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Younossi ZM, Stepanova M, Racila A, Afendy A, Lawitz EJ, Schwabe C, Ruane PJ, Lalezari J, Reddy KR, Jacobson IM, Muir AJ, Gaggar A, Myers RP, Younossi I, Nader F. Long-term Benefits of Sustained Virologic Response for Patient-Reported Outcomes in Patients With Chronic Hepatitis C Virus Infection. Clin Gastroenterol Hepatol 2020; 18:468-476.e11. [PMID: 31376493 DOI: 10.1016/j.cgh.2019.07.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/08/2019] [Accepted: 07/11/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS Patients with hepatitis C virus (HCV) infections who achieve a sustained virologic response (SVR) to treatment have improved patient-reported outcomes (PROs). We compared post-treatment PRO scores between patients with chronic HCV infection who did and did not achieve an SVR to treatment. METHODS Patients who completed treatment in clinical trials were enrolled in 2 registries, depending on the treatment outcome (NCT01457755, NCT01457768), from 2016 to 2017 in 17 countries in North America, Europe, and the Asia-Pacific region. PRO scores (scale, 0-100) were collected at pretreatment (baseline); the last day of treatment; the post-treatment week 12 follow-up visit (in patients with SVR only); the registry baseline; and on registry weeks 12, 24, 36, 48, and 96 (the non-SVR registry) or every 24 weeks until week 96 (SVR registry), using the Short Form-36 (SF-36) instrument. RESULTS Our analysis included 4234 patients with an SVR and 242 without an SVR from whom pretreatment PRO data were available (mean age, 54 ± 10 y; 63% male; 65% enrolled in the United States; 17% with cirrhosis; 12% with human immunodeficiency virus co-infection). Upon registry enrollment, patients with an SVR had significant increases in all PRO scores compared with pretreatment baseline levels (all P < .05). Patients without an SVR had mean reductions of 9.2 points or less in PRO scores while followed up on the registry (P < .05 for 4-8 of 8 PRO domains measured by the SF-36). In contrast, patients with an SVR had sustained increases in PRO scores (mean increase, ≤7.0 points) while on the registry. In multivariate analysis, achieving an SVR was associated independently with superior scores in all SF-36 domains at all registry time points (β, +4.8 to +15.9 points, all P ≤ .01). CONCLUSIONS In a follow-up analysis of participants in clinical trials, we found that those with an SVR to treatment for HCV infection had significant increases in well-being, based on PRO scores. Patients without an SVR had decreasing PRO scores over the follow-up period.
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Affiliation(s)
- Zobair M Younossi
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, Virginia; Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia.
| | - Maria Stepanova
- Center for Outcomes Research in Liver Disease, Washington, District of Columbia
| | - Andrei Racila
- Center for Outcomes Research in Liver Disease, Washington, District of Columbia
| | - Arian Afendy
- Center for Outcomes Research in Liver Disease, Washington, District of Columbia
| | - Eric J Lawitz
- Texas Liver Institute, University of Texas Health, San Antonio, Texas
| | | | - Peter J Ruane
- Ruane Medical and Liver Health Institute, Los Angeles, California
| | - Jay Lalezari
- Quest Clinical Research, San Francisco, California
| | - K Rajender Reddy
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ira M Jacobson
- Department of Medicine, NYU Langone Health, New York, New York
| | - Andrew J Muir
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Anuj Gaggar
- Clinical Research at Gilead Sciences, Foster City, California
| | - Robert P Myers
- Clinical Research at Gilead Sciences, Foster City, California
| | - Issah Younossi
- Center for Outcomes Research in Liver Disease, Washington, District of Columbia
| | - Fatema Nader
- Center for Outcomes Research in Liver Disease, Washington, District of Columbia
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202
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Moon AM, Green PK, Rockey DC, Berry K, Ioannou GN. Hepatitis C eradication with direct-acting anti-virals reduces the risk of variceal bleeding. Aliment Pharmacol Ther 2020; 51:364-373. [PMID: 31773763 PMCID: PMC7416556 DOI: 10.1111/apt.15586] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/03/2019] [Accepted: 10/27/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The real-world, long-term benefits of sustained virologic response (SVR) on the risk of variceal bleeding remain unclear. AIM To assess the association between DAA-induced SVR and post-treatment variceal bleeding METHODS: We identified patients who initiated DAA-only anti-viral treatments in the United States Veterans Affairs healthcare system from 2013 to 2015. We followed patients until 1 January 2019 for the development of gastro-oesophageal variceal bleeding defined by diagnostic codes. We used multivariable Cox proportional hazards regression to assess the association between SVR and development of variceal bleeding, adjusting for potential confounders. RESULTS Among 33 582 DAA-treated patients, 549 (1.6%) developed variceal bleeding after treatment (mean follow-up 3.1 years). Compared to no SVR, SVR was associated with a significantly lower incidence of variceal bleeding among all patients (0.46 vs 1.26 per 100 patient-years, adjusted hazard ratio [AHR] 0.66, 95% CI 0.52-0.83), among patients with pre-treatment cirrhosis (1.55 vs 2.96 per 100 patient-years, AHR 0.73, 95% CI 0.57-0.93) and among patients without pre-treatment cirrhosis (0.07 vs 0.29 per 100 patient-years, AHR 0.33, 95% CI 0.17-0.65). The risk of variceal bleeding after treatment was lower in those who achieved SVR vs no SVR among patients who had non-bleeding varices (3.5 vs 4.9 per 100 patient-years) or bleeding varices (12.9 vs 16.4 per 100 patient-years) diagnosed before treatment, but these differences were not statistically significant in adjusted analyses. CONCLUSION DAA-induced SVR is independently associated with a lower risk of variceal bleeding during long-term follow-up in patients with and without pre-treatment cirrhosis. These findings demonstrate an important real-world benefit of DAA treatment.
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Affiliation(s)
- Andrew M. Moon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Pamela K. Green
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Don C. Rockey
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - George N. Ioannou
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA.,Division of Gastroenterology, Department of Medicine Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
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203
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Liu Z, Mao X, Jin L, Zhang T, Chen X. Global burden of liver cancer and cirrhosis among children, adolescents, and young adults. Dig Liver Dis 2020; 52:240-243. [PMID: 31791699 DOI: 10.1016/j.dld.2019.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/05/2019] [Accepted: 11/05/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Zhenqiu Liu
- State Key Laboratory of Genetic Engineering and Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai, China; Human Phenome Institute, Fudan University, Shanghai, China; Fudan University Taizhou Institute of Health Sciences, Taizhou, China
| | - Xianhua Mao
- State Key Laboratory of Genetic Engineering and Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai, China; Human Phenome Institute, Fudan University, Shanghai, China
| | - Li Jin
- State Key Laboratory of Genetic Engineering and Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai, China; Human Phenome Institute, Fudan University, Shanghai, China; Fudan University Taizhou Institute of Health Sciences, Taizhou, China
| | - Tiejun Zhang
- Fudan University Taizhou Institute of Health Sciences, Taizhou, China; Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China; Key Laboratory of Public Health Safety (Fudan University), Ministry of Education, China.
| | - Xingdong Chen
- State Key Laboratory of Genetic Engineering and Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai, China; Human Phenome Institute, Fudan University, Shanghai, China; Fudan University Taizhou Institute of Health Sciences, Taizhou, China.
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204
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Jiang CH, Yuan X, Li JF, Xie YF, Zhang AZ, Wang XL, Yang L, Liu CX, Liang WH, Pang LJ, Zou H, Cui XB, Shen XH, Qi Y, Jiang JF, Gu WY, Li F, Hu JM. Bioinformatics-based screening of key genes for transformation of liver cirrhosis to hepatocellular carcinoma. J Transl Med 2020; 18:40. [PMID: 32000807 PMCID: PMC6993496 DOI: 10.1186/s12967-020-02229-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 01/14/2020] [Indexed: 02/06/2023] Open
Abstract
Background Hepatocellular carcinoma (HCC) is the most common type of liver tumour, and is closely related to liver cirrhosis. Previous studies have focussed on the pathogenesis of liver cirrhosis developing into HCC, but the molecular mechanism remains unclear. The aims of the present study were to identify key genes related to the transformation of cirrhosis into HCC, and explore the associated molecular mechanisms. Methods GSE89377, GSE17548, GSE63898 and GSE54236 mRNA microarray datasets from Gene Expression Omnibus (GEO) were analysed to obtain differentially expressed genes (DEGs) between HCC and liver cirrhosis tissues, and network analysis of protein–protein interactions (PPIs) was carried out. String and Cytoscape were used to analyse modules and identify hub genes, Kaplan–Meier Plotter and Oncomine databases were used to explore relationships between hub genes and disease occurrence, development and prognosis of HCC, and the molecular mechanism of the main hub gene was probed using Kyoto Encyclopedia of Genes and Genomes(KEGG) pathway analysis. Results In total, 58 DEGs were obtained, of which 12 and 46 were up- and down-regulated, respectively. Three hub genes (CDKN3, CYP2C9 and LCAT) were identified and associated prognostic information was obtained. CDKN3 may be correlated with the occurrence, invasion, and recurrence of HCC. Genes closely related to changes in the CDKN3 hub gene were screened, and Kyoto Encyclopedia of Genes and Genomes (KEGGs) pathway analysis identified numerous cell cycle-related genes. Conclusion CDKN3 may affect the transformation of liver cirrhosis into HCC, and represents a new candidate molecular marker of the occurrence and progression of HCC.
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Affiliation(s)
- Chen Hao Jiang
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China
| | - Xin Yuan
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China
| | - Jiang Fen Li
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China
| | - Yu Fang Xie
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China
| | - An Zhi Zhang
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China
| | - Xue Li Wang
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China
| | - Lan Yang
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China
| | - Chun Xia Liu
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China
| | - Wei Hua Liang
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China
| | - Li Juan Pang
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China
| | - Hong Zou
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China
| | - Xiao Bin Cui
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China
| | - Xi Hua Shen
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China
| | - Yan Qi
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China
| | - Jin Fang Jiang
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China
| | - Wen Yi Gu
- Australian Institute of Bioengineering and Nanotechnology, University of Queensland, Brisbane, QLD, 4072, Australia
| | - Feng Li
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China.,Department of Pathology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jian Ming Hu
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Xinjiang, 832002, China. .,Department of Pathology, The First Affiliated Hospital, Shihezi University School of Medicine, Xinjiang, 832002, China.
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205
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Frey LJ, Talbert DA. Artificial Intelligence Pipeline to Bridge the Gap between Bench Researchers and Clinical Researchers in Precision Medicine. MED ONE 2020; 5:10.20900/mo20200001. [PMID: 33511289 PMCID: PMC7839064 DOI: 10.20900/mo20200001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Precision medicine informatics is a field of research that incorporates learning systems that generate new knowledge to improve individualized treatments using integrated data sets and models. Given the ever-increasing volumes of data that are relevant to patient care, artificial intelligence (AI) pipelines need to be a central component of such research to speed discovery. Applying AI methodology to complex multidisciplinary information retrieval can support efforts to discover bridging concepts within collaborating communities. This dovetails with precision medicine research, given the information rich multi-omic data that are used in precision medicine analysis pipelines. In this perspective article we define a prototype AI pipeline to facilitate discovering research connections between bioinformatics and clinical researchers. We propose building knowledge representations that are iteratively improved through AI and human-informed learning feedback loops supported through crowdsourcing. To illustrate this, we will explore the specific use case of nonalcoholic fatty liver disease, a growing health care problem. We will examine AI pipeline construction and utilization in relation to bench-to-bedside bridging concepts with interconnecting knowledge representations applicable to bioinformatics researchers and clinicians.
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Affiliation(s)
- Lewis J. Frey
- Department of Public Health Science, Biomedical Informatics Center, Hollings Cancer Center, Medical University of South Carolina (MUSC), 135 Cannon St, Charleston, SC 29425, USA
- Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veteran Affairs Medical Center, Charleston, SC 29401, USA
| | - Douglas A. Talbert
- Department of Computer Science, Tennessee Tech University (TTU), 1 William L Jones Dr, Cookeville, TN 38505, USA
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206
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Kumar A, Pathak R, Palfrey HA, Stone KP, Gettys TW, Murthy SN. High levels of dietary methionine improves sitagliptin-induced hepatotoxicity by attenuating oxidative stress in hypercholesterolemic rats. Nutr Metab (Lond) 2020; 17:2. [PMID: 31921324 PMCID: PMC6945706 DOI: 10.1186/s12986-019-0422-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 12/29/2019] [Indexed: 02/06/2023] Open
Abstract
Background Both cholesterol (Cho) and methionine (Met, a precursor for homocysteine) are risk factors for fatty liver disease. Since Western diets are rich in Cho and Met, we investigated the hepatic effects of feeding a diet enriched in Met and Cho. Further, based on the reported anti-oxidative and lipid lowering properties of sitagliptin (an antidiabetic drug), we tested whether it could counteract the negative effects of high Cho and Met. We therefore hypothesized that sitagliptin would ameliorate the development of liver pathology that is produced by feeding diets rich in either Cho, Met, or both. Methods Male Sprague Dawley rats were fed ad libitum a) control diet, or b) high Met or c) high Cho, or d) high Met + high Cho diets for 35 days. From day 10 to 35, 50% of rats in each dietary group were gavaged with either vehicle or an aqueous suspension of sitagliptin (100 mg/kg/day). Liver samples were harvested for histological, molecular, and biochemical analyses. Results The high Cho diet produced significant hepatic steatosis which was unaffected by sitagliptin. Contrary to expectation, sitagliptin exacerbated expression of hepatic markers of oxidative stress and fibrosis in rats fed high Cho. Corresponding increases in 4-hydroxynonenal adducts and collagen deposition were demonstrated by immunohistochemistry and sirius red staining. These hepatic changes were absent in rats on the high Met diet and they were comparable to controls. The inclusion of Met in the high Cho diet resulted in significant reduction of the hepatic steatosis, oxidative stress, and fibrosis produced by high Cho alone. Conclusion Sitagliptin exacerbated the effects of high Cho on both oxidative stress and fibrosis, resulting in NASH like symptoms that were significantly reversed by the inclusion of Met.
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Affiliation(s)
- Avinash Kumar
- 1Environmental Toxicology Department, Southern University and A&M College, Baton Rouge, LA 70813 USA
| | - Rashmi Pathak
- 1Environmental Toxicology Department, Southern University and A&M College, Baton Rouge, LA 70813 USA
| | - Henry A Palfrey
- 1Environmental Toxicology Department, Southern University and A&M College, Baton Rouge, LA 70813 USA
| | - Kirsten P Stone
- 2Laboratory of Nutrient Sensing and Adipocyte Signaling, Pennington Biomedical Research Center, Baton Rouge, LA USA
| | - Thomas W Gettys
- 2Laboratory of Nutrient Sensing and Adipocyte Signaling, Pennington Biomedical Research Center, Baton Rouge, LA USA
| | - Subramanyam N Murthy
- 1Environmental Toxicology Department, Southern University and A&M College, Baton Rouge, LA 70813 USA
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207
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Tapper EB, Hao S, Lin M, Mafi JN, McCurdy H, Parikh ND, Lok AS. The Quality and Outcomes of Care Provided to Patients with Cirrhosis by Advanced Practice Providers. Hepatology 2020; 71:225-234. [PMID: 31063262 PMCID: PMC6834870 DOI: 10.1002/hep.30695] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 05/01/2019] [Indexed: 12/24/2022]
Abstract
Cirrhosis is morbid and increasingly prevalent, yet the U.S. health care system lacks enough physicians and specialists to adequately manage patients with cirrhosis. Although advanced practice providers (APPs) can expand access to cirrhosis-related care, their impact on the quality of care remains unknown. We sought to determine the effect on care quality and outcomes for patients managed by APPs using a retrospective analysis of a nationally representative American commercial claims database (Optum), which included 389,257 unique adults with cirrhosis. We evaluated a complication of process measures (i.e., rates of hepatocellular carcinoma [HCC] screening, endoscopic varices screening, and use of rifaximin after hospitalization for hepatic encephalopathy) and outcomes (30-day readmissions and survival). Compared with patients without APP care, patients with APP care had higher rates of HCC screening (adjusted odds ratio [OR] 1.23, 95% confidence interval 1.19, 1.27), varices screening (OR 1.20 [1.13, 1.27]), use of rifaximin after a discharge for hepatic encephalopathy (OR 2.09 [1.80, 2.43]), and reduced risk of 30-day readmission (OR 0.68 [0.66, 0.70]). Gastroenterology/hepatology consultation was also associated with improved quality metric performance compared with primary care; however, shared visits between gastroenterologists/hepatologists and APPs were associated with the best performance and lower 30-day readmissions compared with subspecialty consultation without an APP (OR 0.91 [0.87, 0.95]. Multivariate analysis adjusting for comorbidities, liver disease severity, and other factors including gastroenterology/hepatology consultation showed that patients seen by APPs were more likely to receive consistent HCC and varices screening over time, less likely to experience 30-day readmissions, and had lower mortality (adjusted hazard ratio 0.57, 95% confidence interval 0.55, 0.60). Conclusion: APPs, particularly when working with gastroenterologists/hepatologists, are associated with improved quality of care and outcomes for patients with cirrhosis.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine. University of Michigan, Ann Arbor MI,Veterans Affairs, Ann Arbor MI
| | | | | | - John N. Mafi
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA,RAND Health, RAND Corporation
| | | | - Neehar D. Parikh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine. University of Michigan, Ann Arbor MI,Veterans Affairs, Ann Arbor MI
| | - Anna S. Lok
- Division of Gastroenterology and Hepatology, Department of Internal Medicine. University of Michigan, Ann Arbor MI,Veterans Affairs, Ann Arbor MI
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208
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Crabb DW, Im GY, Szabo G, Mellinger JL, Lucey MR. Diagnosis and Treatment of Alcohol-Associated Liver Diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases. Hepatology 2020; 71:306-333. [PMID: 31314133 DOI: 10.1002/hep.30866] [Citation(s) in RCA: 450] [Impact Index Per Article: 112.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 12/12/2022]
Affiliation(s)
- David W Crabb
- Indiana University School of Medicine, Indianapolis, IN
| | - Gene Y Im
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gyongyi Szabo
- University of Massachusetts Medical School, Worcester, MA
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209
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Alcoholic Liver Disease Epidemiology in the United States: A Retrospective Analysis of 3 US Databases. Am J Gastroenterol 2020; 115:96-104. [PMID: 31517639 DOI: 10.14309/ajg.0000000000000380] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Alcoholic liver disease (ALD) prevalence, particularly the subset with advanced liver disease, is not well defined. Herein, we aim to provide a comprehensive assessment of ALD epidemiology across the spectrum of disease severity and across different settings using 3 unique US databases. METHODS We performed a retrospective, observational study of US adults with ALD using 2001-2016 National Health and Nutrition Examination Survey (NHANES), 2007-2014 Nationwide Inpatient Sample (NIS), and 2007-2017 United Network for Organ Sharing (UNOS) registry. ALD in the NHANES was defined using clinical laboratory data and self-reported alcohol use, among which fibrosis-4 score of >2.67 defined stage ≥3 fibrosis. Alcoholic cirrhosis (AC) in the NIS was identified using International Classification of Diseases, Ninth Revision codes. ALD in the UNOS was identified using UNOS coding. RESULTS From 2001-2002 to 2015-2016, the overall weighted ALD prevalence was stable from 8.8% to 8.1% (P = 0.102), whereas the proportion of ALD with stage ≥3 fibrosis increased from 2.2% (95% CI: 0.4-4.0) to 6.6% (95% CI: 2.0-9.9; P = 0.007) (NHANES). From 2007 to 2014, the number of hospitalizations among patients with AC per 1,000 increased by 32.8%, and the proportion of hospitalizations among the patients with AC with ≥3 cirrhosis complications increased from 11.6% in 2007 to 25.8% in 2014 (Ptrend < 0.0001) (NIS). From 2007 to 2017, the total number of adults with ALD listed for liver transplant increased by 63.4% and the proportion with concurrent hepatocellular carcinoma increased by 178% (UNOS). DISCUSSION Among these 3 US databases, consistent observations of increasing ALD severity emphasize the urgent need for greater awareness about the consequences of unhealthy alcohol use and interventions aimed specifically at addressing alcohol use disorders.
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210
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Koola JD, Ho S, Chen G, Perkins AM, Cao A, Davis SE, Matheny ME. Development of a national Department of Veterans Affairs mortality risk prediction model among patients with cirrhosis. BMJ Open Gastroenterol 2019; 6:e000342. [PMID: 31875140 PMCID: PMC6904155 DOI: 10.1136/bmjgast-2019-000342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/16/2019] [Accepted: 10/30/2019] [Indexed: 12/20/2022] Open
Abstract
Objective Cirrhotic patients are at high hospitalisation risk with subsequent high mortality. Current risk prediction models have varied performances with methodological room for improvement. We used current analytical techniques using automatically extractable variables from the electronic health record (EHR) to develop and validate a posthospitalisation mortality risk score for cirrhotic patients and compared performance with the model for end-stage liver disease (MELD), model for end-stage liver disease with sodium (MELD-Na), and the CLIF Consortium Acute Decompensation (CLIF-C AD) models. Design We analysed a retrospective cohort of 73 976 patients comprising 247 650 hospitalisations between 2006 and 2013 at any of 123 Department of Veterans Affairs hospitals. Using 45 predictor variables, we built a time-dependent Cox proportional hazards model with all-cause mortality as the outcome. We compared performance to the three extant models and reported discrimination and calibration using bootstrapping. Furthermore, we analysed differential utility using the net reclassification index (NRI). Results The C-statistic for the final model was 0.863, representing a significant improvement over the MELD, MELD-Na, and the CLIF-C AD, which had C-statistics of 0.655, 0.675, and 0.679, respectively. Multiple risk factors were significant in our model, including variables reflecting disease severity and haemodynamic compromise. The NRI showed a 24% improvement in predicting survival of low-risk patients and a 30% improvement in predicting death of high-risk patients. Conclusion We developed a more accurate mortality risk prediction score using variables automatically extractable from an EHR that may be used to risk stratify patients with cirrhosis for targeted postdischarge management.
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Affiliation(s)
- Jejo David Koola
- Veteran's Health Administration, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA.,Department of Medicine, University of California San Diego, La Jolla, California, USA.,UC San Diego Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California, United States
| | - Samuel Ho
- Department of Medicine, University of California San Diego, La Jolla, California, USA.,Department of Medicine, VA San Diego Healthcare System, San Diego, California, USA.,Department of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Guanhua Chen
- Department of Biostatistics and Medical Informatics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Amy M Perkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aize Cao
- Veteran's Health Administration, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sharon E Davis
- Veteran's Health Administration, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael E Matheny
- Veteran's Health Administration, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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211
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Tapper EB, Zhang P, Garg R, Nault T, Leary K, Krishnamurthy V, Su GL. Body composition predicts mortality and decompensation in compensated cirrhosis patients: A prospective cohort study. JHEP Rep 2019; 2:100061. [PMID: 32039402 PMCID: PMC7005567 DOI: 10.1016/j.jhepr.2019.11.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/28/2019] [Accepted: 11/15/2019] [Indexed: 12/13/2022] Open
Abstract
Background & Aims Body composition, particularly sarcopenia, is associated with mortality in patients with decompensated cirrhosis undergoing transplant evaluation. Similar data are limited for non-transplant eligible or compensated patients. Methods A total of 274 patients with cirrhosis were followed prospectively for ≤5 years after a CT scan. We utilized Analytic Morphomics® to measure body composition (fat, muscle, and bone) which was rendered into relative values (percentiles) in relation to a reference population. The model for end-stage liver disease (MELD) score was used as a reference model for survival prediction. We validated our models in a separate cohort. Results Our cohort had a mean Child-Pugh score of 7.0 and a mean MELD of 11.3. The median follow-up time was 5.05 years. The proportion of patients alive at 1, 3 and 5 years was 86.5%, 68.0%, and 54.3%; 13 (4.6%) underwent liver transplantation. Child-Pugh B/C (vs. A) cirrhosis was associated with decreased muscle, subcutaneous, and visceral fat area but increased subcutaneous/visceral fat density. Decreased normal density muscle mass was associated with mortality (hazard ratio [HR] 0.984, p <0.001) as well as visceral and subcutaneous fat density (HR 1.013 and 1.014, respectively, p <0.001). Models utilizing these features outperformed MELD alone for mortality discrimination in both the derivation and validation cohort, particularly for those with compensated cirrhosis (C-statistics of 0.74 vs. 0.58). Using competing risk analysis, we found that subcutaneous fat density was most predictive of decompensation (subdistribution HR 1.018, p = 0.0001). Conclusion The addition of body composition features to predictive models improves the prospective determination of prognosis in patients with cirrhosis, particularly those with compensated disease. Fat density, a novel feature, is associated with the risk of decompensation. Lay summary Am I at high risk of getting sicker and dying? This is the key question on the mind of patients with cirrhosis. The problem is that we have very few tools to help guide our patients, particularly if they have early cirrhosis (without symptoms like confusion or fluid in the belly). We found that how much muscle and fat the patient has and what that muscle or fat looks like on a CT scan provide helpful information. This is important because many patients have CT scans and this information is hiding in plain sight. Features of body composition can predict clinical outcomes in patients with cirrhosis awaiting liver transplantation. Data are lacking regarding long-term outcomes among patients with compensated disease. We show that features of muscle and fat are associated with decompensation and risk of death across the spectrum of cirrhosis. CT scans obtained for unrelated clinical purposes can be analyzed as a digital risk biomarker for patients with compensated cirrhosis.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan.,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Peng Zhang
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Rohan Garg
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Tori Nault
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Kate Leary
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Venkat Krishnamurthy
- Radiology Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Grace L Su
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan.,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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212
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Serper M, Kaplan DE, Shults J, Reese PP, Beste LA, Taddei TH, Werner RM. Quality Measures, All-Cause Mortality, and Health Care Use in a National Cohort of Veterans With Cirrhosis. Hepatology 2019; 70:2062-2074. [PMID: 31107967 PMCID: PMC6864236 DOI: 10.1002/hep.30779] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/10/2019] [Indexed: 02/06/2023]
Abstract
Decompensated cirrhosis is associated with high morbidity and mortality. However, no standardized quality measures (QMs) have yet been adopted widely. The Veterans Affairs (VA) Advanced Liver Disease Technical Advisory Group recently developed a set of six internal QMs to guide quality improvement efforts in cirrhosis in the domains of access to care, hepatocellular carcinoma surveillance, variceal surveillance, quality of inpatient care for upper gastrointestinal bleeding, and cirrhosis-related rehospitalizations. We aimed to (1) quantify adherence to cirrhosis QMs and (2) determine whether adherence was associated with all-cause mortality and health care use within a large national cohort of veterans with cirrhosis. We performed a retrospective study using data from the Veterans Outcomes and Costs Asociated with Liver Disease cohort of 121,129 patients newly diagnosed with cirrhosis from January 1, 2008, to December 31, 2016, at 128 VA facilities. The mean follow-up time was 2.7 years (interquartile range, 1.1-5.1 years). Adherence to outpatient access to specialty care was 71%, variceal surveillance was 32%, and early postdischarge care was 54%. In adjusted analyses, outpatient access to specialty care (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.78-0.82), hepatocellular carcinoma surveillance (HR, 0.92; 95% CI, 0.90-0.95), variceal surveillance (HR, 0.93; 95% CI, 0.89-0.99), and early postdischarge care (HR, 0.57; 95% CI, 0.54-0.60) were associated with lower all-cause mortality. Readmissions after 30 days (HR, 1.53; 1.46-1.60) and 90 days (HR, 1.88; 95% CI, 1.54-1.70) were associated with higher all-cause mortality. Higher adherence to QMs was also associated with lower inpatient health care use. Conclusion: Five of the six proposed VA cirrhosis QMs were measurable using existing data sources, associated with mortality and health care use, and may be used to guide future quality improvement efforts in cirrhosis.
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Affiliation(s)
- Marina Serper
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - David E. Kaplan
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Justine Shults
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Peter P. Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Lauren A. Beste
- VA Puget Sound Health Care System, Health Services Research and Development, Seattle, WA
- VA Puget Sound Health Care System, General Medicine Service, Seattle, WA, USA
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Tamar H. Taddei
- VA Connecticut Healthcare System, West Haven, Connecticut CT
- Division of Gastroenterology, Yale University School of Medicine, New Haven, CT
| | - Rachel M. Werner
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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213
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Dunn SH, Rogal SS, Maier MM, Chartier M, Morgan TR, Beste LA. Access to Comprehensive Services for Advanced Liver Disease in the Veterans Health Administration. Dig Dis Sci 2019; 64:3471-3479. [PMID: 31432344 DOI: 10.1007/s10620-019-05785-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 08/07/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND The Veterans Health Administration (VHA) provides care to the one of the largest cohorts of patients with advanced liver disease (ALD) in the USA. AIMS We performed a national survey to assess system-wide strengths and barriers to care for Veterans with ALD in this national integrated healthcare setting. METHODS A 52-item survey was developed to assess access and barriers to care in Veterans with ALD. The survey was distributed to all VHA medical centers in 2015. Results were analyzed using descriptive statistics. RESULTS One hundred and fifty-three sites responded to this survey. Multidisciplinary services were available on-site at > 80% of sites. Ninety-five percent of sites had mental health and addictions treatment available, with 14% co-locating these services within the liver clinic. Few sites (< 25%) provided pharmacologic treatment for alcohol use disorder in primary care or hepatology settings. Seventy-two percent of sites reported at least one barrier to liver-related care. Of the sites reporting at least one barrier, 53% reported barriers to liver transplant referral, citing complex processes and lack of staff/resources to coordinate referrals. Palliative care was widely available, but 61% of sites reported referring < 25% of their patients with ALD for palliative services. CONCLUSION Multidisciplinary services for Veterans with ALD are widely available at VHA sites, though barriers to optimal care remain. Opportunities for improvement include the expansion of providers with hepatology expertise, integrating pharmacotherapy for alcohol use disorder into hepatology and primary care, streamlining the transplant referral process, and expanding palliative care referrals for patients with ALD.
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Affiliation(s)
- S Hunter Dunn
- Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA.
| | - Shari S Rogal
- Departments of Surgery and Medicine, VA Pittsburgh Healthcare System, 1 University Drive, Pittsburgh, PA, 15240, USA
| | - Marissa M Maier
- Division of Infectious Diseases, VA Portland Health Care System, 3710 SW US Veterans Hospital Road, Portland, OR, 97239, USA
| | - Maggie Chartier
- HIV, Hepatitis, and Related Conditions Programs Office of Specialty Care Services, U.S. Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC, 20571, USA
| | - Timothy R Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, 5901 E. Seventh Street, Long Beach, CA, 90822, USA
| | - Lauren A Beste
- General Medicine Service, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA, 98108, USA
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214
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Bataller R, Cabezas J, Aller R, Ventura-Cots M, Abad J, Albillos A, Altamirano J, Arias-Loste MT, Bañares R, Caballería J, Caballería L, Carrión JA, Diago M, Fernández Rodríguez C, Gallego R, García-Cortes M, García-Monzón C, Genescà J, Ginés P, Hernandez-Guerra M, Jorquera F, Lligoña A, Molina E, Pareja MJ, Planas R, Tomé S, Salmerón J, Romero-Gómez M. Alcohol-related liver disease. Clinical practice guidelines. Consensus document sponsored by AEEH. GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 42:657-676. [PMID: 31771785 DOI: 10.1016/j.gastrohep.2019.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 09/02/2019] [Indexed: 02/07/2023]
Abstract
Alcohol-related liver disease (ARLD) is the most prevalent cause of advanced liver disease and liver cirrhosis in Europe, including Spain. According to the World Health Organization the fraction of liver cirrhosis attributable to alcohol use in Spain is 73.8% among men and 56.3% among women. ARLD includes various stages such as steatohepatitis, cirrhosis and hepatocellular cancer. In addition, patients with underlying ARLD and heavy alcohol intake may develop alcoholic hepatitis, which is associated with high mortality. To date, the only effective treatment to treat ARLD is prolonged withdrawal. There are no specific treatments, and the only treatment that increases life expectancy in alcoholic hepatitis is prednisolone. For patients with alcoholic hepatitis who do not respond to treatment, some centres offer the possibility of an early transplant. These clinical practice guidelines aim to propose recommendations on ARLD taking into account their relevance as a cause of advanced chronic liver disease and liver cirrhosis in our setting. This paper aims to answer the key questions for the clinical practice of Gastroenterology, Hepatology, as well as Internal Medicine and Primary Health Centres, making the most up-to-date information regarding the management and treatment of ARLD available to health professionals. These guidelines provide evidence-based recommendations for the clinical management of this disease.
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Affiliation(s)
- Ramón Bataller
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Center for Liver Diseases, University of Pittsburgh Medical Center, Pittsburgh, PA, Estados Unidos.
| | - Joaquín Cabezas
- Servicio de Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Instituto de investigación Sanitaria Valdecilla (IDIVAL), Santander, Cantabria, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España
| | - Rocío Aller
- Servicio de Gastroenterología, Hospital Clínico Universitario de Valladolid, Valladolid, España; Facultad de Medicina, Universidad de Valladolid, Valladolid, España; Centro de Investigación de Endocrinología y Nutrición, Facultad de Medicina de Valladolid, Valladolid, España
| | - Meritxell Ventura-Cots
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Center for Liver Diseases, University of Pittsburgh Medical Center, Pittsburgh, PA, Estados Unidos; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España
| | - Javier Abad
- Servicio de Gastroenterología y Hepatología, Hospital Puerta de Hierro, Madrid, España
| | - Agustín Albillos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, España
| | - José Altamirano
- Deparmento de Medicina Interna, Hospital Quironsalud, Barcelona, España
| | - María Teresa Arias-Loste
- Servicio de Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Instituto de investigación Sanitaria Valdecilla (IDIVAL), Santander, Cantabria, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España
| | - Rafael Bañares
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Servicio de Gastroenterología y Hepatología, Hospital Gregorio Marañón, Madrid, España
| | - Juan Caballería
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Unidad de Hepatología, Hospital Clínic, IDIBAPS, Barcelona, España
| | - Llorenç Caballería
- Unidad de Apoyo a la Investigación de la Atención Primaria en la Metropolitana Norte, Barcelona, España
| | | | - Moisés Diago
- Servicio de Aparato Digestivo, Hospital General de Valencia, Valencia, España
| | - Conrado Fernández Rodríguez
- Servicio de Gastroenterología, Hospital Universitario Fundación Alcorcón. Facultad de Medicina, Universidad Rey Juan Carlos, Alcorcón, Madrid, España
| | - Rocío Gallego
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; UGC Aparato Digestivo, Instituto de Biomedicina de Sevilla. Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, España
| | | | | | - Joan Genescà
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Servicio de Medicina Interna-Hepatología, Hospital Universitario Vall d'Hebron, Institut de Recerca Vall d'Hebron (VHIR), Universitat Autònoma de Barcelona, Barcelona, España
| | - Pere Ginés
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Unidad de Apoyo a la Investigación de la Atención Primaria en la Metropolitana Norte, Barcelona, España
| | | | - Francisco Jorquera
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Servicio de Aparato Digestivo, Complejo Asistencial Universitario de León, IBIOMED, León, España
| | - Anna Lligoña
- Unidad de Alcohologia, Departamento de Psiquiatría, Hospital Clínic. Barcelona, España
| | - Esther Molina
- Unidad de Hepatología, Servicio de Aparato Digestivo, Hospital Clínico-Xerencia de Xestión Integrada de Santiago de Compostela, Santiago de Compostela, La Coruña, España
| | | | - Ramón Planas
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Departamento de Hepatología, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - Santiago Tomé
- Unidad de Trasplante Hepático, Hospital Clínico Universitario, Santiago de Compostela, La Coruña, España
| | - Javier Salmerón
- UGC de Aparato Digestivo, Hospital San Cecilio, Granada, España
| | - Manuel Romero-Gómez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; UGC Aparato Digestivo, Instituto de Biomedicina de Sevilla. Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, España
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215
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Bajaj JS, Sharma A, Dudeja PK. Targeting Gut Microbiome Interactions in Service-Related Gastrointestinal and Liver Diseases of Veterans. Gastroenterology 2019; 157:1180-1183.e1. [PMID: 31404532 PMCID: PMC7249241 DOI: 10.1053/j.gastro.2019.07.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 07/24/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Jasmohan S Bajaj
- Virginia Commonwealth University and Hunter Holmes McGuire VA Medical Center, Richmond, Virginia.
| | - Arun Sharma
- Office of Research and Development, Veterans Affairs, Washington, DC
| | - Pradeep K Dudeja
- University of Illinois at Chicago and Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois.
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216
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Ioannou GN, Beste LA, Green PK, Singal AG, Tapper EB, Waljee AK, Sterling RK, Feld JJ, Kaplan DE, Taddei TH, Berry K. Increased Risk for Hepatocellular Carcinoma Persists Up to 10 Years After HCV Eradication in Patients With Baseline Cirrhosis or High FIB-4 Scores. Gastroenterology 2019; 157:1264-1278.e4. [PMID: 31356807 PMCID: PMC6815714 DOI: 10.1053/j.gastro.2019.07.033] [Citation(s) in RCA: 245] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/03/2019] [Accepted: 07/22/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is unclear if hepatocellular carcinoma (HCC) risk declines over time after hepatitis C virus (HCV) eradication. We analyzed changes in HCC annual incidence over time following HCV eradication and identified dynamic markers of HCC risk. METHODS We identified 48,135 patients who initiated HCV antiviral treatment from 2000 through 2015 and achieved a sustained virologic response (SVR) in the Veterans Health Administration (29,033 treated with direct-acting antiviral [DAA] agents and 19,102 treated with interferon-based regimens). Patients were followed after treatment until February 14, 2019 (average 5.4 years), during which 1509 incident HCCs were identified. RESULTS Among patients with cirrhosis before treatment with DAAs (n = 9784), those with pre-SVR fibrosis-4 (FIB-4) scores ≥3.25 had a higher annual incidence of HCC (3.66%/year) than those with FIB-4 scores <3.25 (1.16%/year) (adjusted hazard ratio 2.14; 95% confidence interval 1.66-2.75). In DAA-treated patients with cirrhosis and FIB-4 scores ≥3.25, annual HCC risk decreased from 3.8%/year in the first year after SVR to 2.4%/year by the fourth year (P=.01). In interferon-treated patients with FIB-4 scores ≥3.25, annual HCC risk remained above 2%/year, even 10 years after SVR. A decrease in FIB-4 scores from ≥3.25 pre-SVR to <3.25 post-SVR was associated with an approximately 50% lower risk of HCC, but the absolute annual risk remained above 2%/year. Patients without cirrhosis before treatment (n = 38,351) had a low risk of HCC, except for those with pre-SVR FIB-4 scores ≥3.25 (HCC risk 1.22%/year) and post-SVR FIB-4 scores ≥3.25 (HCC risk 2.39%/year); risk remained high for many years after SVR. CONCLUSIONS Patients with cirrhosis before an SVR to treatment for HCV infection continue to have a high risk for HCC (>2%/year) for many years, even if their FIB-4 score decreases, and should continue surveillance. Patients without cirrhosis but with FIB-4 scores ≥3.25 have a high enough risk to merit HCC surveillance, especially if FIB-4 remains ≥3.25 post-SVR.
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Affiliation(s)
- George N. Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA.,Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Lauren A Beste
- Division of General Internal Medicine, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
| | - Pamela K. Green
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas TX
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor MI
| | - Akbar K. Waljee
- Division of Gastroenterology and Hepatology, VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor MI
| | - Richard K. Sterling
- Division of Gastroenterology, Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Jordan J. Feld
- Toronto Centre for Liver Disease, University Health Network, Sandra Rotman Centre for Global Health, University of Toronto
| | - David E. Kaplan
- Division of Gastroenterology, Department of Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center and Perelman University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Tamar H. Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT and VA Connecticut Healthcare System, West Haven, CT
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
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217
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Tapper EB, Henderson JB, Parikh ND, Ioannou GN, Lok AS. Incidence of and Risk Factors for Hepatic Encephalopathy in a Population-Based Cohort of Americans With Cirrhosis. Hepatol Commun 2019; 3:1510-1519. [PMID: 31701074 PMCID: PMC6824059 DOI: 10.1002/hep4.1425] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 08/13/2019] [Indexed: 12/12/2022] Open
Abstract
Hepatic encephalopathy (HE) is a devastating complication of cirrhosis. Data are limited regarding the incidence of and risk factors for HE among contemporary patients in the context of the shifting epidemiology of cirrhosis. We examined a 20% random sample of U.S. Medicare enrollees with cirrhosis and Part D prescription coverage from 2008 to 2014. We modelled incident HE using demographic, clinical, and pharmacologic data. Risk factors for HE were evaluated, including demographics/socioeconomics, cirrhosis etiology, severity of liver disease, and pharmacotherapy, along with gastroenterology consultation, as time-varying covariates. Among 166,192 Medicare enrollees with cirrhosis followed for 5.25 (interquartile range [IQR], 2.00-7.00) years, the overall incidence of HE was 11.6 per 100 patient-years. The cohort's median age was 65 years (IQR, 57-72), 31% had alcohol-related cirrhosis, and 49% had likely nonalcoholic fatty liver disease cirrhosis. The two strongest associations with HE were alcohol-related cirrhosis (adjusted hazard ratio [AHR], 1.44; 95% confidence interval [CI], 1.40, 1.47, relative to nonalcoholic nonviral cirrhosis) and the presence of portal hypertension (AHR, 3.42; 95% CI, 3.34, 3.50). Adjusting for confounders, benzodiazepines (AHR, 1.24; 95% CI, 1.21, 1.27), gamma aminobutyric acid (GABA)ergics (AHR, 1.17; 95% CI, 1.14, 1.21), opioids (AHR, 1.24; 95% CI, 1.21, 1.27), and proton pump inhibitors (PPIs) (AHR, 1.41; 95% CI, 1.38, 1.45) were all associated with incident HE. Only benzodiazepines, however, were associated with the risk of hospitalization with HE (incidence-rate ratio, 1.23; 95% CI, 1.20, 1.26). Conclusion: Novel data regarding the risk of HE for contemporary patients with cirrhosis are provided. The incidence of HE in an older population of Americans with cirrhosis is high, particularly among those with alcohol-related cirrhosis and portal hypertension. Several medication classes, namely PPIs, opiates, GABAergics, and benzodiazepines, represent potentially modifiable risk factors for HE.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMI
- Gastroenterology SectionVA Ann Arbor Healthcare SystemAnn ArborMI
| | - James B. Henderson
- Center for Statistical Consultation and ResearchUniversity of MichiganAnn ArborMI
| | - Neehar D. Parikh
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMI
- Gastroenterology SectionVA Ann Arbor Healthcare SystemAnn ArborMI
| | - George N. Ioannou
- Division of GastroenterologyDepartment of MedicineVeterans Affairs Puget Sound Healthcare System and University of WashingtonSeattleWA
| | - Anna S. Lok
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMI
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218
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Bajaj JS, Sikaroodi M, Fagan A, Heuman D, Gilles H, Gavis EA, Fuchs M, Gonzalez-Maeso J, Nizam S, Gillevet PM, Wade JB. Posttraumatic stress disorder is associated with altered gut microbiota that modulates cognitive performance in veterans with cirrhosis. Am J Physiol Gastrointest Liver Physiol 2019; 317:G661-G669. [PMID: 31460790 PMCID: PMC6879889 DOI: 10.1152/ajpgi.00194.2019] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/12/2019] [Accepted: 08/18/2019] [Indexed: 02/07/2023]
Abstract
Posttraumatic stress disorder (PTSD) is associated with cirrhosis in veterans, and therapeutic results are suboptimal. An altered gut-liver-brain axis exists in cirrhosis due to hepatic encephalopathy (HE), but the added impact of PTSD is unclear. The aim of this study was to define linkages between gut microbiota and cognition in cirrhosis with/without PTSD. Cirrhotic veterans (with/without prior HE) underwent cognitive testing [PHES, inhibitory control test (ICT), and block design test (BDT)], serum lipopolysaccharide-binding protein (LBP) and stool collection for 16S rRNA microbiota composition, and predicted function analysis (PiCRUST). PTSD was diagnosed using DSM-V criteria. Correlation networks between microbiota and cognition were created. Patients with/without PTSD and with/without HE were compared. Ninety-three combat-exposed male veterans [ (58 yr, MELD 11, 34% HE, 31% combat-PTSD (42 no-HE/PTSD, 19 PTSD-only, 22 HE-only, 10 PTSD+HE)] were included. PTSD patients had similar demographics, alcohol history, MELD, but worse ICT/BDT, and higher antidepressant use and LBP levels. Microbial diversity was lower in PTSD (2.1 ± 0.5 vs. 2.5 ± 0.5, P = 0.03) but unaffected by alcohol/antidepressant use. PTSD (P = 0.02) and MELD (P < 0.001) predicted diversity on regression. PTSD patients showed higher pathobionts (Enterococcus and Escherichia/Shigella) and lower autochthonous genera belonging to Lachnospiraceaeae and Ruminococcaceae regardless of HE. Enterococcus was correlated with poor cognition, while the opposite was true for autochthonous taxa regardless of PTSD/HE. Escherichia/Shigella was only linked with poor cognition in PTSD patients. Gut-brain axis-associated microbiota functionality was altered in PTSD. In male cirrhotic veterans, combat-related PTSD is associated with cognitive impairment, lower microbial diversity, higher pathobionts, and lower autochthonous taxa composition and altered gut-brain axis functionality compared with non-PTSD combat-exposed patients. Cognition was differentially linked to gut microbiota, which could represent a new therapeutic target.NEW & NOTEWORTHY Posttraumatic stress disorder (PTSD) in veterans with cirrhosis was associated with poor cognitive performance. This was associated with lower gut microbial diversity in PTSD with higher pathobionts belonging to Enterococcus and Escherichia/Shigella and lower beneficial taxa belonging to Lachnospiraceaeae and Ruminococcaceae, with functional alterations despite accounting for prior hepatic encephalopathy, psychoactive drug use, or model for end-stage liver disease score. Given the suboptimal response to current therapies for PTSD, targeting the gut microbiota could benefit the altered gut-brain axis in these patients.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University Medical Center, Richmond, Virginia
- McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | | | - Andrew Fagan
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University Medical Center, Richmond, Virginia
- McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - Douglas Heuman
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University Medical Center, Richmond, Virginia
- McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - HoChong Gilles
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University Medical Center, Richmond, Virginia
- McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - Edith A Gavis
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University Medical Center, Richmond, Virginia
- McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - Michael Fuchs
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University Medical Center, Richmond, Virginia
- McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - Javier Gonzalez-Maeso
- Department of Physiology and Biophysics, Virginia Commonwealth University, Richmond, Virginia
| | - Shahzor Nizam
- Microbiome Analysis Center, George Mason University, Manassas, Virginia
| | | | - James B Wade
- Department of Psychiatry, Virginia Commonwealth University Medical Center, Richmond, Virginia
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219
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Sigel K, Park L, Justice A. HIV and cancer in the Veterans Health Administration System. Semin Oncol 2019; 46:334-340. [PMID: 31703932 DOI: 10.1053/j.seminoncol.2019.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/25/2019] [Indexed: 12/18/2022]
Abstract
Cancer is a leading cause of death for people with HIV (PWH). The Veterans Healthcare System (VA) is the largest single institutional provider of HIV care in the United States. Cancer among Veterans with HIV is major issue and clinical research has expanded significantly during the antiretroviral therapy (ART) era providing numerous insights regarding cancer incidence, risk factors, prevention, treatment and outcomes for this unique group of patients. This work has been greatly facilitated by the availability of national VA data sources. Notably, patterns of cancer incidence have changed for Veterans with HIV during the ART era; non-AIDS defining malignancies now are the most common tumors. Despite better HIV control in the ART era, immunosuppression measured by low CD4 counts and HIV viremia have been associated with increased cancer risk. Cancer outcomes for Veterans with HIV may now be similar to uninfected Veterans, but information on outcomes and cancer treatment patterns remains limited, requiring further study to help inform prevention and treatment strategies.
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Affiliation(s)
- Keith Sigel
- Icahn School of Medicine at Mount Sinai, NY, NY.
| | - Lesley Park
- Stanford University School of Medicine, Palo Alto, CA
| | - Amy Justice
- VA Connecticut Healthcare System, West Haven, CT; Yale University School of Medicine
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220
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Lim N, Sanchez O, Olson A. Impact on 30-d readmissions for cirrhotic patients with ascites after an educational intervention: A pilot study. World J Hepatol 2019; 11:701-709. [PMID: 31749900 PMCID: PMC6856018 DOI: 10.4254/wjh.v11.i10.701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/23/2019] [Accepted: 10/02/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A low proportion of patients admitted to hospital with cirrhosis receive quality care with timely paracentesis an important target for improvement. We hypothesized that a medical educational intervention, delivered to medical residents caring for patients with cirrhosis, would improve quality of care.
AIM To determine if an educational intervention can improve quality of care in cirrhotic patients admitted to hospital with ascites.
METHODS We performed a pilot prospective cohort study with time-based randomization over six months at a large teaching hospital. Residents rotating on hospital medicine teams received an educational intervention while residents rotating on hospital medicine teams on alternate months comprised the control group. The primary outcome was provision of quality care- defined as adherence to all quality-based indicators derived from evidence-based practice guidelines- in admissions for patients with cirrhosis and ascites. Patient clinical outcomes- including length of hospital stay (LOS); 30-d readmission; in-hospital mortality and overall mortality- and resident educational outcomes were also evaluated.
RESULTS Eighty-five admissions (60 unique patients) met inclusion criteria over the study period-46 admissions in the intervention group and 39 admissions in the control group. Thirty-seven admissions were female patients, and 44 admissions were for alcoholic liver disease. Mean model for end-stage liver disease (MELD)-Na score at admission was 25.8. Forty-seven (55.3%) admissions received quality care. There was no difference in the provision of quality care (56.41% vs 54.35%, P = 0.9) between the two groups. 30-d readmission was lower in the intervention group (35% vs 52.78%, P = 0.1) and after correction for age, gender and MELD-Na score [RR = 0.62 (0.39, 1.00), P = 0.05]. No significant differences were seen for LOS, complications, in-hospital mortality or overall mortality between the two groups. Resident medical knowledge and self-efficacy with paracentesis improved after the educational intervention.
CONCLUSION Medical education has the potential to improve clinical outcomes in patients admitted to hospital with cirrhosis and ascites.
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Affiliation(s)
- Nicholas Lim
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, United States
| | - Otto Sanchez
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN 55455, United States
| | - Andrew Olson
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN 55455, United States
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221
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Pan CQ, Gayam V, Rabinovich C, Normatov M, Fidman B, Wang D, Garlapati P. Efficacy of Direct-Acting Antivirals for Chronic Hepatitis C in a Large Cohort of Older Adults in the United States. J Am Geriatr Soc 2019; 68:379-387. [PMID: 31647119 DOI: 10.1111/jgs.16206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 09/04/2019] [Accepted: 09/08/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Data on the virologic response and tolerability of direct-acting antivirals (DAAs) are lacking in older people because these individuals are underrepresented in clinical trials. This study aimed to assess the effectiveness and tolerability of DAA regimens in older individuals in a large cohort of real-life clinical practice. METHODS In this retrospective study, patients with chronic hepatitis C infection between 2017 and 2018 were divided into patients aged 65 years and older and those younger than 65 years. We evaluated the sustained virologic response rates (SVRs) in both groups. Further subgroup analyses on the SVRs for patients aged 65 to 74, 75 to 84, and 85 years and older were performed. We also analyzed the predictors of treatment response in older individuals. RESULTS Among 1151 eligible patients, 516 were in the older group and 635 were in the younger group. The overall treatment response in the entire cohort was 97.7%. A significantly higher percentage of patients presented with advanced stages of fibrosis in the older group (53.1% vs 39.5%; P = <.001). The SVR rates were similar between the two groups (98.3% vs 97.7%; P = .18). In multivariate models, age was not predictive of SVR after adjusting for confounders. Subgroup analyses in the age groups of 65 to 74, 75 to 84, and older than 85 years showed similar treatment response rates (97.4%, 97.2%, and 86.7, respectively; P = .06) and advanced fibrosis (50.8%, 61.5%, and 53.3%, respectively; P = .14). CONCLUSION Although older people exhibit a significantly higher frequency of fibrosis, DAAs produce high rates of SVR in all age groups, and the age of the patient does not seem to have a significant impact on the efficacy of DAAs including patients in the oldest age category (≥75 y). Treatment should not be withheld in older individuals. J Am Geriatr Soc 68:379-387, 2020.
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Affiliation(s)
- Calvin Q Pan
- Center of Liver Diseases, Capital Medical University Affiliated Beijing Ditan Hospital, Chaoyang District, Beijing, China.,Division of Gastroenterology and Hepatology, NYU Langone Health, New York University School of Medicine, New York, New York
| | - Vijay Gayam
- Interfaith Medical Center, SUNY Downstate University Hospital, Brooklyn, New York
| | | | | | | | - Dan Wang
- St. John's University, Jamaica, New York
| | - Pavani Garlapati
- Interfaith Medical Center, SUNY Downstate University Hospital, Brooklyn, New York
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222
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Pocha C, Xie C. Hepatocellular carcinoma in alcoholic and non-alcoholic fatty liver disease-one of a kind or two different enemies? Transl Gastroenterol Hepatol 2019; 4:72. [PMID: 31728429 DOI: 10.21037/tgh.2019.09.01] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/22/2019] [Indexed: 12/24/2022] Open
Abstract
Hepatocellular cancer (HCC) is a cancer with an overall poor prognosis and an alarming globally rising incidence. While viral etiology of chronic liver disease and HCC is down-trending, alcohol and excess calorie intake have emerged as major culprits. Alcohol related liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD) share similar pathogenetic mechanism of hepatic injury and in promoting development of HCC; yet some genetic and epigenetic features are distinct and may promise clinical utility. Population based intervention are urgently needed to reduce alcohol use and improve metabolic factors such as obesity and diabetes. The goal is to identify at-risk patients, to link these patients to care and to provide effective management of chronic liver disease and HCC. This review focuses on the epidemiology, pathophysiology including genetic and epigenetic altercation as well as clinical aspects of ALD and NAFLD associated HCC.
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Affiliation(s)
- Christine Pocha
- Avera McKennnan Hospital and University Medical Center, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USA.,Department of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Chencheng Xie
- Avera McKennnan Hospital and University Medical Center, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USA.,Department of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA, USA
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223
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Outcomes of Patients With Cirrhosis Undergoing Orthopedic Procedures: An Analysis of the Nationwide Inpatient Sample. J Clin Gastroenterol 2019; 53:e356-e361. [PMID: 30001287 PMCID: PMC6443495 DOI: 10.1097/mcg.0000000000001091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The population of patients with cirrhosis is growing and shifting toward a more elderly demographic and thus are at risk of developing orthopedic complications. There is lack of data on safety of orthopedic procedures in this population. METHODS We performed an analysis of the Nationwide Inpatient Sample from 2005 to 2011 for patients undergoing hip arthroplasty, knee arthroplasty, and spinal laminectomy/fusion, stratified by presence of cirrhosis. The primary endpoint was in-hospital mortality and secondary endpoints included length of stay (LOS) and costs. RESULTS There were 693,610 inpatient stays for orthopedic procedures conducted during the study period, with 3014 (0.43%) patients coded as having cirrhosis. Patients with cirrhosis had a lower median age (62 vs. 66 y; P<0.001) and were more likely to be male (52.3% vs. 41.1%; P<0.001). The inpatient mortality rate was significantly higher in patients with cirrhosis (2.4% vs. 0.4%; P<0.001) as was median LOS (4 vs. 3 d; P<0.001) and mean costs ($19,321 vs. $18,833; P<0.001). Patients with decompensated cirrhosis (vs. compensated cirrhosis) had significantly higher inpatient mortality rates (5.8% vs. 1.1%; P<0.001) with higher LOS and costs (P<0.001). On multivariable analysis, cirrhosis was associated with an increased risk of mortality (odds ratio, 4.22; 95% confidence interval, 2.92-6.10). Hospital cirrhosis volume was inversely associated with mortality, while hospital orthopedic procedure volumes had an inconsistent impact on outcomes. CONCLUSIONS Inpatient orthopedic procedures in patients with cirrhosis result in high postoperative mortality, LOS, and costs. Careful patient selection is warranted to optimize cirrhosis patient postoperative outcomes.
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224
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Gawrieh S, Dakhoul L, Miller E, Scanga A, deLemos A, Kettler C, Burney H, Liu H, Abu-Sbeih H, Chalasani N, Wattacheril J. Characteristics, aetiologies and trends of hepatocellular carcinoma in patients without cirrhosis: a United States multicentre study. Aliment Pharmacol Ther 2019; 50:809-821. [PMID: 31475372 DOI: 10.1111/apt.15464] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 06/30/2019] [Accepted: 07/24/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Limited data exist on the burden and features of non-cirrhotic hepatocellular carcinoma (HCC) in the United States. AIM To evaluate characteristics, aetiologies, trends and outcomes of non-cirrhotic HCC from 2000 to 2014 at five large US centres METHODS: Patient, tumour and liver disease aetiology data were collected. The presence of underlying cirrhosis was assessed based on published criteria. RESULTS Of 5144 eligible patients with HCC, 11.7% had no underlying cirrhosis. Non-cirrhotic patients were older (64.1 vs 61.2 years), more frequently females (33.9% vs 20.8%) and less frequently black (8.3% vs 12.4%) (P < .001 for all). Among non-cirrhotic patients, non-alcoholic fatty liver disease (NAFLD) was the most common liver disease (26.3%), followed by hepatitis C virus (HCV) (12.1%) and hepatitis B virus (HBV) (10%) infections. As of 2014, there was increased percentage of cirrhotic HCC and a decline in non-cirrhotic HCC mainly due to significant annual increases in cirrhotic HCC due to HCV (0.96% [P < .0001]) and NAFLD (0.66% [P = .003]). Patients with non-cirrhotic HCC had larger tumours (8.9 vs 5.3 cm), were less frequently within Milan criteria (15% vs 39%), more frequently underwent resection (43.6% vs 8%) (P < .001 for all) and had better overall survival than cirrhotic HCC patients (median 1.8 vs 1.3 years, P = .004). CONCLUSIONS Nearly 12% of HCCs occurred in patients without underlying cirrhosis. NAFLD was the most common liver disease in these patients. During the study, the frequency of non-cirrhotic HCC decreased, whereas that of cirrhotic HCC increased. Although non-cirrhotic patients presented with more advanced HCC, their survival was better.
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Affiliation(s)
- Samer Gawrieh
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Lara Dakhoul
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Andrew Scanga
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Carla Kettler
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Heather Burney
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Hao Liu
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Naga Chalasani
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Julia Wattacheril
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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225
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Ioannou GN, Green P, Kerr KF, Berry K. Models estimating risk of hepatocellular carcinoma in patients with alcohol or NAFLD-related cirrhosis for risk stratification. J Hepatol 2019; 71:523-533. [PMID: 31145929 PMCID: PMC6702126 DOI: 10.1016/j.jhep.2019.05.008] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 03/12/2019] [Accepted: 05/03/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Hepatocellular carcinoma (HCC) risk varies dramatically in patients with cirrhosis according to well-described, readily available predictors. We aimed to develop simple models estimating HCC risk in patients with alcohol-related liver disease (ALD)-cirrhosis or non-alcoholic fatty liver disease (NAFLD)-cirrhosis and calculate the net benefit that would be derived by implementing HCC surveillance strategies based on HCC risk as predicted by our models. METHODS We identified 7,068 patients with NAFLD-cirrhosis and 16,175 with ALD-cirrhosis who received care in the Veterans Affairs (VA) healthcare system in 2012. We retrospectively followed them for the development of incident HCC until January 2018. We used Cox proportional hazards regression to develop and internally validate models predicting HCC risk using baseline characteristics at entry into the cohort in 2012. We plotted decision curves of net benefit against HCC screening thresholds. RESULTS We identified 1,278 incident cases of HCC during a mean follow-up period of 3.7 years. Mean annualized HCC incidence was 1.56% in NAFLD-cirrhosis and 1.44% in ALD-cirrhosis. The final models estimating HCC were developed separately for NAFLD-cirrhosis and ALD-cirrhosis and included 7 predictors: age, gender, diabetes, body mass index, platelet count, serum albumin and aspartate aminotransferase to √alanine aminotransferase ratio. The models exhibited very good measures of discrimination and calibration and an area under the receiver operating characteristic curve of 0.75 for NAFLD-cirrhosis and 0.76 for ALD-cirrhosis. Decision curves showed higher standardized net benefit of risk-based screening using our prediction models compared to the screen-all approach. CONCLUSIONS We developed simple models estimating HCC risk in patients with NAFLD-cirrhosis or ALD-cirrhosis, which are available as web-based tools (www.hccrisk.com). Risk stratification can be used to inform risk-based HCC surveillance strategies in individual patients or healthcare systems or to identify high-risk patients for clinical trials. LAY SUMMARY Patients with cirrhosis of the liver are at risk of getting hepatocellular carcinoma (HCC or liver cancer) and therefore it is recommended that they undergo surveillance for HCC. However, the risk of HCC varies dramatically in patients with cirrhosis, which has implications on if and how patients get surveillance, how providers counsel patients about the need for surveillance, and how healthcare systems approach and prioritize surveillance. We used readily available predictors to develop models estimating HCC risk in patients with cirrhosis, which are available as web-based tools at www.hccrisk.com.
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Affiliation(s)
- George N Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, United States; Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, United States; Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, United States.
| | - Pamela Green
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, United States
| | - Kathleen F Kerr
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, United States
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226
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Uyei J, Taddei TH, Kaplan DE, Chapko M, Stevens ER, Braithwaite RS. Setting ambitious targets for surveillance and treatment rates among patients with hepatitis C related cirrhosis impacts the cost-effectiveness of hepatocellular cancer surveillance and substantially increases life expectancy: A modeling study. PLoS One 2019; 14:e0221614. [PMID: 31449554 PMCID: PMC6709904 DOI: 10.1371/journal.pone.0221614] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 08/03/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Hepatocelluar cancer (HCC) is the leading cause of death among people with hepatitis C virus (HCV)-related cirrhosis. Our aim was to determine the optimal surveillance frequency for patients with HCV-related compensated cirrhosis. METHODS We developed a decision analytic Markov model and validated it against data from the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) study group and published epidemiologic studies. Four strategies of different surveillance intervals were compared: no surveillance and ultrasound surveillance every 12, 6, and 3 months. We estimated lifetime survival, life expectancy, quality adjusted life years (QALY), total costs associated with each strategy, and incremental cost effectiveness ratios. We applied a willingness to pay threshold of $100,000. Analysis was conducted for two scenarios: a scenario reflecting current HCV and HCC surveillance compliance rates and treatment use and an aspirational scenario. RESULTS In the current scenario the preferred strategy was 3-month surveillance with an incremental cost-effectiveness ratio (ICER) of $7,159/QALY. In the aspirational scenario, 6-month surveillance was preferred with an ICER of $82,807/QALY because treating more people with HCV led to a lower incidence of HCC. Sensitivity analyses suggested that surveillance every 12 months would suffice in the particular circumstance when patients are very likely to return regularly for testing and when appropriate HCV and HCC treatment is readily available. Compared with the current scenario, the aspirational scenario resulted in a 1.87 year gain in life expectancy for the cohort because of large reductions in decompensated cirrhosis and HCC incidence. CONCLUSIONS HCC surveillance has good value for money for patients with HCV-related compensated cirrhosis. Investments to improve adherence to surveillance should be made when rates are suboptimal. Surveillance every 12 months will suffice when patients are very likely to return regularly for testing and when appropriate HCV and HCC treatment is readily available.
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Affiliation(s)
- Jennifer Uyei
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University School of Medicine, New York, NY, United States of America
- * E-mail:
| | - Tamar H. Taddei
- VA Connecticut-Healthcare System, West Haven, CT, United States of America
| | - David E. Kaplan
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States of America
| | - Michael Chapko
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, WA, United States of America
| | - Elizabeth R. Stevens
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University School of Medicine, New York, NY, United States of America
| | - R. Scott Braithwaite
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University School of Medicine, New York, NY, United States of America
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227
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Ioannou GN, Green PK, Berry K, Graf SA. Eradication of Hepatitis C Virus Is Associated With Reduction in Hematologic Malignancies: Major Differences Between Interferon and Direct-Acting Antivirals. Hepatol Commun 2019; 3:1124-1136. [PMID: 31388632 PMCID: PMC6671776 DOI: 10.1002/hep4.1389] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/17/2019] [Indexed: 12/15/2022] Open
Abstract
It is unclear whether eradication of hepatitis C virus (HCV) leads to a reduction in the risk of hematologic malignancies. We aimed to determine the impact of sustained virologic response (SVR) induced by either direct-acting antivirals (DAAs) or interferon (IFN) on the risk of hematologic malignancies. We identified 69,581 patients who initiated antiviral treatment in the Veterans Affairs national health care system from January 1, 1999, to December 31, 2015, including 40,410 (58%) IFN-only regimens, 4,546 (6.5%) DAA + IFN regimens, and 24,625 (35%) DAA-only regimens. We retrospectively followed patients to identify incident cases of hematologic malignancies or monoclonal gammopathy of unknown significance (MGUS), a premalignant precursor of multiple myeloma. Among patients treated with IFN, SVR was significantly associated with a reduction in the risk of lymphoma (adjusted hazard ratio [AHR], 0.70; 95% confidence interval [CI], 0.51-0.97), multiple myeloma (AHR, 0.40; 95% CI, 0.20-0.77), MGUS (AHR, 0.65; 95% CI, 0.42-0.99), or all hematologic malignancies and MGUS combined (AHR, 0.67; 95% CI, 0.53-0.84) over a mean follow-up of 10.6 years. In contrast, among patients treated with DAA, SVR was not associated with the risk of lymphoma, multiple myeloma, MGUS, or all hematologic malignancies and MGUS combined (AHR, 1.08; 95% CI, 0.66-1.78) during a mean follow-up of 2.9 years. Neither IFN-induced SVR nor DAA-induced SVR was associated with risk of colon cancer or prostate cancer, which were chosen a priori as comparison/control malignancies. Conclusion: We describe novel strong associations between IFN-induced SVR and lymphoma, multiple myeloma, MGUS, and all hematologic malignancies combined. Surprisingly, these associations were not observed with DAA-induced SVR.
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Affiliation(s)
- George N. Ioannou
- Division of Gastroenterology, Department of MedicineVeterans Affairs Puget Sound Health Care System and University of WashingtonSeattleWA
- Research and DevelopmentVeterans Affairs Puget Sound Health Care SystemSeattleWA
| | - Pamela K. Green
- Research and DevelopmentVeterans Affairs Puget Sound Health Care SystemSeattleWA
| | - Kristin Berry
- Research and DevelopmentVeterans Affairs Puget Sound Health Care SystemSeattleWA
| | - Solomon A. Graf
- Division of Oncology, Department of MedicineVeterans Affairs Puget Sound Health Care System and University of WashingtonSeattleWA
- Clinical Research DivisionFred Hutch Cancer Research CenterSeattleWA
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Garvin JH, Ducom J, Matheny M, Miller A, Westerman D, Reale C, Slagle J, Kelly N, Beebe R, Koola J, Groessl EJ, Patterson ES, Weinger M, Perkins AM, Ho SB. Descriptive Usability Study of CirrODS: Clinical Decision and Workflow Support Tool for Management of Patients With Cirrhosis. JMIR Med Inform 2019; 7:e13627. [PMID: 31271153 PMCID: PMC6636234 DOI: 10.2196/13627] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/13/2019] [Accepted: 05/15/2019] [Indexed: 01/16/2023] Open
Abstract
Background There are gaps in delivering evidence-based care for patients with chronic liver disease and cirrhosis. Objective Our objective was to use interactive user-centered design methods to develop the Cirrhosis Order Set and Clinical Decision Support (CirrODS) tool in order to improve clinical decision-making and workflow. Methods Two work groups were convened with clinicians, user experience designers, human factors and health services researchers, and information technologists to create user interface designs. CirrODS prototypes underwent several rounds of formative design. Physicians (n=20) at three hospitals were provided with clinical scenarios of patients with cirrhosis, and the admission orders made with and without the CirrODS tool were compared. The physicians rated their experience using CirrODS and provided comments, which we coded into categories and themes. We assessed the safety, usability, and quality of CirrODS using qualitative and quantitative methods. Results We created an interactive CirrODS prototype that displays an alert when existing electronic data indicate a patient is at risk for cirrhosis. The tool consists of two primary frames, presenting relevant patient data and allowing recommended evidence-based tests and treatments to be ordered and categorized. Physicians viewed the tool positively and suggested that it would be most useful at the time of admission. When using the tool, the clinicians placed fewer orders than they placed when not using the tool, but more of the orders placed were considered to be high priority when the tool was used than when it was not used. The physicians’ ratings of CirrODS indicated above average usability. Conclusions We developed a novel Web-based combined clinical decision-making and workflow support tool to alert and assist clinicians caring for patients with cirrhosis. Further studies are underway to assess the impact on quality of care for patients with cirrhosis in actual practice.
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Affiliation(s)
- Jennifer Hornung Garvin
- Health Information Management and Systems, The Ohio State University, Columbus, OH, United States.,Center for Health Information and Communication, Richard L Roudebush Department of Veterans Affairs Medical Center, Indianapolis, IN, United States.,Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States.,Department of Biomedical Informatics, The Ohio State University, Columbus, OH, United States.,Department of Veteran Affairs Salt Lake City Healthcare System, Salt Lake City, UT, United States.,Division of Epidemiology, University of Utah, Salt Lake City, UT, United States
| | - Julie Ducom
- Department of Veterans Affairs San Diego Healthcare System, San Diego, CA, United States
| | - Michael Matheny
- Geriatric Research Education and Clinical Center, Department of Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States.,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Anne Miller
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Dax Westerman
- Geriatric Research Education and Clinical Center, Department of Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Carrie Reale
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jason Slagle
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Natalie Kelly
- Department of Veteran Affairs Salt Lake City Healthcare System, Salt Lake City, UT, United States
| | - Russ Beebe
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jejo Koola
- Geriatric Research Education and Clinical Center, Department of Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States.,Department of Medicine, University of California San Diego, San Diego, CA, United States
| | - Erik J Groessl
- Department of Veterans Affairs San Diego Healthcare System, San Diego, CA, United States.,Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, United States
| | - Emily S Patterson
- Health Information Management and Systems, The Ohio State University, Columbus, OH, United States
| | - Matthew Weinger
- Geriatric Research Education and Clinical Center, Department of Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States.,Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Amy M Perkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Samuel B Ho
- Department of Veterans Affairs San Diego Healthcare System, San Diego, CA, United States.,Department of Medicine, University of California San Diego, San Diego, CA, United States.,Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
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229
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Tapper EB. Predicting Overt Hepatic Encephalopathy for the Population With Cirrhosis. Hepatology 2019; 70:403-409. [PMID: 30703852 PMCID: PMC6597301 DOI: 10.1002/hep.30533] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 01/25/2019] [Indexed: 12/20/2022]
Abstract
Hepatic encephalopathy (HE) is associated with poor quality of life, sharply increased mortality, repeated hospitalizations, falls, and motor vehicle accidents. HE manifests with a dynamic spectrum of severity. Overt HE is clinically obvious disorientation, even coma. Although multiple strategies are available to characterize early-stage HE, data are limited that validate these methods in predicting overt HE, many are impractical in clinical practice, and test cutoffs relevant to the average patient clinicians manage are lacking. To accurately and efficiently classify the risk of overt HE in the population with cirrhosis, novel strategies may be needed. Herein, we review the potential competing strategies for the prediction of overt HE. Conclusion: We propose refining diagnostic cutoffs for tests that are designed to define early HE, using overt HE as a gold standard and expanding prediction tools by using measures of components from the risk pathway for HE.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor
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230
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Zhou X, Li Y, Zhang X, Guan YY, Puentes Y, Zhang F, Speliotes EK, Ji L. Independent markers of nonalcoholic fatty liver disease in a gentrifying population-based Chinese cohort. Diabetes Metab Res Rev 2019; 35:e3156. [PMID: 30892820 PMCID: PMC6606362 DOI: 10.1002/dmrr.3156] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 03/15/2019] [Accepted: 03/17/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Prevalence of nonalcoholic fatty liver disease (NAFLD) is increasing in developing countries, but its causes are not known. We aimed to ascertain the prevalence and determinants of NAFLD in a new largely unmedicated population-based cohort from the rapidly gentrifying region of Pinggu, China. METHODS We randomized cluster sampled 4002 Pinggu residents aged 26 to 76 years. Data from 1238 men and 1928 women without significant alcohol drinking or hepatitis virus B or C infection were analysed. NAFLD was defined using a liver-spleen ratio (L/S ratio) ≤1.1 on unenhanced abdominal computed tomography (CT) scanning. RESULTS Of men and women, 26.5% and 20.1%, respectively, had NAFLD. NAFLD prevalence was highest in younger men and older women. In multivariate logistic regression models, higher body mass index, waist circumference, serum triglyceride, alanine transaminase, and haemoglobin A1c independently increased the odds of NAFLD in both men and women separately. Higher annual household income and systolic blood pressure for men and higher serum uric acid and red meat intake and lower physical activity levels for women also independently associated with higher odds of NAFLD. Individuals with L/S ratio ≤1.1 had linearly increasing rates of obesity, diabetes, and metabolic syndrome that paralleled fatty liver increase. CONCLUSIONS NAFLD is common in a gentrifying Chinese population particularly in younger men of high socioeconomic status and older women with sedentary behaviour who eat red meat. Demographic factors add independent risk of NAFLD above traditional metabolic risk factors. A CT L/S ratio of ≤1.1 identifies individuals at high risk of metabolic disease.
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Affiliation(s)
- Xianghai Zhou
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Yufeng Li
- Department of Endocrinology and Metabolism, Pinggu Hospital, Beijing, China
| | - Xiuying Zhang
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Ying Ying Guan
- Department of Environmental Health Sciences, University of Michigan, Ann Arbor, Michigan
| | - Yindra Puentes
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
| | - Fang Zhang
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Elizabeth K. Speliotes
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
- Divisions of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
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231
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Pinheiro PS, Callahan KE, Jones PD, Morris C, Ransdell JM, Kwon D, Brown CP, Kobetz EN. Liver cancer: A leading cause of cancer death in the United States and the role of the 1945-1965 birth cohort by ethnicity. JHEP Rep 2019; 1:162-169. [PMID: 32039366 PMCID: PMC7001577 DOI: 10.1016/j.jhepr.2019.05.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/23/2019] [Accepted: 05/26/2019] [Indexed: 02/06/2023] Open
Abstract
Liver cancer is highly fatal and the most rapidly increasing cancer in the US, where chronic hepatitis C (HCV) infection is the leading etiology. HCV is particularly prevalent among the 1945-1965 birth cohort, the so-called “baby boomers”. Focusing on this cohort-etiology link, we aim to characterize liver cancer patterns for 15 unique US populations: White, African American, Mexican Immigrant, Mexican American, Cuban and Chinese, among others. Methods Individual-level mortality data from 2012–2016 from the health departments of 3 large states – California, Florida, New York – were pooled to compute liver cancer mortality rates for each racial/ethnic group and for 2 birth cohorts of interest: “1945–1965 cohort” and “older cohort”. Results Liver cancer is a major cause of cancer death among all US male groups and the leading cause in Mexican American men. Over 50% of the age-adjusted liver cancer mortality of White, African American, Mexican American, and Puerto Rican males came from the 1945-1965 birth cohort. In contrast, foreign-born male and all female populations had higher liver cancer mortality originating from the older cohort. Internationally, US White male baby boomers had a 49% higher liver cancer mortality rate than their counterparts in Europe (mortality rate ratio 1.49; 95% CI 1.43–1.56). Conclusions Populations burdened disproportionately by liver cancer in the 1945–1965 cohort include US-born males who were all present in the US during the 1960s–1990s when significant HCV transmission took place; these individuals will benefit most from HCV screening and treatment. For the others, including all women, Asian subgroups, and especially burgeoning Hispanic immigrant populations, comprehensive liver cancer prevention efforts will require detailed study of the distribution of etiologies. Lay summary Liver cancer, a major cause of cancer death among US males, is increasing. The causes of liver cancer are varied, including hepatitis C, hepatitis B, alcohol-related liver disease, and non-alcoholic fatty liver disease. Racial/ethnic groups are impacted differently, but the highest rates are seen among US-born men born between 1945–1965, the so-called “baby boomers”, whether White, Black, or Hispanic, likely linked to the known high prevalence of hepatitis C infection among this cohort. Liver cancer is now the leading cause of cancer death among Mexican American males. Rates vary intra-racially: e.g. Vietnamese have high rates; South Asians have low. US-born male “baby boomers” of any race/ethnicity have the highest liver cancer mortality. Foreign-born men and all women have higher mortality at older ages, 70 or more. In the “baby boomer” cohort, US Whites have higher liver cancer mortality than Europeans.
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Affiliation(s)
- Paulo S Pinheiro
- Department of Public Health Sciences, Division of Epidemiology & Population Health Sciences, University of Miami School of Medicine
| | | | - Patricia D Jones
- University of Miami School of Medicine, Department of Medicine, Division of Hepatology
| | - Cyllene Morris
- CalCARES Program, Institute for Population Health Improvement, University of California Davis Health System
| | - Justine M Ransdell
- Department of Public Health Sciences, University of Miami School of Medicine
| | - Deukwoo Kwon
- University of Miami School of Medicine, Department of Public Health Sciences, Biostatistics
| | - Clyde Perry Brown
- Florida A&M University College of Pharmacy and Pharmaceutical Sciences
| | - Erin N Kobetz
- Sylvester Comprehensive Cancer Center, University of Miami School of Medicine
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232
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Orman ES, Roberts A, Ghabril M, Nephew L, Desai A, Patidar K, Chalasani N. Trends in Characteristics, Mortality, and Other Outcomes of Patients With Newly Diagnosed Cirrhosis. JAMA Netw Open 2019; 2:e196412. [PMID: 31251379 PMCID: PMC6604080 DOI: 10.1001/jamanetworkopen.2019.6412] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Changes in the characteristics of patients with cirrhosis are likely to affect future outcomes and are important to understand in planning for the care of this population. OBJECTIVE To identify changes in demographic and clinical characteristics and outcomes in patients with newly diagnosed cirrhosis. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of patients with a new diagnosis of cirrhosis was conducted using the Indiana Network for Patient Care, a large statewide regional health information exchange, between 2004 and 2014. Patients with at least 1 year of continuous follow-up before the cirrhosis diagnosis were followed up through August 1, 2015. The analysis was conducted from December 2018 to January 2019. EXPOSURES Age, cause of cirrhosis, and year of diagnosis. MAIN OUTCOMES AND MEASURES Overall rates for mortality, liver transplant, hepatocellular carcinoma, and hepatic decompensation (composite of ascites, hepatic encephalopathy, or variceal bleeding). RESULTS A total of 9261 patients with newly diagnosed cirrhosis were identified (mean [SD] age, 57.9 [12.6] years; 5109 [55.2%] male). A 69% increase in new diagnoses occurred over the course of the study period (620 in 2004 vs 1045 in 2014). The proportion of those younger than 40 years increased by 0.20% per year (95% CI, 0.04% to 0.36%; P for trend = .02), and the proportion of those aged 65 years and older increased by 0.81% per year (95% CI, 0.51% to 1.11%; P for trend < .001). The proportion of patients with alcoholic cirrhosis increased by 0.80% per year (95% CI, 0.49% to 1.12%), and the proportion with nonalcoholic steatohepatitis increased by 0.59% per year (95% CI, 0.30% to 0.87%), whereas the proportion with viral hepatitis decreased by 1.36% per year (95% CI, -1.68% to -1.03%) (P < .001 for all). In patients younger than 40 years, 40 to 64 years, and 65 years and older, mortality rates were 6.4 (95% CI, 5.4 to 7.6), 9.9 (95% CI, 9.5 to 10.4), and 16.2 (95% CI, 15.2 to 17.2) per 100 person-years, respectively (P < .001). Mortality rates decreased during the study period (11.9 [95% CI, 10.7-13.1] per 100 person-years in 2004 vs 10.0 [95% CI, 8.1-12.2] per 100 person-years in 2014; annual adjusted hazard ratio, 0.87 [95% CI, 0.86 to 0.88]) and were lower in those with alcoholic cirrhosis compared with patients with viral hepatitis (adjusted hazard ratio, 0.89 [95% CI, 0.80 to 0.98]). Rates of hepatocellular carcinoma were low in patients younger than 40 years (0.5 [95% CI, 0.2 to 0.9] per 100 person-years). Liver transplant rates were low throughout the study period (0.3 [95% CI, 0.3-0.4] per 100 person-years). In patients with compensated cirrhosis, rates of hepatic decompensation were lower in patients younger than 40 years (adjusted subhazard ratio 0.78; 95% CI, 0.62 to 0.99) and in patients with nonalcoholic steatohepatitis (adjusted subhazard ratio, 0.51; 95% CI, 0.43 to 0.60). CONCLUSIONS AND RELEVANCE The population of patients with newly diagnosed cirrhosis in Indiana has experienced changes in the age distribution and cause of cirrhosis, with decreasing mortality rates. These findings support investment in the prevention and treatment of alcoholic liver disease and nonalcoholic steatohepatitis, particularly in younger and older patients. Additional study is needed to identify the reasons for decreasing mortality rates.
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Affiliation(s)
- Eric S. Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Anna Roberts
- Regenstrief Institute, Inc, Indianapolis, Indiana
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Archita Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Kavish Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
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233
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Shu Z, Liu W, Wu H, Xiao M, Wu D, Cao T, Ren M, Tao J, Zhang C, He T, Li X, Zhang R, Zhou X. Symptom-based network classification identifies distinct clinical subgroups of liver diseases with common molecular pathways. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 174:41-50. [PMID: 29502851 DOI: 10.1016/j.cmpb.2018.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 02/22/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND AND OBJECTIVE Liver disease is a multifactorial complex disease with high global prevalence and poor long-term clinical efficacy and liver disease patients with different comorbidities often incorporate multiple phenotypes in the clinic. Thus, there is a pressing need to improve understanding of the complexity of clinical liver population to help gain more accurate disease subtypes for personalized treatment. METHODS Individualized treatment of the traditional Chinese medicine (TCM) provides a theoretical basis to the study of personalized classification of complex diseases. Utilizing the TCM clinical electronic medical records (EMRs) of 6475 liver inpatient cases, we built a liver disease comorbidity network (LDCN) to show the complicated associations between liver diseases and their comorbidities, and then constructed a patient similarity network with shared symptoms (PSN). Finally, we identified liver patient subgroups using community detection methods and performed enrichment analyses to find both distinct clinical and molecular characteristics (with the phenotype-genotype associations and interactome networks) of these patient subgroups. RESULTS From the comorbidity network, we found that clinical liver patients have a wide range of disease comorbidities, in which the basic liver diseases (e.g. hepatitis b, decompensated liver cirrhosis), and the common chronic diseases (e.g. hypertension, type 2 diabetes), have high degree of disease comorbidities. In addition, we identified 303 patient modules (representing the liver patient subgroups) from the PSN, in which the top 6 modules with large number of cases include 51.68% of the whole cases and 251 modules contain only 10 or fewer cases, which indicates the manifestation diversity of liver diseases. Finally, we found that the patient subgroups actually have distinct symptom phenotypes, disease comorbidity characteristics and their underlying molecular pathways, which could be used for understanding the novel disease subtypes of liver conditions. For example, three patient subgroups, namely Module 6 (M6, n = 638), M2 (n = 623) and M1 (n = 488) were associated to common chronic liver disease conditions (hepatitis, cirrhosis, hepatocellular carcinoma). Meanwhile, patient subgroups of M30 (n = 36) and M36 (n = 37) were mostly related to acute gastroenteritis and upper respiratory infection, respectively, which reflected the individual comorbidity characteristics of liver subgroups. Furthermore, we identified the distinct genes and pathways of patient subgroups and the basic liver diseases (hepatitis b and cirrhosis), respectively. The high degree of overlapping pathways between them (e.g. M36 with 93.33% shared enriched pathways) indicates the underlying molecular network mechanisms of each patient subgroup. CONCLUSIONS Our results demonstrate the utility and comprehensiveness of disease classification study based on community detection of patient network using shared TCM symptom phenotypes and it can be used to other more complex diseases.
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Affiliation(s)
- Zixin Shu
- Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430061, China; The clinical medical college of Traditional Chinese Medicine, Hubei University of Traditional Chinese Medicine, Wuhan 430065, China
| | - Wenwen Liu
- School of Computer and Information Technology and Beijing Key Lab of Traffic Data Analysis and Mining, Beijing Jiaotong University, Beijing 100044, China
| | - Huikun Wu
- Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430061, China; Hubei Province Academy of Traditional Chinese Medicine, Wuhan 430061, China
| | - Mingzhong Xiao
- Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430061, China; Hubei Province Academy of Traditional Chinese Medicine, Wuhan 430061, China
| | - Deng Wu
- Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430061, China; Hubei Province Academy of Traditional Chinese Medicine, Wuhan 430061, China
| | - Ting Cao
- Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430061, China; Hubei Province Academy of Traditional Chinese Medicine, Wuhan 430061, China
| | - Meng Ren
- Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430061, China; Hubei Province Academy of Traditional Chinese Medicine, Wuhan 430061, China
| | - Junxiu Tao
- Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430061, China; Hubei Province Academy of Traditional Chinese Medicine, Wuhan 430061, China
| | - Chuhua Zhang
- Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430061, China; Hubei Province Academy of Traditional Chinese Medicine, Wuhan 430061, China
| | - Tangqing He
- Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430061, China; Hubei Province Academy of Traditional Chinese Medicine, Wuhan 430061, China
| | - Xiaodong Li
- Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430061, China; Hubei Province Academy of Traditional Chinese Medicine, Wuhan 430061, China.
| | - Runshun Zhang
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China.
| | - Xuezhong Zhou
- School of Computer and Information Technology and Beijing Key Lab of Traffic Data Analysis and Mining, Beijing Jiaotong University, Beijing 100044, China.
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234
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Saviano A, Baumert TF. Mortality from liver cirrhosis and HCC in the DAA era: success in viral control is darkened by raise of metabolic disease. Hepatobiliary Surg Nutr 2019; 8:307-310. [PMID: 31245422 DOI: 10.21037/hbsn.2019.01.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Antonio Saviano
- Inserm U1110, Institut de Recherche sur les Maladies Virales et Hépatiques, Université de Strasbourg, F-67000 Strasbourg, France.,Pôle Hépato-digestif, Institut Hopitalo-Universitaire, Hôpitaux Universitaires, F-67000 Strasbourg, France
| | - Thomas F Baumert
- Inserm U1110, Institut de Recherche sur les Maladies Virales et Hépatiques, Université de Strasbourg, F-67000 Strasbourg, France.,Pôle Hépato-digestif, Institut Hopitalo-Universitaire, Hôpitaux Universitaires, F-67000 Strasbourg, France
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235
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Singal AG, Lim JK, Kanwal F. AGA Clinical Practice Update on Interaction Between Oral Direct-Acting Antivirals for Chronic Hepatitis C Infection and Hepatocellular Carcinoma: Expert Review. Gastroenterology 2019; 156:2149-2157. [PMID: 30878469 PMCID: PMC6529246 DOI: 10.1053/j.gastro.2019.02.046] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/19/2019] [Indexed: 02/08/2023]
Abstract
DESCRIPTION The purpose of this clinical practice update is to evaluate the evidence describing the interaction between direct-acting antiviral (DAA) therapy for hepatitis and hepatocellular carcinoma (HCC) with regard to HCC incidence, HCC recurrence, and DAA efficacy, and to summarize best practice advice regarding HCC surveillance and timing of DAA therapy. METHODS The recommendations outlined in this expert review are based on available published evidence, including observational studies and systematic reviews, and incorporates expert opinion where applicable. BEST PRACTICE ADVICE 1: DAA treatment is associated with a reduction in the risk of incident HCC. The relative risk reduction is similar in patients with and without cirrhosis. BEST PRACTICE ADVICE 2: Patients with advanced liver fibrosis (F3) or cirrhosis should receive surveillance imaging before initiating DAA treatment. BEST PRACTICE ADVICE 3: Patients with advanced liver fibrosis (F3) or cirrhosis at the time of DAA treatment represent the highest-risk group for HCC after DAA-induced sustained virologic response. These patients should stay in HCC surveillance. BEST PRACTICE ADVICE 4: HCC surveillance should be performed using ultrasound with or without α-fetoprotein every 6 months. Current data do not support shorter surveillance intervals or the use of alternative surveillance modalities. BEST PRACTICE ADVICE 5: Future studies may show a reduction in HCC risk over time after DAA-induced sustained virologic response. However, in the interim, HCC surveillance should continue indefinitely if patients are otherwise eligible for potentially curative therapy. BEST PRACTICE ADVICE 6: The presence of active HCC is associated with a small but statistically significant decrease in sustained virologic response with DAA therapy. BEST PRACTICE ADVICE 7: Patients with HCC who are eligible for potentially curative therapy with liver resection or ablation should defer DAA therapy until after HCC treatment is completed. BEST PRACTICE ADVICE 8: Timing of DAA therapy for patients with HCC who are listed for liver transplantation should be determined with consideration of median wait times, availability of hepatitis C virus-positive organs, and degree of liver dysfunction. BEST PRACTICE ADVICE 9: There are insufficient data evaluating benefits and cost-effectiveness of DAA therapy in patients with active intermediate or advanced HCC. Decisions regarding DAA treatment in these patients should be considered in light of HCC tumor burden, degree of liver dysfunction, life expectancy, and patient preferences. BEST PRACTICE ADVICE 10: There are no conclusive data that DAA therapy is associated with increased or decreased risk, differential time to recurrence, or aggressiveness of recurrent HCC in patients with complete response to HCC therapy. BEST PRACTICE ADVICE 11: DAA therapy should not be withheld from patients with complete response to HCC therapy; however, DAA therapy can be deferred 4-6 months to confirm response to HCC therapy. BEST PRACTICE ADVICE 12: Patients with complete response to HCC therapy who are treated with DAAs have a continued risk of HCC recurrence and require HCC surveillance, which should be conducted indefinitely with dynamic contrast-enhanced computed tomography or magnetic resonance imaging every 3-6 months. Current data do not support more frequent surveillance in these patients. This Clinical Practice Update was produced by the AGA Institute.
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Affiliation(s)
- Amit G. Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Joseph K. Lim
- Yale Liver Center and Section of Digestive Diseases; Yale University School of Medicine, New Haven, CT
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston TX;,Houston Veterans Affairs Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
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Mellinger JL. Epidemiology of Alcohol Use and Alcoholic Liver Disease. Clin Liver Dis (Hoboken) 2019; 13:136-139. [PMID: 31236261 PMCID: PMC6544412 DOI: 10.1002/cld.806] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 01/08/2019] [Indexed: 02/06/2023] Open
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237
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Wrighton PJ, Oderberg IM, Goessling W. There Is Something Fishy About Liver Cancer: Zebrafish Models of Hepatocellular Carcinoma. Cell Mol Gastroenterol Hepatol 2019; 8:347-363. [PMID: 31108233 PMCID: PMC6713889 DOI: 10.1016/j.jcmgh.2019.05.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/03/2019] [Accepted: 05/03/2019] [Indexed: 12/16/2022]
Abstract
The incidence of hepatocellular carcinoma (HCC) and the mortality resulting from HCC are both increasing. Most patients with HCC are diagnosed at advanced stages when curative treatments are impossible. Current drug therapy extends mean overall survival by only a short period of time. Genetic mutations associated with HCC vary widely. Therefore, transgenic and mutant animal models are needed to investigate the molecular effects of specific mutations, classify them as drivers or passengers, and develop targeted treatments. Cirrhosis, however, is the premalignant state common to 90% of HCC patients. Currently, no specific therapies are available to halt or reverse the progression of cirrhosis to HCC. Understanding the genetic drivers of HCC as well as the biochemical, mechanical, hormonal, and metabolic changes associated with cirrhosis could lead to novel treatments and cancer prevention strategies. Although additional therapies recently received Food and Drug Administration approval, significant clinical breakthroughs have not emerged since the introduction of the multikinase inhibitor sorafenib, necessitating alternate research strategies. Zebrafish (Danio rerio) are effective for disease modeling because of their high degree of gene and organ architecture conservation with human beings, ease of transgenesis and mutagenesis, high fecundity, and low housing cost. Here, we review zebrafish models of HCC and identify areas on which to focus future research efforts to maximize the advantages of the zebrafish model system.
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Affiliation(s)
- Paul J Wrighton
- Division of Genetics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Isaac M Oderberg
- Division of Genetics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Wolfram Goessling
- Division of Genetics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Harvard Stem Cell Institute, Cambridge, Massachusetts; Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts; Broad Institute, Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts; Division of Health Sciences and Technology, Harvard and Massachusetts Institute of Technology, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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238
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Abstract
PURPOSE OF REVIEW Nonalcoholic fatty liver disease (NAFLD) is a growing cause of chronic liver disease globally and nonalcoholic steatohepatitis is projected to become the most common indication for liver transplantation. The purpose of this review is to highlight key issues surrounding NAFLD as an indication for liver transplantation, including its increasing prevalence, outcomes related to liver transplantation, development of post liver transplant NAFLD and NAFLD in the liver donor pool. RECENT FINDINGS With the advent of direct-acting antiviral therapies, the proportion of patients on the liver transplant list or undergoing liver transplant for chronic hepatitis C infection is steadily decreasing. In contrast, the number transplants performed for NAFLD is increasing. By 2030, it is estimated that the incidence of decompensated cirrhosis and hepatocellular carcinoma will increase by 168 and 137%, respectively, and the number of deaths will increase by 178%. SUMMARY Liver transplantation cures cirrhosis but does not treat the underlying metabolic disease associated with NAFLD. Thus, strategies to control comorbidities in patients with NAFLD prior to transplant are needed to decrease waitlist mortality and the recurrence of NAFLD after liver transplant. NAFLD in the donor pool is also a growing concern. Strategies to minimize steatosis and expand the number of donors are critical to meet the growing demand for liver transplantation.
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239
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Rogal SS, Beste LA, Youk A, Fine MJ, Ketterer B, Zhang H, Leipertz S, Chartier M, Good CB, Kraemer KL, Chinman M, Morgan T, Gellad WF. Characteristics of Opioid Prescriptions to Veterans With Cirrhosis. Clin Gastroenterol Hepatol 2019; 17:1165-1174.e3. [PMID: 30342261 PMCID: PMC8108399 DOI: 10.1016/j.cgh.2018.10.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 10/01/2018] [Accepted: 10/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Despite increased risks for adverse effects in patients with cirrhosis, little is known about opioid prescriptions for this population. We aimed to assess time trends in opioid prescribing and factors associated with receiving opioids among patients with cirrhosis. METHODS Among Veterans with cirrhosis, identified using national Veterans Health Administration data (2005-2014), we assessed characteristics of patients and their prescriptions for opioids. We calculated the annual proportion of patients receiving any opioid prescription. Among opioid recipients, we assessed prescriptions that were long-term (>90 days' supply), for high doses (>100 MME/day), or involved combinations of opioids and acetaminophen or benzodiazepine. We evaluated patient characteristics independently associated with long-term and any opioid prescriptions using mixed-effects regression models. RESULTS Among 127,239 Veterans with cirrhosis, 97,974 (77.0%) received a prescription for an opioid. Annual opioid prescriptions increased from 36% in 2005 to 47% in 2014 (P < .01). Among recipients of opioids, the proportions of those receiving long-term prescriptions increased from 47% in 2005 to 54% in 2014 (P < .01), and19%-21% received prescriptions for high-dose opioids. Prescriptions for combinations of opioids and acetaminophen decreased from 68% in 2005 to 50% in 2014 (P < .01) and for combinations of opioids and benzodiazepines decreased from 24% to 19% over this time (P < .01). Greater probability of long-term opioid prescriptions was independently associated with younger age, female sex, white race, hepatitis C, prior hepatic decompensation, hepatocellular carcinoma, mental health disorders, nicotine use disorders, medical comorbidities, surgery, and pain-related conditions. CONCLUSION Among Veterans with cirrhosis, 36%-47% were prescribed opioids in each year. Mental health disorders and hepatic decompensation were independently associated with long-term opioid prescriptions.
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Affiliation(s)
- Shari S Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Lauren A Beste
- Primary Care Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Ada Youk
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Department of of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Bryan Ketterer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Hongwei Zhang
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Steven Leipertz
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Maggie Chartier
- HIV, Hepatitis, and Related Conditions Programs, Office of Specialty Care Services, Veterans Health Administration, Washington, DC
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Center for High Value Pharmacy Initiatives, University of Pittsburgh Medical Center Health Plan, Pittsburgh, Pennsylvania
| | - Kevin L Kraemer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; RAND Corporation, Pittsburgh, Pennsylvania
| | - Timothy Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, California; Division of Gastroenterology, Department of Medicine, University of California, Irvine, California
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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240
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Mahmud N, Kaplan DE, Taddei TH, Goldberg DS. Incidence and Mortality of Acute-on-Chronic Liver Failure Using Two Definitions in Patients with Compensated Cirrhosis. Hepatology 2019; 69:2150-2163. [PMID: 30615211 PMCID: PMC6461492 DOI: 10.1002/hep.30494] [Citation(s) in RCA: 130] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 12/20/2018] [Indexed: 12/12/2022]
Abstract
The term acute-on-chronic liver failure (ACLF) is intended to identify patients with chronic liver disease who develop rapid deterioration of liver function and high short-term mortality after an acute insult. The two prominent definitions (European Association for the Study of the Liver [EASL] and Asian Pacific Association for the Study of the Liver [APASL]) differ, and existing literature applies to narrow patient groups. We sought to compare ACLF incidence and mortality among a diverse cohort of patients with compensated cirrhosis, using both definitions. This was a retrospective cohort study of patients with incident compensated cirrhosis in the Veterans Health Administration from 2008 to 2016. First ACLF events were identified for each definition. Incidence rates were computed as events per 1,000 person-years, and mortality was calculated at 28 and 90 days. Among 80,383 patients with cirrhosis with 3.35 years median follow-up, 783 developed EASL and APASL ACLF, 4,296 developed EASL ACLF alone, and 574 developed APASL ACLF alone. The incidence rate of APASL ACLF was 5.7 per 1,000 person-years (95% confidence interval [CI]: 5.4-6.0), and the incidence rate of EASL ACLF was 20.1 (95% CI: 19.5-20.6). The 28-day and 90-day mortalities for APASL ACLF were 41.9% and 56.1%, respectively, and were 37.6% and 50.4% for EASL ACLF. The median bilirubin level at diagnosis of EASL-alone ACLF was 2.0 mg/dL (interquartile range: 1.1-4.0). Patients with hepatitis C or nonalcoholic fatty liver disease had among the lowest ACLF incidence rates but had the highest short-term mortality. Conclusion: There is significant discordance in ACLF events by EASL and APASL criteria. The majority of patients with EASL-alone ACLF have preserved liver function, suggesting the need for more liver-specific ACLF criteria.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David E. Kaplan
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - David S. Goldberg
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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241
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Kaplan DE, Serper MA, Mehta R, Fox R, John B, Aytaman A, Baytarian M, Hunt K, Albrecht J, Njei B, Taddei TH. Effects of Hypercholesterolemia and Statin Exposure on Survival in a Large National Cohort of Patients With Cirrhosis. Gastroenterology 2019; 156:1693-1706.e12. [PMID: 30660733 DOI: 10.1053/j.gastro.2019.01.026] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 12/17/2018] [Accepted: 01/09/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Concerns related to hepatotoxicity frequently lead to discontinuation or non-initiation of 3-hydroxy-3-methylglutaryl-coenzyme A reductase therapy in patients with cirrhosis despite data supporting statin use. We investigated the independent effects of hyperlipidemia and statin exposure on mortality, hepatic decompensation, and hepatocellular carcinoma development in a large national cohort of patients with cirrhosis. METHODS We performed a retrospective cohort study of patients with newly diagnosed cirrhosis from January 1, 2008 through June 30, 2016 in the Veterans Health Administration. Subjects were divided into 2 cohorts: 21,921 patients with prior statin exposure (existing users) and 51,023 statin-naïve individuals, of whom 8794 subsequently initiated statin therapy (new initiators) and 44,269 did not (non-initiators). Multivariable Cox proportional hazard models with inverse probability weighting were constructed to assess the effects of time-updating lipid profiles and cumulative exposure to statins on survival and hepatic decompensation. Statin-naïve new initiators were propensity matched with non-initiators to simulate a randomized controlled trial of statin use in cirrhosis. RESULTS In statin-naïve subjects, every 10-mg/dL increase in baseline total cholesterol was associated with a 3.6% decrease in mortality. In existing users, each year of continued statin exposure was associated with a hazard ratio of 0.920 (95% confidence interval 0.0.897-0.943) for mortality. After risk-set matching, each year of statin exposure among new initiators was associated with a hazard ratio of 0.913 (95% confidence interval 0.890-0.937) for mortality. CONCLUSIONS In a retrospective cohort study of veterans with a new diagnosis of cirrhosis, we associated hypercholesterolemia with well-preserved hepatic function and decreased mortality. Nonetheless, each cumulative year of statin exposure was associated with an independent 8.0%-8.7% decrease of mortality of patients with cirrhosis of Child-Turcotte-Pugh classes A and B.
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Affiliation(s)
- David E Kaplan
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania; Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Marina A Serper
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania; Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rajni Mehta
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Rena Fox
- San Francisco VA Medical Center, San Francisco, California
| | - Binu John
- Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
| | - Ayse Aytaman
- VA New York Harbor Health Care System, Brooklyn, New York
| | | | - Kristel Hunt
- James J. Peters VA Medical Center, Bronx, New York
| | | | - Basile Njei
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Tamar H Taddei
- VA Connecticut Healthcare System, West Haven, Connecticut
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242
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Abstract
Portal hypertension, a consequence of end-stage liver disease and liver cirrhosis can lead to significant morbidity and mortality for patients through abnormal fluid accumulation as well as the formation of portosystemic shunts and varices. Treatment of the sequelae of portal hypertension can be achieved through endovascular management by referral to an interventional radiologist on an outpatient or emergent basis as required. Current techniques include the placement of peritoneovenous shunts and tunneled peritoneal drains, the creation of transjugular intrahepatic portosystemic shunts, or the obliteration of shunts via balloon-occluded retrograde transvenous obliteration (BRTO). In addition, newer procedural techniques utilizing vascular plugs and coils have reduced risks of the traditional BRTO procedure. Modified-BRTO procedures, known as plug-assisted and coil-assisted retrograde transvenous obliteration (PARTO and CARTO, respectively) have become the standard of care at many institutions for the treatment of gastric varices and portosystemic shunt-induced hepatic encephalopathy. This review examines the most recent literature of the management of portal hypertension by interventional radiologists, evaluating treatment options as well as the clinical and technical outcomes of TIPS, peritoneovenous shunts, tunneled peritoneal drains, BRTOs, and modified-BRTOs as well as future directions in the development of procedural techniques.
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243
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Arab JP, Arrese M, Trauner M. Recent Insights into the Pathogenesis of Nonalcoholic Fatty Liver Disease. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2019; 13:321-350. [PMID: 29414249 DOI: 10.1146/annurev-pathol-020117-043617] [Citation(s) in RCA: 344] [Impact Index Per Article: 68.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a burgeoning health problem worldwide and an important risk factor for both hepatic and cardiometabolic mortality. The rapidly increasing prevalence of this disease and of its aggressive form nonalcoholic steatohepatitis (NASH) will require novel therapeutic approaches based on a profound understanding of its pathogenesis to halt disease progression to advanced fibrosis or cirrhosis and cancer. The pathogenesis of NAFLD involves a complex interaction among environmental factors (i.e., Western diet), obesity, changes in microbiota, and predisposing genetic variants resulting in a disturbed lipid homeostasis and an excessive accumulation of triglycerides and other lipid species in hepatocytes. Insulin resistance is a central mechanism that leads to lipotoxicity, endoplasmic reticulum stress, disturbed autophagy, and, ultimately, hepatocyte injury and death that triggers hepatic inflammation, hepatic stellate cell activation, and progressive fibrogenesis, thus driving disease progression. In the present review, we summarize the currently available data on the pathogenesis of NAFLD, emphasizing the most recent advances. A better understanding of NAFLD/NASH pathogenesis is crucial for the design of new and efficient therapeutic interventions.
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Affiliation(s)
- Juan Pablo Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago 8330077, Chile.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Marco Arrese
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago 8330077, Chile.,Centro de Envejecimiento y Regeneración (CARE), Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna A-1090, Austria;
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244
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Abstract
PURPOSE OF REVIEW We sought to review the contemporary epidemiology of cirrhosis, focusing on the relative burden of the most common chronic liver diseases. RECENT FINDINGS The key findings in the review highlight the increasing prevalence and impact of alcohol-related liver disease, particularly among young people, and the epidemic of nonalcoholic fatty liver commensurate with rising rates of obesity. We also contrast recent advances in the care of persons with hepatitis C with the lamentable rise in new infections associated with intravenous drug use. Finally, we highlight the impact of both conventional complications of cirrhosis (namely hepatic encephalopathy) but also the host of patient-reported outcomes adversely impacted by the symptoms of cirrhosis. Cirrhosis is associated with an expanding footprint in contemporary public health. In order to improve global outcomes, we must not only focus on the identifying and treating persons with viral hepatitis but also preventing the rise of alcohol-related liver disease and nonalcoholic fatty liver disease while attending to the urgent patient-centered needs posed by the symptoms of cirrhosis.
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Affiliation(s)
- Jad A Baki
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA. .,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
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245
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Shan S, Chen W, Jia JD. Transcriptome Analysis Revealed a Highly Connected Gene Module Associated With Cirrhosis to Hepatocellular Carcinoma Development. Front Genet 2019; 10:305. [PMID: 31001331 PMCID: PMC6454075 DOI: 10.3389/fgene.2019.00305] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 03/19/2019] [Indexed: 12/27/2022] Open
Abstract
Introduction Cirrhosis is one of the most important risk factors for development of hepatocellular carcinoma (HCC). Recent studies have shown that removal or well control of the underlying cause could reduce but not eliminate the risk of HCC. Therefore, it is important to elucidate the molecular mechanisms that drive the progression of cirrhosis to HCC. Materials and Methods Microarray datasets incorporating cirrhosis and HCC subjects were identified from the Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) were determined by GEO2R software. Functional enrichment analysis was performed by the clusterProfiler package in R. Liver carcinogenesis-related networks and modules were established using STRING database and MCODE plug-in, respectively, which were visualized with Cytoscape software. The ability of modular gene signatures to discriminate cirrhosis from HCC was assessed by hierarchical clustering, principal component analysis (PCA), and receiver operating characteristic (ROC) curve. Association of top modular genes and HCC grades or prognosis was analyzed with the UALCAN web-tool. Protein expression and distribution of top modular genes were analyzed using the Human Protein Atlas database. Results Four microarray datasets were retrieved from GEO database. Compared with cirrhotic livers, 125 upregulated and 252 downregulated genes in HCC tissues were found. These DEGs constituted a liver carcinogenesis-related network with 272 nodes and 2954 edges, with 65 nodes being highly connected and formed a liver carcinogenesis-related module. The modular genes were significantly involved in several KEGG pathways, such as “cell cycle,” “DNA replication,” “p53 signaling pathway,” “mismatch repair,” “base excision repair,” etc. These identified modular gene signatures could robustly discriminate cirrhosis from HCC in the validation dataset. In contrast, the expression pattern of the modular genes was consistent between cirrhotic and normal livers. The top modular genes TOP2A, CDC20, PRC1, CCNB2, and NUSAP1 were associated with HCC onset, progression, and prognosis, and exhibited higher expression in HCC compared with normal livers in the HPA database. Conclusion Our study revealed a highly connected module associated with liver carcinogenesis on a cirrhotic background, which may provide deeper understanding of the genetic alterations involved in the transition from cirrhosis to HCC, and offer valuable variables for screening and surveillance of HCC in high-risk patients with cirrhosis.
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Affiliation(s)
- Shan Shan
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Digestive Disease, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wei Chen
- Experimental and Translational Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Tolerance Induction and Organ Protection in Transplantation, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ji-Dong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Digestive Disease, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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246
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Tapper EB, Baki J, Parikh ND, Lok AS. Frailty, Psychoactive Medications, and Cognitive Dysfunction Are Associated With Poor Patient-Reported Outcomes in Cirrhosis. Hepatology 2019; 69:1676-1685. [PMID: 30382584 PMCID: PMC6438757 DOI: 10.1002/hep.30336] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/22/2018] [Indexed: 12/17/2022]
Abstract
Cirrhosis is associated with disabling symptoms and diminished health-related quality of life (HRQOL). However, for patients with compensated disease, data are limited regarding associations with poor patient-reported outcomes (PROs). We prospectively enrolled 300 patients with cirrhosis and portal hypertension without a history of hepatic encephalopathy (HE) and reviewed medical and pharmacy records. We characterized determinants of PROs using the 8-item Short-Form Health Survey (SF-8) scale (0-100) and sleep quality using the Pittsburgh Sleep Quality Index (PSQI; poor sleep >5). Disability and frailty measures were assessed using activities of daily living (ADLs), falls, hand-grip, and chair-stands. Cognitive function was measured using weighted-lures from the Inhibitory Control Test (ICT). The median age of our cohort was 60 (interquartile range [IQR], 52-66) years, 56.3% were male, and 70% Child class A. All patients had portal hypertension, 76% had varices, and 41% had a history of ascites (predominantly well controlled). The median Model for End-Stage Liver Disease with Sodium (MELD-Na) score was 9 (IQR, 7-13). The overall median SF-8 was 70 (IQR, 54-86). Multivariate analysis showed that after adjusting for age, sex, education, and MELD-Na, performance on chair-stands (9.28 HRQOL points [95% confidence interval {CI}, 4.76-13.8] per 10-stands), ADL dependence (-6.06 [-10.8 to -1.36]), opiate use (-5.01 [-7.84 to -2.19]), benzodiazepine use (-3.50 [-6.58 to -0.42]), and ICT performance (-0.10 [-0.20 to 0.001] per weighted-lure) were significantly associated with HRQOL. Among patients completing the ICT, poor HRQOL (score <50) was significantly associated with chair-stands (odds ratio [OR] per 10-stands, 0.24; 95% CI [0.11-0.56]) and weighted lures (OR per weighted-lure, 1.01 [1.00-1.03]). Poor sleep quality was associated with opiate use (OR, 2.85 [1.11-7.29]) and lures (OR per-lure, 1.03 [1.00-1.05]). Conclusion: Disability, chair-stand performance, cognitive dysfunction, as well as psychoactive medication use are significantly associated with PROs in patients with clinically stable cirrhosis.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Jad Baki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Neehar D. Parikh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Anna S. Lok
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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247
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Liu Z, Jiang Y, Yuan H, Fang Q, Cai N, Suo C, Jin L, Zhang T, Chen X. The trends in incidence of primary liver cancer caused by specific etiologies: Results from the Global Burden of Disease Study 2016 and implications for liver cancer prevention. J Hepatol 2019; 70:674-683. [PMID: 30543829 DOI: 10.1016/j.jhep.2018.12.001] [Citation(s) in RCA: 393] [Impact Index Per Article: 78.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 11/28/2018] [Accepted: 12/01/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Liver cancer is a common malignant neoplasm worldwide. The etiologies for liver cancer are diverse and the incidence trends of liver cancer caused by specific etiologies are rarely studied. We therefore aimed to determine the pattern of liver cancer incidence, as well as temporal trends. METHODS We collected detailed information on liver cancer etiology between 1990-2016, derived from the Global Burden of Disease study in 2016. Estimated annual percentage changes (EAPCs) in liver cancer age standardized incidence rate (ASR), by sex, region, and etiology, were calculated to quantify the temporal trends in liver cancer ASR. RESULTS Globally, incident cases of liver cancer increased 114.0% from 471,000 in 1990 to 1,007,800 in 2016. The overall ASR increased by an average 0.34% (95% CI 0.22%-0.45%) per year in this period. The ASR of liver cancer due to hepatitis B, hepatitis C, and other causes increased between 1990 and 2016. The corresponding EAPCs were 0.22 (95% CI 0.08-0.36), 0.57 (95% CI 0.48-0.66), and 0.51 (95% CI 0.41-0.62), respectively. The ASR of liver cancer due to reported alcohol use remained stable (EAPC = 0.10, 95% CI -0.06-0.25). This increasing pattern was heterogeneous across regions and countries. The most pronounced increases were generally observed in countries with a high socio-demographic index, including the Netherlands, the UK, and the USA. CONCLUSIONS Liver cancer remains a major public health concern globally, though control of hepatitis B and C virus infections has contributed to the decreasing incidence in some regions. We observed an unfavorable trend in countries with a high socio-demographic index, suggesting that current prevention strategies should be reoriented, and much more targeted and specific strategies should be established in some countries to forestall the increase in liver cancer. LAY SUMMARY Liver cancer is a common malignant neoplasm worldwide. The incidence patterns of liver cancer caused by different etiologies varied considerably across the world. In this study, we aim to determine the pattern of liver cancer incidence as well as the temporal trends, thereby facilitating the establishment of more tailored prevention strategies for liver cancer.
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Affiliation(s)
- Zhenqiu Liu
- State Key Laboratory of Genetic Engineering and Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai 200438, China; Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China; Key Laboratory of Public Health Safety (Fudan University), Ministry of Education, China; Fudan University Taizhou Institute of Health Sciences, Taizhou, China
| | - Yanfeng Jiang
- State Key Laboratory of Genetic Engineering and Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai 200438, China; Fudan University Taizhou Institute of Health Sciences, Taizhou, China
| | - Huangbo Yuan
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China; Key Laboratory of Public Health Safety (Fudan University), Ministry of Education, China
| | - Qiwen Fang
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China; Key Laboratory of Public Health Safety (Fudan University), Ministry of Education, China
| | - Ning Cai
- State Key Laboratory of Genetic Engineering and Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai 200438, China; Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China; Key Laboratory of Public Health Safety (Fudan University), Ministry of Education, China; Fudan University Taizhou Institute of Health Sciences, Taizhou, China
| | - Chen Suo
- State Key Laboratory of Genetic Engineering and Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai 200438, China; Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China; Key Laboratory of Public Health Safety (Fudan University), Ministry of Education, China; Fudan University Taizhou Institute of Health Sciences, Taizhou, China
| | - Li Jin
- State Key Laboratory of Genetic Engineering and Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai 200438, China; Fudan University Taizhou Institute of Health Sciences, Taizhou, China; Human Phenome Institute, Fudan University, 825 Zhangheng Road, Shanghai 201203, China
| | - Tiejun Zhang
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China; Key Laboratory of Public Health Safety (Fudan University), Ministry of Education, China.
| | - Xingdong Chen
- State Key Laboratory of Genetic Engineering and Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai 200438, China; Fudan University Taizhou Institute of Health Sciences, Taizhou, China; Human Phenome Institute, Fudan University, 825 Zhangheng Road, Shanghai 201203, China.
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248
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Arora SS, Axley P, Ahmed Z, Satapathy SK, Wong R, Kuo YF, Singal AK. Decreasing frequency and improved outcomes of hepatitis C-related liver transplantation in the era of direct-acting antivirals - a retrospective cohort study. Transpl Int 2019; 32:854-864. [PMID: 30866110 DOI: 10.1111/tri.13424] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/16/2018] [Accepted: 03/08/2019] [Indexed: 12/12/2022]
Abstract
Benefit of direct-acting antivirals (DAA) for hepatitis C virus (HCV) on clinical outcomes is unclear. We examined temporal trends in liver transplant (LT) listings, receipt of LT, re-LT, and survival between pre-DAA (2009-2012) and DAA era (2013-2016) using UNOS database. Of 32 319 first adult LT, 15 049 (47%) were performed for HCV. Trends on listing, first LT, and of re-LT for HCV showed 23%, 20%, and 21% decrease in DAA compared to pre-DAA era (P < 0.0001). One-year liver graft and patient survival among HCV LT improved in DAA era (90% vs. 86% and 92% vs. 88%, respectively, P < 0.0001). Non-HCV LT showed no improvement in survival (89% vs. 89% and 92% vs. 92.4%, P = NS). On cox regression, compared to non-HCV LTs in DAA era, LT for HCV in pre-DAA era had worse patient survival (HR 1.56 [1.04-2.35]). The outcome was similar when compared to LTs for HCV in DAA era and for non-HCV in pre-DAA era. Burden of HCV-related LT waitlist and LT is declining in DAA era, with improved post-transplant outcomes, more so in later than earlier DAA era. Our findings negate recent Cochrane meta-analysis on DAA therapy and encourage studies to examine HCV clinical outcomes outside LT setting.
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Affiliation(s)
- Sumant S Arora
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Iowa Hospital & Clinics, Iowa City, IA, USA
| | - Page Axley
- Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zunirah Ahmed
- Department of Internal Medicine, University of Alabama at Birmingham - Montgomery Regional Campus, Birmingham, AL, USA
| | - Sanjaya K Satapathy
- Division of Transplant Hepatology, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Robert Wong
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, CA, USA
| | - Young-Fang Kuo
- Department of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
| | - Ashwani K Singal
- Sanford School of Medicine and Avera Transplant Institute, University of South Dakota, Sioux Falls, SD, USA
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249
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Tapper EB, Baki J, Hummel S, Lok A. Design and rationale of a randomized-controlled trial of home-delivered meals for the management of symptomatic ascites: the SALTYFOOD trial. Gastroenterol Rep (Oxf) 2019; 7:146-149. [PMID: 30976428 PMCID: PMC6454849 DOI: 10.1093/gastro/goz005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/09/2018] [Accepted: 11/06/2018] [Indexed: 01/08/2023] Open
Abstract
Background When patients with cirrhosis develop ascites, it is associated with sharply increased mortality and healthcare utilization with decreased quality of life. Dietary salt restriction is first-line therapy for ascites but it is limited by poor adherence. Methods We will recruit 40 patients with cirrhosis and ascites who have received a recent paracentesis or hospitalization for a 1:1 randomized trial of standard care (education on salt restriction) versus home-delivered meals. Our primary outcome is the number of paracenteses needed over 12 weeks. Secondary outcomes include hospital-bed days, health-related quality of life (HRQOL, Ascites Symptom Inventory-7 and Visual Analogue Scale) and performance on batteries of physical function including hand grip (kg) and walk speed (m/s). All subjects follow up through a series of calls where any paracenteses, hospital readmissions, weight changes and diuretic dosage changes are recorded. In a final Week 12 visit, knowledge of dietary sodium intake, quality of life and frailty are reassessed, and satisfaction with the meal-delivery program is evaluated. Paired comparison testing will be conducted between the two arms. Discussion A nutritionally standardized meal-delivery program for patients with cirrhosis and ascites post discharge has a variety of potential patient-based benefits, including the effective management of ascites, reduction of healthcare utilization and improvement of HRQOL. We have three core hypotheses. First, patients will report interest in and satisfaction with a home-delivered meals program. Second, subjects on a salt-restricted (2 g sodium) meal-delivery program will have fewer therapeutic paracenteses and all-cause readmissions than subjects receiving standard of care. Third, subjects on a salt-restricted (2 g sodium) meal-delivery program will report increased HRQOL compared to subjects receiving standard of care.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jad Baki
- University of Michigan, Ann Arbor, Michigan, USA
| | - Scott Hummel
- Division of Cardiology, Department of Internal Medicine University of Michigan, Ann Arbor, Michigan, USA
| | - Anna Lok
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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250
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Kim D, Li AA, Perumpail BJ, Gadiparthi C, Kim W, Cholankeril G, Glenn JS, Harrison SA, Younossi ZM, Ahmed A. Changing Trends in Etiology-Based and Ethnicity-Based Annual Mortality Rates of Cirrhosis and Hepatocellular Carcinoma in the United States. Hepatology 2019; 69:1064-1074. [PMID: 30014489 PMCID: PMC6709988 DOI: 10.1002/hep.30161] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/23/2018] [Indexed: 12/25/2022]
Abstract
With recent improvements in the treatment of end-stage liver disease (ESLD), a better understanding of the burden of cirrhosis and hepatocellular carcinoma (HCC) is needed in the United States. A population-based study using the US Census and national mortality database was performed. We identified the age-standardized etiology-specific mortality rates for cirrhosis and HCC among US adults ages 20 years or older from 2007 to 2016. We determined temporal mortality rate patterns by joinpoint analysis with estimates of annual percentage change (APC). Age-standardized cirrhosis-related mortality rates increased from 19.77/100,000 persons in 2007 to 23.67 in 2016 with an annual increase of 2.3% (95% confidence interval [CI] 2.0-2.7). The APC in mortality rates for hepatitis C virus (HCV)-cirrhosis shifted from a 2.9% increase per year during 2007 to 2014 to a 6.5% decline per year during 2014 to 2016. Meanwhile, mortality for cirrhosis from alcoholic liver disease (ALD, APC 4.5%) and NAFLD (APC 15.4%) increased over the same period, whereas mortality for hepatitis B virus (HBV)-cirrhosis decreased with an average APC of -1.1%. HCC-related mortality increased from 3.48/100,000 persons in 2007 to 4.41 in 2016 at an annual rate of 2.0% (95% CI 1.3-2.6). Etiology-specific mortality rates of HCC were largely consistent with cirrhosis-related mortality. Minority populations had a higher burden of HCC-related mortality. Conclusion: Cirrhosis-related and HCC-related mortality rates increased between 2007 and 2016 in the United States. However, mortality rates in HCV-cirrhosis demonstrated a significant decline from 2014 to 2016, during the direct-acting antiviral era. Mortality rates for ALD/NAFLD-cirrhosis and HCC have continued to increase, whereas HBV-cirrhosis-related mortality declined during the 10-year period. Importantly, minorities had a disproportionately higher burden of ESLD-related mortality.
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Affiliation(s)
- Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA
| | - Andrew A. Li
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | | | - Chiranjeevi Gadiparthi
- Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, TN
| | - Won Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA
| | - Jeffrey S. Glenn
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA
| | - Stephen A. Harrison
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Zobair M. Younossi
- Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA
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