bluuebunny/crossref_metadata_2025_split huggingface dataset:
1113 Epidemiological Study of Liver Cancer Incidence in the U.S.-Mexico Border Region
Authors: Robles Alejandro , Contreras Alberto , Chavez Luis O. , Deoker Abhizith 
Published: October 2019

INTRODUCTION:
Liver cancer is the fifth most common cause of cancer-related death in men and the seventh most common in women, accounting for 7% and 4%, respectively, of all cancer-related deaths. In the United States, the incidence of liver cancer has more than tripled since 1980, and it continues to increase by about 3% per year in women and 4% per year in men. Mortality rates from liver cancer have also increased at a faster pace than all other cancer sites. The rising trend of liver cancer is likely attributed to an aging population with chronic hepatitis C virus infection and the increasing prevalence of diabetes, obesity, metabolic syndrome, and NAFLD; risk factors that are amenable to intervention. In this study, we investigate the burden of liver cancer in persons living near the U.S.-Mexico border.

METHODS:
Incidence statistics for liver cancer in counties along the U.S.-Mexico border were obtained from the NIH National Cancer Institute, State Cancer Profiles. Incidence rates (per 100,000 population) were compared by race (non-Hispanic white and Hispanic) and gender from 2011 to 2015. Variability in rates and changes in trends over the period were reported with 95% confidence intervals. Only descriptive data was reported - a statistical trend test was not used to analyze incidence rates over time.

RESULTS:
Incidence rates of liver cancer are higher in states that border Mexico. In general, Hispanics have higher average annual incidence rates of liver cancer than non-Hispanic whites, and this finding is even more noticeable in those living in counties along the U.S.-Mexico border, where rates of liver cancer in Hispanic men and women are higher than the state and national averages for Hispanics. Furthermore, an upward trend in liver cancer incidence was noted in Hispanic men living in El Paso County and Hispanic women living in San Diego County (Figure 1).

CONCLUSION:
Hispanics have the highest incidence rates of liver cancer, and this finding is more pronounced in those living near the U.S.-Mexico border; where the prevalence of known risk factors are higher. Increasing awareness and targeting preventive practices are needed to reduce the future impact imposed by liver cancer.
1114 The Effect of Metabolic Syndrome on Acetaminophen-Induced Acute Liver Injury/Failure - Morbidity and Mortality: A Single Liver Transplant Center Experience
Authors: Ghanimeh Mouhanna Abu , Baltarowich Lydia , Miller Joseph , Varma Adarsh , Brown Kimberly 
Published: October 2019

INTRODUCTION:
Acetaminophen (N-acetyl-p-aminophenol; APAP) toxicity is a major cause of acute liver injury in USA. Several risk factors could increase the risk and severity of APAP-induced acute liver injury/failure (APAP-ALI/ALF), including malnutrition, chronic hepatitis C, alcoholism, hepatic cytochrome P450-inducing medications, and pre-existing liver disease. Whether metabolic syndrome affects the risk or the severity of APAP-ALI/ALF has not been definitively confirmed. Clinical and animal studies show conflicting results. We aim to assess the effect of pre-existing metabolic syndrome on the natural history of APAP-ALI/ALF, including morbidity and mortality

METHODS:
This was a retrospective study performed at a tertiary care liver transplant center. A collective database of all patients with APAP-ALI/ALF from 2001-2012 was reviewed. Primary outcomes were 28-day mortality and the need for liver transplantation. Secondary outcomes were the degree of liver injury and elevation of biochemical markers

RESULTS:
A total of 327 patients were evaluated with APAP-ALI/ALF. A subset of 219 patients who had a recorded BMI in the medical record were included for analysis. There were 151 females and 68 males, with a mean age of 39.1 years old. Benzodiazepine or opioid co-ingestion occurred in 116 patients. A total of 60 patients were obese (BMI > 30 Kg/m2) with a mean BMI of 38.3 Kg/m2, and 21 were morbidly obese (BMI > 40 Kg/m2). 58 patients died (24 obese and 34 non-obese). Liver transplantation was performed in 4 out of the 7 patients who were listed. There was a statistically significant association between obesity and the 28-day mortality, OR 2.451 (95% CI 1.291-4.651) and P 0.005. No significant association was found between obesity and either listing for liver transplantation or liver transplantation (P 0.351 and 0.916 respectively). Maximum total bilirubin and INR were slightly higher in obese patients; however, this was not statistically significant (P 0.08 and 0.823, respectively). Pearson correlation showed a weak association between rising BMI and a higher maximum total bilirubin and INR, but this was not statistically significant (r 0.08, P 0.201 for total bilirubin and r 0.07, P 0.307 for INR)

CONCLUSION:
Our study demonstrates that obesity is associated with a higher mortality in patients with APAP-ALI/ALF. Preexisting hepatocyte lipid accumulation, CYP2E1 induction, reduced hepatic glutathione stores as well as mitochondrial dysfunction have been proposed as risk factors that may be contributing.
1115 Spontaneous Bacterial Peritonitis: We Are Still Behind
Authors: Numan Laith , Tomaw Andrew , Elkafrawy Ahmed A. , Kaddourah Osama , Saeed Lyla , Zafar Yousaf , Al-Sayyed Leen 
Published: October 2019

INTRODUCTION:
Spontaneous bacterial peritonitis (SBP) is an infection in the ascitic fluid when there is no evidence of intra-abdominal surgically treatable source of infection. It has an estimated in-hospital mortality rate of 20%. Despite the published guidelines, inappropriate diagnosis of SBP is frequent. In this study, we aim to measure the percentage of inappropriate diagnosis and treatment of SBP.

METHODS:
A retrospective study was conducted between Jan-2015 and Jan-2018. Based on the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of Liver (EASL) two authors judged the adherence to the guidelines in diagnosis and management of SBP. A third author resolved conflicts. Data was analyzed by chi-square analysis/Mann Whitney U Tests, ANOVA, and t-tests.

RESULTS:
One hundred six patients were included in the study. 93.3% (98/106) of them were hospitalized. Mean age was 56.9 years (range 32-87). 58.5% (62/106) of the patients were males. Caucasian was the most common ethnicity, with 86.8% (92/106). Smoking use was present in 41.5%, and alcohol use was present in 28.3% of our sample. Alcohol was the most common cause of cirrhosis in 50% of the patients, and viral hepatitis was the second (21.7%). Prior SBP was found in 24.5% of the population. Mean WBC 11.1, Mean MELD-Na score 23.5 (range 8-42), and mean Albumin 2.8 (1.6-4.9). Polymorphonuclear neutrophils (PMN) was neutrocytic (>250) in 54.8% (46/106). 81.8% of the ascitic cultures were negative. 16.2% of the cultures grew one organism, and 1.9% of them were polymicrobial. Albumin was given in 62.1%, and 52.4% on day 1 and day 3, respectively. Hepatology was consulted on 80.2% of the patients. Authors judged that only 52.4% of patients were appropriately diagnosed, and only 67.3% were managed with appropriate treatment. Inpatient mortality documented in 5 patients. The readmission rate was 29.3%.

CONCLUSION:
SBP is a common complication of cirrhosis, that can be easily managed if we adhere to the published guidelines. In our population, nearly half of the patients were diagnosed and treated inappropriately; this was mostly due to misdiagnosis of SBP with secondary peritonitis or non-neutrocytic bacteriascites, starting antibiotics before performing the paracentesis, and even given broader antibiotics when it is not needed. Further efforts should stress to adopt the guidelines in clinical practice.
1117 Same Day, Walk-In Ultrasound Appointments Improve Hepatocellular Carcinoma Screening Rates in Patients With Cirrhosis at a Veterans Affairs Center
Authors: Ward Christopher , Tse Chung Sang , Shittu Yetunde , Promrat Kittichai 
Published: October 2019

INTRODUCTION:
The incidence of hepatocellular carcinoma (HCC) is rapidly increasing in the United States and 80% have pre-existing cirrhosis. It is imperative to implement effective screening programs to detect clinically silent or early stage HCC in patients with cirrhosis to improve cancer-related mortality. The 2018 American Association for the Study of Liver Diseases (AASLD) Guidelines recommends surveillance using ultrasound (US), with or without alpha fetal protein (AFP), every 6 months. Prior studies have shown low HCC surveillance rates of approximately 20% among eligible patients in clinical practice. Our aim is to improve the HCC surveillance rate at our local Veterans Affairs Medical Center (VAMC).

METHODS:
We developed a process map and an apparent cause analysis (fishbone) to identify the barriers to HCC screening. We implemented a quality improvement initiative and collected the HCC screening compliance rates on a monthly basis on all eligible patients with cirrhosis seen at a local VAMC between January 2018 and February 2019.

RESULTS:
Based on our process map (Figure 1) and apparent cause analysis (Figure 2), the barriers to HCC screening at our local VAMC included the lack of a set protocol in our radiology department for limited ultrasound scans which limited patient access and compliance, such as the schedulers’ inability to reach patients for ultrasound appointments and patients’ no-show on ultrasound appointments. Our primary intervention was to institute same day walk-in ultrasounds, such that patients could go directly from their liver clinic appointment to the radiology department for a dedicated HCC screening ultrasound, without the need for patients to fast or return on a different date. At the start of the study period in January 2018, the HCC screening compliance rate was 39.6%, with 195/324 patients overdue. The same day walk-in ultrasound was implemented on 31 July 2018, at a time when the compliance rate was 42.1%. Six months after the intervention, the compliance rate in February 2019 was 66% with just 90/215 patients overdue for their ultrasounds. (Figure 2)

CONCLUSION:
It is standard of care to provide biannual screening ultrasounds for HCC surveillance in patients with cirrhosis. At our local VAMC, providing patients with same day walk-in ultrasounds to coincide with their liver clinic appointment days eliminated a number of barriers to HCC screening and lead to an increase in compliance.
1119 Assessment of Utility of Prognostic Models for Predicting Short-Term Mortality of Patients With Acute-on-Chronic Liver Failure
Authors: Margaret Teng Li Peng , Phyo Wah Wah , Lee Guan Huei 
Published: October 2019

INTRODUCTION:
Acute-on-chronic liver failure (ACLF) is a clinical syndrome associated with high short-term mortality. Numerous models have been proposed to predict outcomes in ACLF patients, including novel ones by Asian Pacific Association for the Study of the Liver (APASL) ACLF Research Consortium (AARC), but their utility in a heterogeneous population of ACLF patients remains inconclusive. The study aims to assess the performance of established and newer models for predicting mortality of ACLF patients.

METHODS:
A retrospective study of 96 patients fulfilling either APASL or European Association for the Study of the Liver (EASL) criteria for ACLF admitted to a tertiary hospital in Singapore between 2004 and 2018 was performed. Child-Turcotte-Pugh (CTP) score, Model for End-Stage Liver Disease (MELD)-Na, Chronic Liver Failure Consortium (CLIF)-SOFA, CLIF-C ACLF and AARC prognostic scores (MELD-lactate, AARC-ACLF) were calculated on days 1, 4, 7 of hospital admission and days 1, 4 of ICU admission. Outcomes assessed were survival to discharge without transplant, 30-day survival and 90-day survival. The scores were evaluated by measuring area under receiver operating characteristic (AUROC) curve at each time point and compared.

RESULTS:
28 patients (29.2%) survived to discharge without transplant, 21 patients (21.9%) underwent urgent transplant and 47 patients (49%) died before discharge. 30-day transplant-free survival was 21.9% and 90-day survival was 19.8%. CTP, MELD-Na, MELD-lactate, CLIF-C ACLF and AARC-ACLF scores had high accuracy in predicting hospital mortality on day 4 admission (CTP D1 AUROC 0.642, D4 0.715; MELD-Na D1 0.607, D4 0.721; MELD-lactate D1 0.664, D4 0.861; CLIF-C ACLF D1 0.559, D4 0.697; AARC-ACLF D1 0.571, D4 0.747). CTP, MELD-Na and MELD-lactate scores also had good predictive utility on day 7 admission (CTP D7 0.684; MELD-Na 0.67; MELD-lactate 0.848). This held true regardless of whether APASL or EASL criteria was applied. In addition, the sequential change in CLIF-SOFA and CLIF-C ACLF scores from day 1 to day 4 was significantly associated with need for urgent transplant or death before discharge.

CONCLUSION:
CTP, MELD-Na and MELD-lactate scores are superior at prognosticating outcomes on day 4 and 7 of admission in our multi-ethnic Asian population. The trend of CLIF-SOFA and CLIF-C ACLF scores from day 1 to day 4 of admission may also contribute valuable information to our assessment of ACLF patients.
1120 Assessment of Risk Factors for Mortality With TIPS Placement: Age or Frailty
Authors: Mahmoud Khalid , Abdel Aal Ahmed Kamel , Osman Sarah , Massoud Moustafa , Bae Sejong , Shoreibah Mohamed 
Published: October 2019

INTRODUCTION:
The Model for End-stage Liver Disease (MELD) score is used for prediction of mortality in cirrhotics undergoing :following transjugular intrahepatic portosystemic shunt (TIPS) placement. Our recent work showed that frailty (measured by psoas muscle density) is associated with increased risk of mortality. Purpose: We performed a post hoc analysis to examine the association of age on mortality in cirrhotics undergoing TIPS placement as there is a tendency to avoid TIPS in older patients with limited data to guide the decision making.

METHODS:
This a retrospective study encompassing 241 patients with cirrhosis who underwent TIPS placement. The patients had two main indications for TIPS placement, variceal bleeding (VB; n = 113) and volume overload (VO; n = 128). The study included 149 men (62%), and mean patient age was 56 years ± 9.6 (range 24–83). Mean MELD score before TIPS creation was 11.8 ± 5.7. Frailty was assessed by measuring psoas muscle density (PD). A threshold sensitivity of pre-TIPS PD for the assessment of mortality was calculated and then correlated with survival after TIPS creation.

RESULTS:
Mean follow up duration was 29.9 month ± 34.1 (range 1–3700 days). The increase in MELD score after TIPS creation was significant in both groups (VB, P = .0013; VO, P < .0001). The threshold of pre-TIPS PD for discrimination of survival was 29.4 HU (P < .0001), and PD measurements greater than this threshold were associated with a lower risk of mortality (HR: 0.27; 95% confidence interval, 0.13–0.57; P = 0.0006). Conversely, age was not associated with mortality (P = 0.2461).

CONCLUSION:
High MELD score and frailty (determined by PD), not age, are associated with mortality in cirrhotic patients undergoing TIPS placement. Further studies are needed to confirm our findings.
1122 Geriatric Bariatrics: Do Post-Operative Patients Remain at Risk for Micronutrient Deficiencies?
Authors: Nath Anand , Shope Timothy R. , Koch Timothy 
Published: October 2019

INTRODUCTION:
We have previously described high prevalence of thiamine deficiency and gastrointestinal symptoms (Nath et al, Nutrition Res, 2017) and of hypovitaminosis D and IBS-like symptoms (Nath et al, Nutrition Res, 2019) in individuals with medically-complicated obesity. As individuals who have undergone bariatric surgery age, it becomes increasingly difficult to obtain blood tests to look for micronutrient deficiencies. Our hypothesis is that older bariatric patients seen for evaluation in gastrointestinal clinic remain at risk for micronutrient deficiencies.

METHODS:
From April 2018 to April 2019, 33 postoperative patients (Gastric Bypass: n = 27; Sleeve Gastrectomy: n = 6) were seen in gastrointestinal clinic in an urban, community teaching hospital. This study included 3 males and 30 females with a mean age of 70 years (SD: 3.4; range 66 to 79), mean body mass index of 35 kg/m 2 (SD: 6.3; range 25.9 to 55.1), and a mean of 11 years since bariatric surgery (SD: 6.7; range 1 to 30). Six patients (22%) had anemia; 5 patients (17%) had weekly or more frequent alcohol use; 12 patients (36%) had a history of diabetes mellitus; 11 patients (33%) were using a diuretic; and 5 patients (15%) were not taking a daily multivitamin. Nine micronutrients were evaluated using commercially available blood testing, but 2 patients did not complete the suggested blood tests.

RESULTS:
Serum folic acid level was elevated in 17 of 22 patients (77%), which supports the presence of small bowel bacterial overgrowth. Hypovitaminosis D was identified in 32 of 33 patients (97%). Low vitamin B12 was identified in 10 of 31 patients (32%). Low vitamin B12 was identified in 10 of 31 patients (32%). Low vitamin A was identified in 3 of 18 patients (16%). Low vitamin E was identified in 4 of 13 patients (31%). Low zinc was identified in 2 of 9 patients (22%) and low iron was identified in 9 of 26 patients (35%), while 10 patients had normal serum copper level. Clinical Vitamin B1 deficiency was identified in 27 of 33 patients (82%).

CONCLUSION:
This study supports our hypothesis that geriatric patients who have undergone bariatric surgery are at risk for multiple micronutrient deficiencies. These results support the notion that ordering of specific micronutrients should focus on thiamine, 25 hydroxy-vitamin D, and serum folic acid in patients evaluated in gastrointestinal clinic. These micronutrients may provide explanations for complaints of gastrointestinal symptoms in this patient population.
1123 Utility of Non-Invasive Screening Tools for Assessing Liver Fibrosis in Individuals With Medically Complicated Obesity
Authors: Nath Anand , Lameda Ivanesa Pardo , Shope Timothy R. , Koch Timothy 
Published: October 2019

INTRODUCTION:
Individuals with medically-complicated obesity are at risk for cirrhosis as the result of chronic nonalcoholic steatohepatitis (NASH). Several cases of acquired ornithine transcarbamylase (OTC) deficiency have been reported after bariatric surgery, and underlying liver disease is hypothesized as a risk factor. Liver biopsy has been the gold standard for diagnosis and staging of fibrosis, but it is not favored as a screening test due to cost, invasive nature of the test. Commercial blood testing for ALT may be useful for screening for NASH, while the NAFLD Fibrosis Score (NFS) has gained popularity to assess fibrosis. We hypothesize that non-invasive screening can identify both at risk individuals in whom bariatric surgery will potentially halt and reverse fibrosis as well as at risk individuals who should be monitored for signs and symptoms of postoperative OTC deficiency

METHODS:
This is a retrospective study of 593 consecutive individuals evaluated for bariatric surgery at our urban, community teaching hospital. Each individual is assessed for risk of liver fibrosis with NFS evaluated at their initial visit. ALT levels are also recorded using ACG guidelines for elevation (women > 25 U/L; men > 33 U/L). Intraoperative liver biopsies were suggested in individuals with elevated ALT levels or NFS which was > - 0.70. Steatohepatitis on liver biopsies is staged based on the NAFLD Activity Score (NAS), which in previous studies is reported to have a sensitivity of 43% to 77%. The potential correlation between NFS and NAS is assessed with simple linear regression (Statview, SAS Institute Inc.).

RESULTS:
Among the 593 subjects, 102 (17.2%) had elevated ALT. Forty-nine individuals underwent liver biopsy (6 for elevated ALT and 43 for NFS > -0.70). Table 1 shows the demographics of these patients. The mean NFS was 0.580 (SD: 1.01) and the mean NAS was 2.9 (SD 1.2). Correlation Coefficient (R: 0.025, P = .86) between NFS calculated at the initial visit and NAS on liver biopsies is not significant.

CONCLUSION:
Elevated ALT levels may be useful for assessment of risk in individuals with medically-complicated obesity. Our retrospective study has not identified a significant correlation between NFS (from routine parameters) and NAS (from liver biopsies). This finding suggests that NFS is not a sensitive non-invasive screening tool in individuals with medically-complicated obesity. Future studies can be designed to utilize ALT levels and NAS to look at the risk of developing postoperative OTC deficiency.
1127 Hepatic Blood Flow and Oxygen Delivery in Metabolic Syndrome
Authors: Zakaria Ali , Wider Michael , Selis James , Williams Michael , Marshall Michael 
Published: October 2019

INTRODUCTION:
Metabolic syndrome MS is defined as the co-occurrence of metabolic risk factors for both DMII and cardiovascular disease. There is no consensus on the diagnostic criteria of the MS due to unclear pathogenesis uniting its components. We propose that compromised hepatic arterial blood supply and oxygen delivery as a response to a nutrient load in patients with MS will lead to hepatorenal activation of sympathetic overdrive, which can be the single common factor in MS pathogenesis

METHODS:
This prospective case-control study included patients 18-65 y/o diagnosed with MS and control healthy individuals with BMI 30-50 kg/m2. Subjects underwent an initial pre-prandial US, followed by drinking 8 oz of TwoCal high calorie drink immediately and in 15 mins. A second post-prandial US was performed 15mins after completing the second drink. US using the standard procedure for mesenteric artery examination for intestinal ischemia was performed to evaluate the diameter, velocity and flow of the superior mesenteric artery, hepatic artery, and portal vein. Both US images were interpreted by experienced diagnostic US radiologist. The results were analyzed using t-test

RESULTS:
Ten MS patients (age 55 ± 8) and ten control subjects (age 38 ± 11) with BMI 30-50 kg/m2 (37.6 ± 6.1) were compared. The relative change in blood flow in response to the nutrient load was reflected by the ratio of post- to pre-prandial readings. Total hepatic blood flow was calculated as the sum of HA and PV blood flow. The mean difference between post to pre-prandial ratio of total hepatic blood flow and total blood flow in all three vessels in MS group vs control group were 1.66 ± 0.57 vs 1.37 ± 0.40 (P = 0.162), 1.80 ± 0.42 vs 1.42 ± 0.27 (P = 0.025); respectively. The increase in postprandial total hepatic blood was 17.65% less in MS group.

CONCLUSION:
Why some obese patients develop MS while others don't raises the question of what is different between these cohorts. Excessive eating can produce obesity by causing chronic relative hypoxia in the liver. This produces sympathetic overdrive which causes insulin resistance, hypertension and dyslipidemia. Bariatric surgeries limit contact of nutrient with the GI mucosa resulting in increased splanchnic O2 delivery to the liver and preventing the hepatorenal reflex. The relative increase in total hepatic blood flow in response to a nutrient load was less in patients with MS compared to healthy obese controls. The difference was not statistically significant. Further studies with larger sample size needed.