bluuebunny/crossref_metadata_2025_split huggingface dataset:
1038 Outcomes of Non-Alcoholic Steatohepatitis in African American Patients With Human Immunodeficiency Virus (HIV)
Authors: Ajose Taiwo A. , Kagbokue Suaka , Abe Temidayo , Ajose Afolarin , Richter Seth 
Published: October 2019

INTRODUCTION:
Non-alcoholic steatohepatitis (NASH) is the hepatic manifestation of metabolic syndrome and is highly prevalent in patients with HIV, ranging from 13% to 55%. According to the center for disease control and prevention (CDC), in 2016 African Americans(AA) had the highest rate of HIV diagnosis (44%).Minorities are disproportionately affected by HIV and have a higher risk of developing NASH and progressive liver disease. Data on the outcomes of NASH in AA patients with HIV and the disease progression is scanty and poorly studied.

METHODS:
We retrieved data from the Nationwide Inpatient Sample (NIS) database for the year 2012.The study group consisted of AA patients between ages 18–75 years with NASH and HIV/AIDS (n = 138). Control group included subjects with NASH alone (n = 3681). Our outcomes of interest were: overall mortality, Ascites, Hepatocellular carcinoma (HCC), End stage liver disease (ESLD), Hepatic encephalopathy (HE), Liver cirrhosis and Portal hypertension. All clinical characteristics were defined as per the International Classification of Disease 9th revision (ICD-9) codes. Logistics regression analysis was used to estimate the adjusted odds ratio (aOR) of outcomes amongst participants with coexisting NASH/HIV while accounting for comorbidities and this was compared to those with NASH alone.

RESULTS:
The mean age sample was 49 ± 12 (61% female, 39% male). The rates of ascites were higher among those with NASH/HIV compared to NASH alone (10.1% vs 4.6%, P < 0.005). After adjusting for comorbidities, the aOR for hepatic encephalopathy 1.232 (0.379-4.009), ascites 1.753 (0.962-3.196) and portal hypertension 2.258 (0.276-18.465) was higher in NASH/HIV group compared to NASH alone. Stratified analysis based on age and sex revealed that females with NASH/HIV have a statistically significant higher odd for ascites; age 18-45, aoR 4.752 (2.155-10.478) and portal hypertension age 46- 75 aoR 19.832 (1.182 - 332.644) compared with NASH alone.

CONCLUSION:
African American female patients with NASH coexisting with HIV were at a higher risk for portal hypertension and ascites when compared to those with NASH alone. Further studies will look to evaluate and mitigate the impact of HIV on NASH in this patient population.
1041 Implementation of a Chronic Hepatitis Panel to Improve Viral Hepatitis Screening in Chronic Liver Disease
Authors: Umapathy Chandraprakash , Pham Jonathan , Stokes Linda , Roytman Marina 
Published: October 2019

INTRODUCTION:
In 2015, 40,326 or 12.5 per 100,000 population died from chronic liver disease. Viral hepatitis is associated with 18.5% of chronic liver disease related deaths. The vast majority of patients with liver disease present in the chronic phase, however, Community Regional Medical Center was using an acute hepatitis panel (HAV Ab IgM, HBsAg, HBcAb IgM, and HCV Ab) to evaluate for viral hepatitis. We created and implemented a chronic hepatitis panel (HAV Ab Total, HBsAg, HBsAb, HBcAb Total, and HCV Ab) with the aim of improving screening for chronic viral hepatitis, identifying patients at risk for HBV reactivation and patients in need for HAV and HBV vaccinations.

METHODS:
Baseline clinical and laboratory data including the number of acute hepatitis panels were collected from July 2017 to June 2018. Post-implementation data were collected from November 2018 to April 2019. The primary outcome was the utilization of the appropriate hepatitis panel to the presenting clinical syndrome. Secondary outcomes were vaccination rates for HAV and HBV in the setting of chronic liver disease and healthcare cost utilization of patients with chronic liver disease.

RESULTS:
Of 17,357 patients screened, acute hepatitis panel was ordered in 40.2%, mainly in the emergency department (42%) and inpatient (40%) setting. Of these, 26.9% of acute hepatitis panels were ordered with ALT < 150 or prior to ALT results. 64.7% of patients completed chronic hepatitis panel components afterward. Chronic hepatitis panel components were ordered more than once in 47.4%. Post-implementation data was collected in 6298 patients of which, 14% completed the chronic hepatitis panel. There was a 220% increase in the number of chronic hepatitis panels ordered, from November 2018 to April 2019. The average number of hepatitis labs (panel or components) ordered per patient decreased from 3.4 to 2.2 post implementation of the chronic panel. The cost for the chronic hepatitis panel is $214.20 compared to $325.38 for the acute hepatitis panel, reflecting a cost savings of 34% per panel. This is in addition to the projected savings from the decrease in the inappropriate ordering of labs.

CONCLUSION:
The chronic hepatitis panel can improve screening for chronic viral hepatitis, and potentially improve vaccination rates against Hepatitis A and Hepatitis B, as well as help prevent HBV reactivations, while lowering costs, in chronic liver disease. Longitudinal studies are needed to assess the impact of chronic hepatitis panel on disease outcomes.
1043 Effect of Dose Modification of Ribavirin on SVR 12 in Difficult to Treat Patients on Sofosbuvir, Daclatasvir Based DAA Therapy for Chronic HCV
Authors: Nawaz Arif , Iqbal Haseeb , Khan Zohaib , Riaz Saherish , Chowdhry Asad , Ali Bushra , Nawaz Shahmeer , Chaudhry Hafsa 
Published: October 2019

INTRODUCTION:
DAAs are recommended as the first line treatment for chronic HCV with SVR rates >95%. Certain groups of patients, cirrhotics and treatment failures, continue to pose challenges for health care providers. In spite of a relatively poor tolerability, weight based Ribavirin has been recommended in these difficult to treat patients. We conducted a study to determine the effect of Ribavirin dose modification on SVR in these patients.

METHODS:
This was a retrospective chart review of cirrhotic (treatment experienced and naïve) and non-cirrhotic (treatment experienced) HCV patients on Sofosbuvir, Daclatasivir and Ribavirin. Patients aged 18 to 80 were included while those with HCV/ HBV or HCV/ HIV co-infection were excluded. Data was collected using a structured questionnaire and frequencies and percentages were calculated to examine the responses.

RESULTS:
A total of 100 patients (54 M, 46 F) receiving triple combination of Sofosbuvir, Daclatasvir and Ribavirin for HCV were included. There were 65 non-cirrhotic (all treatment experienced) and 35 cirrhotic patients (22 treatment naïve, 6 relapsers and 7 non-responders). In the cirrhotic group 81.6% of patients achieved SVR 12 (84% treatment naïve, 81% treatment experienced and 80% non-responders). .Amongst the treatment naïve cirrhotics, SVR was 100% and 71% respectively in the moderate (600-1000 mg) and low dose groups respectively. All 9 treatment experienced, 4 relapsers and 5 non-responder, received low dose Ribavirin with an SVR of 80% and 62.5% respectively. Amongst the 65 non-cirrhotic patients, SVR 12 was 91% with no patients on low dose Ribavirin. In the relapser group SVR was 100 % in the high dose Ribavirin group that dropped to 50% in the 2 patients having received moderate dose of ribavirin. In the non-responder group (total of 41 patients) 38 patients received high dose (SVR 95%) and 3 patients received moderate dose of ribavirin (SVR 43%)

CONCLUSION:
Ribavirin continues to play an important role in resource constrained countries due to its efficacy as part of the most cost-effective Sofosbuvir/ Daclatasvir based DAA therapy for HCV. Our study reemphasizes the need for treating difficult to treat HCV patients with the maximum possible dose of Ribavirin that can be tolerated by these patients. Dose reduction in these difficult to treat patients compromises the outcome and should be discouraged. Various measures to improve the tolerability of Ribavirin should be instituted in order to achieve higher SVRs.
1045 BMI Is an Independent Predictor for the Occurrence of HCC Following DAA Therapy in HCV Related Cirrhosis
Authors: Shrestha Shreesh , Dhungana Yogesh , Ali Bilal , Satapathy Sanjaya Kumar 
Published: October 2019

INTRODUCTION:
Treatment for Hepatitis C Virus (HCV) has made a significant stride with the advent of direct-acting antiviral (DAA) therapy with SVR rates higher than 95%. Despite such a big feat, questions have been raised regarding the rate of occurrence and recurrence of HCC following treatment with DAA, especially in those with cirrhosis.

METHODS:
Using our database, we first identified all patients with liver cirrhosis secondary to HCV with no prior history of HCC, who were treated with DAA between 01/01/2014 to 04/01/2018 at our institution. We then performed a detailed review of their electronic medical records and obtained relevant clinical data. Patients who developed HCC in the follow-up period were identified. HCC screening was carried out every 3-6 months with US or CT abdomen. Categorical variables were calculated as frequencies(percentages), and continuous variables were calculated as median (range). Cumulative incidence of de novo HCC was calculated using the Kaplan-Meier method. Univariate and multivariate Cox regression analysis was performed to identify predictors for the development of HCC.

RESULTS:
We identified 254 patients meeting the criteria mentioned above. The basic demographics and key variables were identified and computed for those with and without the occurrence of HCC, as shown in Table 1. The two groups were quite similar in terms of the different variables that were studied. The patients had a median follow up of 21 months (3-55 months) following the start of DAA therapy. Sixteen patients subsequently developed de novo HCC with an occurrence rate of 6.3%. The cumulative incidence of HCC at 1,2 and 3 years of follow up are 1.6%, 6.6 %, and 11.3 %, respectively (Figure 1). Univariate analysis revealed a higher BMI of > 30, was statistically significant (P value = 0.047) for an association with the occurrence of HCC ( HR of 4.06 with a CI of 0.9-18.19) (Figure 2). The median time to the occurrence of HCC following DAA therapy was 17 months. Multivariate analysis was performed to analyze the interaction between different variables on HCC occurrence, namely BMI, CHILD class, AFP, and Viral load, which did not reveal any significant association.

CONCLUSION:
Of the various risk factors that have been identified for de novo HCC occurrence, our study identified higher BMI as an independent risk factor for HCC occurrence. Further large-scale prospective studies should be performed to identify and confirm these risk factors associated with increased HCC occurrence.
1052 Delayed Paracentesis Is Common for Patients With Spontaneous Bacterial Peritonitis: A Multicenter Retrospective Experience
Authors: Abdu Backer , Akolkar Shalaka , Picking Christopher , Boura Judith , Piper Marc 
Published: October 2019

INTRODUCTION:
In cirrhotic patients, spontaneous bacterial peritonitis (SBP) is associated with significant mortality. Additional studies have also shown that delayed diagnosis (due to delayed paracentesis (DP)) has been associated with worse outcomes and mortality. We aimed to assess how often patients with SBP had delayed paracentesis. We also assessed for factors associated with DP.

METHODS:
Retrospectively studied patients who were hospitalized in 4 community hospitals with SBP, using ICD 9/10 codes, between 12/2013 and 12/2018. We excluded patients who were found to have other contributing causes of peritonitis. Delayed paracentesis was defined as a paracentesis that occurred > 12 hours from initial encounter. Data collected included: (1) patient factors (i.e., age, race, gender, etiology of liver disease, history of SBP and MELD; and (2) physician factors (i.e., admission service, shift times, and types of providers performing paracentesis (interventional radiology (IR), emergency department (ED) or other). Multivariable logistic regression analysis was performed to assess for factors associated with DP.

RESULTS:
A total of 119 patients were found to have SBP. Delayed paracentesis occurred 78% of the time (n = 93). The median time to paracentesis for patients with SBP was 26 hours (IQR = 14-57). Of the patients who received DP, 54% were male, 58% were Caucasian and 90% were performed by IR (P < 0.01). In comparison, early paracentesis was more often performed by the ED provider. In regression analysis, the factor most associated with delayed paracentesis was IR service performing paracentesis procedures (OR: 82; 95% CI 7.68 - 883). Factors associated with less DP was a known previous history of SBP (OR: 19.4; 95% CI 1.4 - 266.4).

CONCLUSION:
Previous studies have suggested that DP is associated with increase mortality in patients with SBP. Despite this, DP is common in the community setting and is often due to paracentesis being performed by IR rather than the ED or admitting service. Future studies are needed on how to best implement faster recognition and urgent diagnostic paracentesis in this setting.
1054 Prognostic Value of NIACE Score in Patients With Hepatocellular Carcinoma Undergoing Transarterial Radioembolization
Authors: Lynch Jeffrey M. , Thandassery Ragesh , Beheshti Michael V. 
Published: October 2019

INTRODUCTION:
The NIACE score provides prognostic value for hepatocellular carcinoma (HCC) undergoing TACE. We aimed to evaluate the prognostic value of the NIACE score in patients undergoing Transarterial Radioembolization with Yttrium-90 (TARE).

METHODS:
In a retrospective multicenter study from the US, patients with HCC undergoing TARE as their initial intervention between January 2012 and April 2019 were analyzed. The NIACE score was calculated according to the Nodularity, tumor Infiltration, Alpha-fetoprotein level, Child-Pugh score, and ECOG score. Patients were stratified in low (<2.5) medium (2.5 to 3) and high risk (≥4) groups. The prognostic values of NIACE score for overall survival according to individual treatment and the Barcelona clinic liver cancer (BCLC) staging were analyzed.

RESULTS:
A total of 116 patients (85.3% males) were included with a median follow-up of 21.7 (range 78.5) months. Predominant etiology for liver disease was Hepatitis C virus infection (52, 44.8%) followed by alcohol (23, 19.8%). A total of 39 (38.2%), 29 (28.4%), and 33(32.4%) patients had BCLC A, B, and C stages respectively. The median MELD score was 9 and the range is 25. Overall transplant free survival (TFS) was 55.4% (n = 56); BCLC A, B, and C stages had 64.1%, 62.1%, and 39.4% survival respectively. Predictive accuracy of different NIACE score groups and BCLC stages were comparable and showed no significant difference (logrank, P = 0.73). Stratified analysis of NIACE score groups within individual BCLC stages also didn’t reveal any significant difference in TFS (BCLC A, logrank P = 0.47; BCLC B, logrank P = 0.87; and BCLC C, logrank P = 0.15).

CONCLUSION:
In our study of patients with HCC undergoing TARE, the TFS predicted by the NIACE score groups were comparable with BCLC staging system. The proposition that in TARE treated patients NIACE score could aid in treatment allocation by adding additional granularity to BCLC may need further studies.
1059 Effects of HCV Eradication on Glycemic Control in Type 2 Diabetics
Authors: Joshi Tejas V. , Roessler Eric , Das Anushka , Cefalu John , Raines Daniel 
Published: October 2019

INTRODUCTION:
A meta-analysis of 34 studies estimated that the risk was increased by almost 70 percent in HCV-infected patients compared with non-infected controls. Insulin resistance has been hypothesized to develop via a multimodal pathway. The virus itself causes this through serine and threonine phosphorylation of insulin receptor substrate-1. Hepatitis creates a ubiquitous inflammatory state by releasing proinflammatory cytokines such as interleukin-6 and tumor necrosis factor-α, which upregulates gluconeogenesis. We aimed to analyze the unique patient population cared for at Louisiana State University diagnosed with DM2 and HCV who have completed direct-acting antiviral treatment with a sustained viral response (SVR). We attempted to establish a connection between a SVR and improved glycemic control and quantify the variations in HbA1C.

METHODS:
Using ICD 9/10/CPT codes the study included all patients with DM2 who underwent HCV treatment with DAA. SVR was achieved in all patients using non-ribavirin and non-interferon based therapies. SVR was defined as viral load below the lower limit of quantification after the completion of treatment. Treatments varied between 8 weeks and 12 weeks. We further divded the patient population into two groups and statistically analyzed patients with Severe Fibrosis/Cirrhosis to those without. Comparative analysis and Fisher’s exact test was performed.

RESULTS:
The F-test for increase in Metavir score correlated with a mean drop of 0.5% in HbA1c gives a P Value of 0.01652. DM2 Pts who achieved SVR had an overal drop in HbA1C of 0.39 (P = 0.009), while Cirrhotics experieces the largest median decrease 0.65% (P = 0.004). SF/Cirrhotic patients experienced the largest drop in median Isulin requirements post-treatment, decrease of 6.32 Units (P = .206). SF/Cirrhotic patients also experienced the largest median decrease in number of classes of anti-diabetic medications (P = .445).

CONCLUSION:
Analysis revealed statistically signficant results in regards to reduction in HbA1C, with the greatest benefits experiened by the SF/Cirrhotic cohort.The improvement in microvascular complications in diabetics with a reduction in HbA1C has been confirmed by multiple studies. An increase in the number of investigations with similar findings can assist insurance companies in completing a risk benefit analysis in providing full treatment compensation to all HCV patients with concomitant DM2.
1063 Clostridioides difficile Infection in Liver Cirrhosis: A Multiyear Nationwide Analysis
Authors: Aloreidi Khalil , Barakat Mohamed , Ramai Daryl , Xie Chencheng , Aamar Ali , Reddy Madhavi 
Published: October 2019

INTRODUCTION:
For the past two decades, the incidence and severity of Clostridium Difficile Infection (CDI) have been increasing. Many risk factors have been identified in an effort to explain this phenomenon including broad-spectrum antibiotic therapy, prolonged hospitalization, immunosuppression, multiple comorbidities, and use of proton pump inhibitors (PPIs). Interestingly, all these factors occur frequently in patients with liver cirrhosis.

METHODS:
The Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (2010-2014) was used for this analysis. Patients discharged with a diagnosis of cirrhosis and CDI were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes (ICD-9-CM). Our primary outcomes were the prevalence of CDI and the effects of CDI on inpatient mortality. Our secondary outcomes were the length of stay and hospitalization charges. Categorical variables were compared using the chi-square test, and continuous variables were compared using student t-test. The analysis was performed with SPSS 25 (IBM, USA).

RESULTS:
Over the study period, a total of 738,199 patients with liver cirrhosis were identified. Among those, 15,791 had CDI. Cirrhosis patients with CDI and Cirrhosis patients without CDI had comparable mean age, sex, and race (Table 1). The prevalence of CDI was 2.1% among the cirrhosis population compared to 1.1% in the non-cirrhosis population with unadjusted OR of 1.95 (95% CI 1.92 to 1.98, P < 0.0001). CDI among patients with cirrhosis was associated with a higher mortality rate of 12.1% compared to 6.7% in cirrhosis-only patients (OR 1.91, 95% CI 1.82 to 2, P < 0.0001). The mean length of stay was higher in cirrhosis patients with CDI compared to cirrhosis-only patients (12.79 days vs 6.25 days, P < 0.0001). The mean hospitalization cost was also higher in cirrhosis patients with CDI ($117661.51 vs $56241.81, P < 0.0001). After adjustment for patient characteristics on a multivariable analysis (Table 2), CDI was independently associated with higher mortality among patients with cirrhosis (OR 1.88, 95% CI 1.79 to 1.97, P < 0.0001).

CONCLUSION:
The prevalence of CDI is higher for cirrhosis patients compared to non-cirrhotics. CDI among cirrhosis patients was associated with nearly twice the mortality rate compared to cirrhosis-only patients. Similarly, the mean length of stay and mean hospitalization cost were significantly higher in cirrhosis patients with CDI.
1068 Ethnic Minorities With Primary Biliary Cholangitis in the U.S. Are More Likely to Be Hospitalized at Higher Safety-Net Burden Hospitals
Authors: Galoosian Artin , Hirode Grishma , Wong Robert 
Published: October 2019

INTRODUCTION:
Primary biliary cholangitis (PBC) is a progressive cholestatic liver disease associated with significant morbidity; its progression to cirrhosis and its complications contributes to significant healthcare resource utilization. Underserved communities, which include safety-net hospital populations, represent a major contributor to healthcare costs in the US. We aim to evaluate ethnic disparities by safety-net burden (SNB) and associated hospitalization costs.

METHODS:
Using the 2012-2014 National Inpatient Sample, we evaluated US adults hospitalized with PBC (using ICD-9 codes). Hospital SNB was defined as percentage of hospitalizations with PBC with Medicaid or uninsured payer status per hospital, and was categorized into two groups: no SNB vs. any SNB. Ethnicity-specific differences by SNB were analyzed with chi-squared testing. Logistic regression was used to analyze odds of being hospitalized at a SNB hospital (vs. no SNB). Multivariate linear regression was performed after logarithmic transformation of the outcome to identify factors associated with mean hospitalization costs, inflation-adjusted to 2014 US dollars. Coefficients were exponentiated to yield percentage change associated with each predictor.

RESULTS:
Among 7,364 hospitalizations with PBC (mean age 64.0 + 14.3 years, 16.1% men, 70.3% non-Hispanic white, 11.8% Hispanic, 5.9% African-American), 65.3% were no SNB and 34.7% with higher SNB. Compared to non-Hispanic whites, Hispanics (30.5% vs 52.1%; OR: 2.49, 95% CI: 2.02-3.05, P < 0.001) and African-Americans (30.5% vs 43.3%; OR: 1.75, 95% CI: 1.38-2.21, P < 0.001) were more likely to be hospitalized at a hospital with SNB. From 2012-2014, the total estimated national burden of PBC hospitalizations was $564 million. On adjusted regression, being admitted to a hospital with SNB (vs. no SNB) resulted in higher mean hospitalization costs (9.0% higher, 95% CI: 2.7%-15.6%, P < 0.001). African-Americans had higher mean hospitalization costs compared to non-Hispanic whites (11.4% higher, 95% CI: 1.6%-22.3%, P = 0.02). Finally, larger (vs. small) and urban (vs. rural) hospitals were more likely to have higher hospitalization costs, and hospitals in the Western region (vs. Northeast) were also more likely to have higher hospitalization costs.

CONCLUSION:
Among hospitalized adults with PBC, ethnic minorities were significantly more likely to be cared for at SNB hospitals. African-Americans and Hispanics had a higher inpatient economic burden compared to non-Hispanic whites.