those with NLR >2.5, P = 0.01).

CONCLUSION:
We found younger diagnosis of HCC in individuals infected with HBV. The great majority of patients received non-curative therapy. A small sub-group of individuals showed a reasonable survival benefit with sorafenib.
1078 Impact of GLP-1 Agonist Use on Non-Alcoholic Fatty Liver Disease Among Patients at a Large, Tertiary Care Center
Authors: Aggarwal Soorya , Sullivan Matthew J. , Kloska Michal , Magdaleno Angela , Perilli Gretchen , Wong She-Yan 
Published: October 2019

INTRODUCTION:
Non-alcoholic fatty liver disease (NAFLD) is on target to become the leading cause of cirrhosis by 2030. The GLP-1 agonist class of medications, which are highly effective weight loss agents, may result in reducing inflammation and fibrosis in NAFLD. The aim of this study was to evaluate the effects of these medications amongst NAFLD patients.

METHODS:
This was a single center, retrospective study of NAFLD patients who had initiated a GLP-1 agonist between January 2012 and January 2018. Patient demographics, medical co-morbidities and laboratory values were obtained from the electronic medical record. Additionally, the NAFLD fibrosis score (NFS) was calculated before and after initiation of GLP-1 agonist.

RESULTS:
In total 149 patients were studied of which 45% were male and 55% were female. 78.5% of the patients were Caucasian. 60.8% of patients were on Liraglutide and all had a diagnosis of diabetes mellitus. Prior to initiation of GLP-1 agonist, 59% of patients were in the indeterminate NFS category followed by 33.6% in F3-4 and 7.4% in F0-2. Treatment lasted on average of 29.06 months (range of 5 to 80 months). After medication use, there was a statistically significant change in patient’s BMI (P = 0.018), correlating to degree of fibrosis. F3-4 patients who became intermediate stage after GLP-1 use had the largest percent change in BMI of 8.5%. In 71% of initially abnormal ALT ( >30) 17% of those patients, normalized ALT after GLP-1 agonist use. Of the 66% of patients with abnormal triglycerides ( >150), 28% normalized triglycerides after use of these medications. There was no statistically significant change in NAFLD fibrosis score after the use of GLP-1 agonist.

CONCLUSION:
In our study of fatty liver disease in diabetics, we found that over one-third of patients had severe F3-4 stage fibrosis prior to initiation of GLP-1 agonist. In this population, we showed statistically significant improvement in BMI, supporting GLP-1 agonists’ role in weight loss. Additionally, with use of GLP-1 agonist, when fibrosis stage improved, other measures of metabolic syndrome including BMI, triglycerides, and ALT also improved. Although there was no statistically significant change in NFS, this could be explained by the fact that the majority of patients had an indeterminant score prior to GLP-1 agonist use, rendering this interpretation difficult. Future investigation of histopathology with GLP-1 agonist use will help to elucidate these conclusions further.
1080 Bilirubin and QT Interval Prolongation (From the Third National Health and Nutrition Examination Survey)
Authors: Majeed Chaudry N. , Ahmad Muhammad Imtiaz , Anees Muhammad Ali , Soliman Elsayed Z. 
Published: October 2019

INTRODUCTION:
The association of bilirubin with cardiovascular disease (CVD) is controversial. We sought to explore the association of total bilirubin levels with QT interval in a multiracial cohort.

METHODS:
A total of 6,627 participants (59.0 ± 13.3 years; 52.6%% women, 49.7% Non-Hispanic Whites) without cardiovascular disease (CVD) from the Third National Health and Nutrition Examination Survey (NHANES-III) were included in this analysis. QT was automatically measured from digital 12-lead electrocardiogram in a central reading center. A multivariable logistic regression model was used to examine cross-sectional association between tertiles of total bilirubin and prolonged QT interval (≥450 ms in men, ≥460 ms in women).

RESULTS:
The prevalence of prolonged QT was higher among those with higher levels of total bilirubin (prolonged QT prevalence was 4.7%, 6.8%, and 7.0% across total bilirubin lower (0-0.4 mg/dl), middle (0.5-1.6 mg/dl) and higher (0.70-4.30 mg/dl) tertiles respectively). In a model adjusted for potential confounders, participants within the highest total bilirubin tertile had significantly greater odds of prolonged QT interval (OR (95% CI): 1.53 (1.16-2.02) compared to those with bilirubin levels in the first tertile. Each 0.29 mg/dl increase in total bilirubin levels was associated with a 12% (P-value < .0001) increase in the prevalence of prolonged QT interval (Table 1). This association was stronger in men than women (interaction P-value = 0.04).

CONCLUSION::
Recent evidence suggests worse cardiovascular (CV) outcomes with high levels of bilirubin but the mechanism behind worse CV events remains to be elucidated. Our study showed that elevated bilirubin levels are associated with prolonged QT interval. QT interval has been consistently associated with increased risk of all-cause and CV death. Thus, finding an association between total bilirubin levels and prolonged QT interval in our study extends our current knowledge on the relationship between serum bilirubin and CVD by demonstrating a link between higher total bilirubin and abnormal cardiac repolarization. To the best of our knowledge, this is the first study to demonstrate the association between bilirubin and prolonged QT. This association was stronger in men than women. Future studies are needed to establish the causal relationship between bilirubin and QT prolongation and how this association between bilirubin and QT interval could be harnessed to improve CVD risk estimation.
1081 Direct-Acting Antiviral Therapy Against Hepatitis C in Patients With Liver Cancer: Is It Safe?
Authors: Kang MItchell , Jung Jeah , Kalidindi Yamini , Riley Thomas 
Published: October 2019

INTRODUCTION:
The effect of direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) patients with hepatocellular carcinoma (HCC) has been controversial, as initial studies reported increasing incidence and aggressiveness of HCC post-DAA treatment with more recent literature contradicting this claim. Furthermore, questions remain regarding overall survival in this high risk population after DAA treatment, as previous studies have suffered from small sample sizes of HCC cases.

METHODS:
Data was obtained from the Medicare database on patients diagnosed with HCV and HCC in 2014, and followed for 3 years. Subjects who received DAA therapy were matched to controls based on age, gender, race, and cirrhosis. Outcomes including HCV-related costs, hospitalizations, and mortality rates were measured. Paired t-test was used for independent variables; logistic regression was used to compare outcomes between groups.

RESULTS:
1208 subjects were included in this study. 604 of these had received DAA therapy with HCC and were matched to controls who did not receive DAA therapy with HCC. Baseline characteristics were similar between groups (Table 1). The control group had a total of 445 deaths. Those who received DAA therapy had lower rates of mortality through time, with a total of 94 deaths (see Figure 1 for mortality rates through time). HCV-related hospitalizations for those who received DAA therapy significantly declined through time, with 19.5% requiring hospitalization within the first 6 months and 9.4% at 30 months (P = 0.01), whereas the hospitalization rates for the control group did not significantly change. HCV-related costs (Figure 2) also significantly declined through time for those who received DAA therapy (P = 0.02). The costs for the non-DAA therapy group did not significantly decrease (P = 0.63).

CONCLUSION:
In this largest study to date of HCV patients with HCC, the group selected to receive DAA treatment fared better in the short and long term than those not selected to receive DAA therapy. Patients who received DAA therapy had a low mortality rate over the 3 years of follow up. DAA therapy in the follow up period did not accelerate mortality from baseline. This data supports the paradigm that treating HCV in the setting of HCC is beneficial and is not detrimental either from a mortality or cost perspective. Further investigation including prospective randomized control studies would be warranted to elucidate these findings.
1084 Does Viremia in Patients With Hepatitis C Antibody Positivity Alter Mortality in People Who Inject Drugs With Infective Endocarditis?
Authors: Tom Chloe K. , Kovalic Alexander J. , Huang Glen , Peacock James E. , Majeed Chaudry N. , Davis Kyle A. 
Published: October 2019

INTRODUCTION:
Injection drug use [IDU] is a well-known risk factor for both infective endocarditis [IE] and hepatitis C virus [HCV] infections. In parallel with the opioid epidemic, the incidence of both infections has increased in recent years. In this retrospective study, the impact of HCV on mortality of people who inject drugs [PWID] with IE is assessed.

METHODS:
Electronic medical records of adult patients diagnosed with IE according to modified Duke criteria from January 2012 through May 2018 at an academic tertiary medical center were analyzed. Patients were identified as PWID based on IDU documentation within 3 months of admission. The study included all patients with a positive HCV antibody. Patients were then stratified into two groups: “Positive HCV viremia” [positive HCV antibody and viral load] or “Negative HCV viremia” [positive HCV antibody but negative viral load]. Prior HCV treatment, HIV infection, and absence of documented HCV seropositivity precluded study enrollment. Pertinent demographic, clinical, laboratory, microbiologic, and outcome data were recorded and analyzed.

RESULTS:
One hundred and twenty-nine PWID with IE were identified, of whom 110 [85.2%] had a positive HCV antibody. Of these, 23 patients were excluded due to lack of testing for viral RNA. , resulting in 87 HCV study patients [67.4%]. Fifty-three [61.0%] patients had viremia and 34 [39.1%] did not. Of the 87 study patients, 85.1% were Caucasian and 52.9% were female with a median age of 25. Six [6.9%] patients had previous IE. The most commonly injected drug was prescription opioids [69.0%]. The tricuspid valve was involved in 56.3% of patients and the most common pathogen was Staphylococcus aureus [71.3%]. Prescription opioid injection, S. aureus infection, tricuspid valve involvement, and 10-week mortality did not differ between the viremic and non-viremic HCV groups [Table 1].

CONCLUSION:
While several host and clinical factors affect mortality in PWID with IE, HCV viremia does not appear to increase mortality. However, larger, prospective studies will be required to better delineate the significance of HCV viremia among PWID with IE.
1093 Longitudinal Follow-Up of Malnutrition in U.S. Veterans With Decompensated Cirrhosis
Authors: Edwards Jade , Narayanan Shreya , Hiller Lynn D. , Smith Tristan , Kumar Ambuj , Foulis Philip , Vidyarthi Gitanjali 
Published: October 2019

INTRODUCTION:
This retrospective cohort study aims to address the overall incidence of formal malnutrition assessments of U.S. veteran patients with decompensated cirrhosis and how these assessments impact clinical outcomes.

METHODS:
All consecutive adult U.S. veteran patients with a diagnosis of decompensated cirrhosis were identified in the James A. Haley VA Computerized Patient Record System using ICD-9 and ICD-10 codes associated with decompensated cirrhosis. Patients were included in the study if they had at least 2 cross-sectional imaging studies (CT or MRI) approximately 2 years apart from one another in order to identify significant changes in skeletal muscle composition and body fat as a primary outcome. These studies were reviewed and compared by one independent radiologist. Demographic and clinical data were also extracted. Malnutrition assessments were evaluated by one registered dietician (RD) based on review of prior dietician consultation notes that documented clinical evidence of malnutrition.

RESULTS:
101 subjects with decompensated cirrhosis met inclusion criteria; 97% were male with a median age of 60 years. The most common etiology of cirrhosis was due to hepatitis C virus. The overall incidence of at least one documented nutritional assessment conducted by a registered dietician (RD) was 69% (70/101). Approximately 41% of those patients evaluated by an RD were confirmed as being malnourished and had significant reductions in the dimensions of their gluteus maximus, erector spinae muscles and flank fat while their BMI and MELD scores were relatively unchanged over a 2-year period. Cirrhotic veterans that were not evaluated by an RD had similar reductions in fat and muscle mass compositions. Only 17% of malnourished subjects that were evaluated by an RD had a billing code (ICD-9 or ICD-10) in their medical record that corresponded to their malnutrition.

CONCLUSION:
Nearly one-third of U.S. veterans with decompensated cirrhosis had a documented diagnosis of malnutrition. There were significant reductions in skeletal muscle mass and fat mass over a 2-year time period that correlated with their chronic disease-related malnutrition. Interestingly, the presence or absence of an RD evaluation had no significant impact on these reductions. Corresponding ICD-9/ICD-10 billing codes associated with malnutrition were underreported, which may be a potential barrier in identifying and optimally treating malnutrition in U.S. veteran patients with decompensated cirrhosis.
1107 Novel Therapy for Hepatocellular Carcinoma: Immunotherapy
Authors: Jones Patricia D. , Gmunder Kristin , McLaughlin Jeremy , Martin Paul M. , Herrera Cristina , Feun Lynn 
Published: October 2019

INTRODUCTION:
Over 50% of patients with hepatocellular carcinoma (HCC) present with advanced disease for which therapeutic options have been limited to locoregional therapy and/or systemic chemotherapy. Since 2017, three multi-kinase inhibitors and two checkpoint inhibitors have received FDA approval, expanding the treatment armamentarium for advanced HCC. We aimed to describe our early institutional experience with immunotherapy including response to treatment and frequency of adverse events.

METHODS:
We identified patients diagnosed with HCC (C22.0) from the Cancer Registry and Electronic Data Warehouse at the University of Miami /Jackson Memorial Hospitals and identified those who were treated with immunotherapy (IT). We used bivariate and Pearson’s chi-squared analyses to describe participant characteristics.

RESULTS:
Forty patients have been treated with immunotherapy to date. Median age at diagnosis was 65; 87.5% were male. Cirrhosis was present in 70%; 17 patients had hepatitis C, 5 had hepatitis B, 7 had alcoholic liver disease and 9 had non-alcoholic fatty liver disease. At diagnosis, 17 patients were Barcelona Clinic Liver Cancer (BCLC) Stage 0/A, 16 were BCLC B and 6 were BCLC C. Four had metastasis at presentation and 2 had tumor thrombus. At diagnosis, median AFP was 44 ng/mL. Median MELD score was 7. See Table 1 for baseline characteristics. Prior to receiving IT, patients received a median of 3 other treatment modalities. (Figure 1) Median time from diagnosis to first treatment was 48.5 days. Prior to IT, 3 patients were BCLC B, 36 were BCLC C and 1 was BCLC D. Median time from diagnosis to IT was 834.5 days. Twenty-eight patients received pembrolizumab and 12 received nivolumab. Patients received a median 5 doses of IT; side effects occurred in 85%. However, only 6% had treatment discontinuation due to patient intolerance of side effects. Elevated liver enzymes occurred in 40%; of these, 2 developed autoimmune-type hepatitis and 1 experienced significant liver dysfunction. Fatigue occurred in 37.5% and rash in 27.5%. Prednisone was used to treat side effects in 22 patients. At present, 21 are alive and 8 are still receiving IT. See Table 2 for IT characteristics. There were no significant baseline or survival differences comparing pembrolizumab vs. nivolumab.

CONCLUSION:
Although IT is promising in the treatment of advanced HCC, future research must identify which patient characteristics predict treatment response and development of side effects.