bluuebunny/crossref_metadata_2025_split huggingface dataset:
1053 Hepatocellular Carcinoma (HCC) Diagnosis, Treatment and Outcome in a Primarily African American Population
Authors: Jan Jenny , Benjaram Sindhuri , Rutledge Brian , Kutaimy Raya , Philip Philip , Ehrinpreis Murray N. , Mutchnick Milton , Naylor Paul 
Published: October 2019

INTRODUCTION:
HCC is the most common primary liver cancer and five-year survival of HCC depends on the extent of disease and liver reserve. The objective of this study was to determine the impact of racial disparity in identification, treatment and outcome in HCC patients seen in a predominately African American (AA) population.

METHODS:
From a database of HCC patients diagnosed between 2009 and 2017, 227 patients had a sufficient number of visits to identify treatment and outcomes. Date of diagnosis was defined by definitive imaging or biopsy. Tumor size (small = < 5 cm) was used as a surrogate for calculating Child’s-Pugh score in these predominately Hepatitis C cirrhotic patients. Outcomes was determined as death or transfer to hospice, while survival was defined by death only. Patients being sent to transplant (9 AA and 1 Non-AA ) were excluded from the analysis since transplant was at a different institution.

RESULTS:
There were 194 AA and 33 non-AA patients and hepatitis C was the dominant risk factor (n = 192; 85%). Only 29 patients (13%) were diagnosed under even a minimal surveillance protocol defined as a normal ultrasound within 6-12 months prior to diagnosis. AA patients were more likely to have a large tumor burden as compared to non-AA (AA = 74% and Non-AA = 51 %; P < 0.01). A variety of treatments for the HCC were use in the 61% of patients who received treatment. The remaining 39% of patients either died in the hospital prior to treatment or were sent to hospice for palliative care. Median outcome was better for patients with a small tumor at diagnosis, treated patients and for non-HCV patients (Table 1). When survival was evaluated, results were similar (44 months for small tumors vs 10 months for large tumors P < 0.001). Race did not have a major impact on overall outcome (AA = 16 months vs Non-AA = 20 months, P = 0.33) or survival (20 months vs 34 months P = 0.35).

CONCLUSION:
Most patients diagnosed with HCC in this urban medical center presented with large tumors with AA patients likelier to have large tumor burden. Outcome was better for patients with small tumors or who were treated regardless of tumor size. However, overall outcome was similar regardless of race. Our study reaffirms the potential importance of surveillance of high-risk individuals to identify early HCC tumors and thus increase survival in our AA population. Moreover, addressing the major risk factor of HCV by treatment with highly effective DAA would also impact the development of HCC especially in our AA population.
1055 Results of a Hepatitis C Outreach Initiative and Identification of Barriers to Treatment
Authors: Pogosky Alexandra , Wungjiranirun Manida , Molino Janine , Callahan Marlene , Furtado Christina , Shittu Yetunde , Promrat Kittichai 
Published: October 2019

INTRODUCTION:
Over 80% of veterans born between 1945-1965 in the Veterans Affairs system have been tested for hepatitis C (HCV). In December 2016 the Providence VA Medical Center implemented an outreach initiative that targeted veterans who were untreated for HCV. The purpose of this study is to evaluate the impact of the outreach program on HCV treatment initiation rates. The study also aims to identify factors associated with successful linkage to care and barriers to treatment.

METHODS:
Veterans with HCV viremia were targeted for outreach. Outreach entailed mailing letters to patients offering treatment, followed by telephone calls. The outreach team collaborated with primary care providers (PCP), social workers, the homeless clinic, and addiction services. Medical records were reviewed for demographics, disease characteristics and co-morbidities. The primary outcome was initiation of HCV treatment. Differences in characteristics between treated and untreated patients were studied to identify potential treatment barriers.

RESULTS:
334 patients were treated for HCV prior to the start of the outreach initiative in December 2016. The outreach program targeted 175 patients with untreated HCV. Among these 175 patients, 116 (66.3%) were initiated on treatment, while 59 (33.7%) were not. Characteristics associated with treatment initiation include presence of psychiatric co-morbidities (P = 0.055), history of substance use (P = 0.03), and having a PCP located in-state (P = 0.02). Patients treated before the outreach initiative had higher rates of cirrhosis (P = 0.001), and higher APRI (P = 0.01), FIB-4 (P = 0.001), and Fibroscan scores (P = 0.001).

CONCLUSION:
The outreach program successfully initiated treatment in two-thirds of targeted patients. Prior to the program, HCV treated patients had higher rates of cirrhosis and more advanced liver disease based on non-invasive markers. This disparity may be related to increased screening in high-risk populations or a higher likelihood of establishment in the hepatology clinic. These findings suggest that outreach may improve access for patients who do not see a hepatologist. Higher rates of substance use and psychiatric disease in patients who were treated highlight the impact of coordinating care with mental health and addiction specialists. The data also shows that having a PCP out-of-state or not having a PCP listed is associated with non-treatment. Training more local providers in HCV management may aid in increasing treatment rates.
1056 Incorporation of Obesity Management into the Care of Patients With Nonalcoholic Steatohepatitis: The Yale Fatty Liver Disease Model
Authors: Mankash M. Salah , Kelly Maureen , Dean Jessica , Duffy Andrew J. , Mehal Wajahat Z. , Do Albert 
Published: October 2019

INTRODUCTION:
Nonalcoholic fatty liver disease (NAFLD) is fundamentally a disease of excess weight and is worsening in tandem with the obesity epidemic. Nonalcoholic steatohepatitis (NASH) places patients at risk for advanced fibrosis and cirrhosis and the most effective treatment is weight loss, but there is limited efficacy data of clinical care models incorporating obesity management into hepatology practice. We aim to report clinical characteristics and outcomes from the Yale Fatty Liver Disease Program which incorporates all aspects of medical and surgical weight loss into the management of patients with NASH.

METHODS:
Patients from local and community practices were referred to the Yale Fatty Liver Disease Program, which provides comprehensive hepatology as well as nutritional, medical, and surgical care for obesity. We included patients seen for initial evaluation from 7/1/2018 to 10/31/2018, and extracted data on clinical characteristics, care provision, and changes in weight and alanine aminotransferase (ALT) levels.

RESULTS:
62 patients diagnosed with NASH, who were followed for median 112 days: 32 (52%) males, average age 55 ± 10.6 years, and body mass index (BMI) 35.4 ± 6.1 kg/m2, 4 (12%) had a new diagnosis of cirrhosis. Obesity related comorbidities were prevalent: 38 (62%) hypertension, 33 (53%) dyslipidemia, 11 (18%) diabetes mellitus, 19 (31%) obstructive sleep apnea. In this cohort, 40 (64%) received referral to a dietitian, 4 (6%) initiated meal replacement therapy, 14 (23%) were prescribed weight loss medications, and 19 (31%) were referred to bariatric surgery. Of those referred to bariatric surgery, 8 (13%) received surgery, 5 (8%) declined surgery, and 6 (10%) are currently undergoing evaluation. Average weight loss was as follows: Overall 5.1 ± 6.4 lbs, lifestyle alone 8.8 ± 16.7 lbs (paired t-test comparing start with final P = 0.008), WLM 10.8 ± 19.6 lbs (P = 0.003), bariatric surgery 52 ± 5.5 lbs (P = 0.008). On last follow up, average serum ALT decreased by average 33 ± 47 U/l (P = 0.008).

CONCLUSION:
A hepatology clinic incorporating the full range of weight loss options can provide effective treatment of NASH when additional modalities such as weight loss medications and bariatric surgery are utilized. Further study of this practice model would inform specific measures hepatologists can undertake to optimize weight loss while concurrently treating chronic liver disease.
1062 Improvement in Reliability of Acoustic Radiation Force Impulse Elastography Studies Using Feedback and Benchmarking: A Single Center Experience
Authors: Rahman Asad Ur , Zahid Effa , Wasser Elliot 
Published: October 2019

INTRODUCTION:
Periodic feedback and use of standardized benchmarks has historically been used to improve quality of various diagnostic studies including screening colonoscopy. Acoustic radiation force impulse (ARFI) elastography is utilized as an important non invasive test to quantify the degree of liver fibrosis. Since this is dependent on obtaining accurate and reliable readings from radiology technicians, we aimed to improve the reliability of clinically significant studies which are defined as at least ten readings with an interquartile range of <0.3.

METHODS:
We initially did a retrospective analysis of all ARFI elastography studies performed at our center over the course of January and February 2018 in order to assess baseline performance. We subsequently shared individual data with each radiology technician in March 2018. We also recommended that technicians who performed with < 50% reliability should shadow their colleagues who were able to get reliable readings beyond 75%. We then longitudinally followed the quality of studies over the ensuing few months. We repeated the same intervention in July 2018 to see if there was any attrition in response. Follow up was then done up until December 2018 to assess performance of studies.

RESULTS:
186 ARFI studies were completed over the course of 12 months. 12 radiology technicians were involved in performed these studies (range 5-25 exams). Average BMI of patients undergoing the exam was 29.2 (range 16.3 to 45.2). No difference was seen in terms of reliability in obese patients. The proportion of reliable studies (10 or more readings with IQR < 0.3) was 44% in January. After the first session of feedback, this proportion increased to 78% in April. However, it decreased to 43% in July at which point a second formal session of feedback was done. A subsequent increase was noticed with reliable studies going up to 70% in August. However, this improvement did not remain sustained with decline in performance to 43% in December.

CONCLUSION:
Based on this study spanning a total of 12 months, we demonstrate that providing feedback to individual technicians and tutorials by high performing technicians leads to improvement in overall performance. Albeit, this effect is not sustained if provided intermittently. This calls for regular feedback and follow up over longer duration to assess for more sustained improvement. This would in turn translate into a diminished need for repeat testing which would curtail cost and patient time as well as need for liver biopsy.
1065 Thirty-Day Readmissions in Patients Admitted With Hepatic Encephalopathy Between 2010-2015: A Study From the Nationwide Readmission Database
Authors: Elkafrawy Ahmed A. , Kaddourah Osama , Kennedy Kevin F. , Likhitsup Alisa 
Published: October 2019

INTRODUCTION:
Hepatic encephalopathy (HE) is a common diagnosis of hospital admissions. Our aim in this study is to identify trends, causes and predictors of 30-day readmissions in patients admitted with HE.

METHODS:
The Nationwide Readmissions Database (NRD) was queried to identify index admissions with HE between 2010-2015 using the ICD-9 code 572.2. All the patients non-electively admitted within 30 days of Index admission were included. We excluded patients who died during their index admission or left against medical advice. Chi-Square, Fisher’s Exact and Student-t tests were used for statistical analysis to compare baseline characteristics among patients with and without 30-day readmission. Multivariate logistic regression models were used to predict factors associated with readmissions. All analyses were performed with SAS 9.4 (Cary, NC).

RESULTS:
We identified 196,730 eligible index admissions. The 30-day readmission rate was 29.4% and stable over time (Figure 1). Median (IQR) age was 60 (52, 68) years, 42% were female and the median length of stay was 5 (3, 10) days. Among patients with 30-day readmission, there is a higher proportion of patients with Medicaid (23.5 vs 20%, P < 0.001), residing in the metro area (32.3 vs 29.5%, P < 0.001), being discharged from metro-teaching hospital (P < 0.001). The hospital bed size and ownership setting were similar between the groups. The proportion of patient readmitted to the hospital was lower among patients who were discharged to a skilled facility (24 vs 27%, P < 0.001) but higher among patients who were discharged to home with self-care (53 vs 50%, P < 0.001). The main reason for 30-day readmission was liver disease-related complications (37.6%), followed by sepsis, mental health or substance use disorder (Figure 2). Multivariate analysis showed Metro-teaching hospital, presence of diabetes, renal failure, presence of ascites, required paracentesis, presence of portal hypertension were predictive factors associated with 30-day readmissions (Table 1).

CONCLUSION:
Approximately a third of patients admitted with HE were readmitted to the hospital, and the trend has been stable over a 6-year period. From our study, health-care provider education in the metro-teaching hospitals regarding cirrhosis, renal failure, and ascites management will likely improve 30-day readmission rate among patients with HE.
1067 Use of Obeticholic Acid in Patients With Primary Biliary Cholangitis: A Systematic Review and Meta-Analysis
Authors: Anugwom Chimaobi , Dirweesh Ahmed , Singh Dupinder , Levy Cynthia , Sultan Shahnaz 
Published: October 2019

INTRODUCTION:
Obeticholic acid (OCA), a farnesoid-X receptor agonist, has been approved for the management of PBC since 2016. It has been shown to significantly decrease serum alkaline phosphatase (ALP) and total bilirubin levels in patients with primary biliary cholangitis (PBC), either alone or in combination with ursodiol. Data on the efficacy of OCA in PBC is limited. We conducted a systematic review and meta-analysis to evaluate the efficacy of OCA in patients with PBC.

METHODS:
We searched PubMed, Cochrane and Embase databases for randomized control trials (RCTs) comparing OCA to placebo in the management of PBC through 2019. The Cochrane Risk of Bias tool was used to assess the quality of the RCTs. We estimated odds ratio (OR) with 95% confidence interval (CI) for each outcome using a random effects model. The quality of the evidence was assessed using the GRADE approach.

RESULTS:
A total of 3 randomized controlled trials including 440 patients were identified. The mean age of patients was 54 and follow up ranged from 3-12 months. The studies varied with respect to whether OCA was used as monotherapy or added to standard of care (ursodiol). Compared to placebo, OCA resulted in reduction of ALP to < 1.67X the ULN with an OR of 5.92 (CI 2.98 – 11.94, P < 0.00001); and 1.76X the ULN with an OR of 5.95 (CI 3.25 – 10.93; P < 0.00001). Across the three studies, patients on OCA experienced higher rates of pruritus as compared with placebo. The overall certainty of evidence was moderate. Data on clinical endpoints such as quality of life, progression to cirrhosis or liver transplantation, and mortality were lacking.

CONCLUSION:
Obeticholic acid is superior to placebo in reducing ALP in patients with PBC. An important limitation in these studies is the lack of data on clinical endpoints however, ALP levels have been shown to correlate with risk of liver transplantation and death. More RCT data with longer follow up is needed to fully assess the net benefits and harms of OCA in patients with PBC.
1069 Overutilization of CT Scan of the Brain in the Diagnosis of Hepatic Encephalopathy: Choosing Wisely
Authors: Khan Ahmad , Sohail Abdullah , Cipriani Allison , McDaniel Bryce A. , Farooq Junaid , Chowdhry Monica , Singh Shailendra 
Published: October 2019

INTRODUCTION:
Hepatic encephalopathy (HE) is a clinical diagnosis and rarely requires neuroimaging. Hepatic encephalopathy (HE) is the most common diagnosis for patients with cirrhotic patients presenting with altered mental status (AMS). It is a clinical diagnosis, and computed tomography (CT) of the brain does not contribute to the diagnostic or grading information. However, patients with cirrhosis are at increased risk of intracerebral hemorrhage, and therefore, CT scans are usually performed to rule out other etiologies of AMS, which may lead to overutilization of CT scans. There is limited data on the magnitude and yield of CT scan utility in the workup for HE. This study aims to assess the magnitude and yield of CT scan for the workup of HE in a large tertiary care hospital.

METHODS:
An electronic medical query for adult patients discharged from our center between September 2016 to June 2019 with ICD-10 codes for liver cirrhosis and its complications was made. A total of 300 patient charts were randomly selected for detailed review. Patients with an established diagnosis of advanced dementia, stroke, intracranial tumor, or bleed were excluded. We collected patient demographics, admission records, readmissions, laboratory values, and imaging records.

RESULTS:
A total of 214 patients met our search criteria. Out of these, 64 patients admitted with a complaint of AMS were included in the final analysis. The mean age of these patients was 61 ± 9 years, and 54% were males. A total of 152 HE-related hospitalizations were recorded for these 64 patients (an average of 2.3 admissions per patient). In the study duration, a total of 178 brain CT scans were performed for 152 hospitalizations. Out of the total 178 scans, only 2 CT (1.1%) scans revealed intracranial bleed leading to change in diagnosis or management. Notably, 12 (18.75%) patients had multiple CT scans during a single hospitalization.

CONCLUSION:
The yield of CT scan brain in patients with an established diagnosis of hepatic encephalopathy is low (1%) and usually does not influence the diagnosis or management. CT scans are likely overutilized, leading to unnecessary excessive radiation exposure to the patients and increases the total costs of hospitalization. Institutional efforts should be implied for the judicious use of CT scans in patients with HE. Further large multicenter studies are needed.
1073 Integration of Cirrhosis Best Practices Into Electronic Medical Record Associated With Reduction in 30-Day Mortality
Authors: Sherman Zachary , Wahid Nabeel , Soltani Amin K. , Wagner Michael , Jesudian Arun 
Published: October 2019

INTRODUCTION:
Hospital admissions for patients with cirrhosis continue to increase. In New York City, 25-30% of hospitalized cirrhotics are readmitted within 30 days. Re-hospitalization is associated with increased mortality, poor quality of life, and financial burden to patients, hospitals, and payers. Preventable readmissions are partially accounted for by a well documented quality gap between evidence based guidelines for cirrhosis management and real world adherence to these recommendations.

METHODS:
We performed a prospective cohort study that compared outcomes among cirrhotic patients admitted to four internal medicine teams over a 6-month period. An electronic medical record (EMR) note template that outlined best practice measures for cirrhotics was developed. Inpatient providers on two teams were instructed to include it in daily progress notes and discharge summaries. The recommended practices included diagnostic paracentesis and diuretics for ascites, rifaximin and lactulose for hepatic encephalopathy, beta blockers for esophageal varices, and antibiotic prophylaxis for spontaneous bacterial peritonitis. The remaining two teams continued standard of care of cirrhotic patients. The primary outcome was 30-day readmissions. Secondary outcomes included in-hospital mortality, 30-day mortality, length of stay, and adherence to best practice guidelines.

RESULTS:
Over a 6-month period, 108 cirrhotic patients were admitted, 83 in the interventional group and 25 in the control group. MELD-Na scores on admission did not differ between the groups (20.1 v 21.1, P = 0.57). Thirty-day readmissions were not significantly different between the interventional and control groups (19.3% v 24%, P = 0.61). However, 30-day mortality was significantly lower in the interventional group (7.2% v 24%, P = 0.02). There was no difference between the two groups in in-hospital mortality (3.6% v 0%, P = 0.34) or length of stay (10.2 days v 12.6 days, P = 0.34). Adherence to best practice metrics was similar between the groups, except for rates of diagnostic paracentesis, which were higher in the interventional group (98% v 80%, P = 0.01).

CONCLUSION:
Implementation of an EMR note template with cirrhosis best practices was associated with lower 30-day mortality and higher rates of diagnostic paracentesis among admitted patients with cirrhosis. These findings suggest that integration of best practice measures into the EMR may improve outcomes in hospitalized cirrhotic patients. Larger studies are required to validate these findings.
1079 Advanced HCC Management in Clinical Practice Evolves Beyond BCLC Guideline
Authors: Al-Omary Ahmed , Cheng Robert 
Published: October 2019

INTRODUCTION:
Hepatocellular carcinoma (HCC) represents 90% of all primary liver cancer and is the fifth commonest malignancy. BCLC staging and treatment recommendations have been adopted worldwide as standard of care for HCC management. Hence, Australian practice was reviewed over heterogeneous period of time in two main tertiary centres; Royal Prince Alfred Hospital (RPA) and Westmead Hospital (WM).

METHODS:
After obtaining ethics approval, 838 patients underwent active HCC surveillance, with 597 being followed-up at WM and 241 being followed-up at RPA. Cirrhosis staging and HCC staging were recorded as well as treatment received and survival outcomes of the 95 patients who developed HCC.

RESULTS:
More than half of the HCC patients (61%) were BCLC stage 0 or A at diagnosis when they are eligible for curative treatments. BCLC-0 patients were appropriately treated with liver resection or locoregional therapy (LRT). All achieved adequate disease control without requiring further therapy. BCLC-A patients were treated with liver resection, liver transplant (LT) and LRT at a rate of 24%, 9% and 63% respectively. Half of the liver resection patients had HCC recurrence and required LRT, but eventually went on to have sorafenib. Two patients from the LRT primary treatment group (7% of this subgroup) went on to have sorafenib. Deviating from BCLC guideline, one patient (8%) from the BCLC-B group received liver transplant and continued to enjoy cancer-free survival. Two patients (17%) from BCLC-B group had liver resection; one of them had HCC recurrence and received sorafenib as salvage therapy. Only a quarter of BCLC-C patients received sorafenib as primary therapy in accordance with BCLC guideline. The other 75% of BCLC-C patients received LRT first, and eventually went on to have sorafenib as secondary treatment. Most surprisingly, as primary treatment two of the 17 BCLC-D patients (12%) received sorafenib and 7 (17%)received LRT. Only 8 of them (47%) were managed according to BCLC guideline and received palliative care first.

CONCLUSION:
In this multi-centre HCC cohort, BCLC-0 and A patients were treated in accordance with BCLC guideline. However, some of our BCLC-B patients also received LT or liver resection and enjoyed positive survival outcome. Interestingly, the majority of BCLC-C and 17% of BCLC-D patients received LRT. The difference in practice may be attributed to increasingly published data on survival benefits of giving LRT to BCLC late stage patients.