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Feldman TC, Kaplan DE, Lin A, La J, Lee JSH, Aljehani M, Tuck DP, Brophy MT, Fillmore NR, Do NV. Phenotyping Hepatic Immune-Related Adverse Events in the Setting of Immune Checkpoint Inhibitor Therapy. JCO Clin Cancer Inform 2024; 8:e2300159. [PMID: 38728613 DOI: 10.1200/cci.23.00159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/27/2023] [Accepted: 03/19/2024] [Indexed: 05/12/2024] Open
Abstract
PURPOSE We present and validate a rule-based algorithm for the detection of moderate to severe liver-related immune-related adverse events (irAEs) in a real-world patient cohort. The algorithm can be applied to studies of irAEs in large data sets. METHODS We developed a set of criteria to define hepatic irAEs. The criteria include: the temporality of elevated laboratory measurements in the first 2-14 weeks of immune checkpoint inhibitor (ICI) treatment, steroid intervention within 2 weeks of the onset of elevated laboratory measurements, and intervention with a duration of at least 2 weeks. These criteria are based on the kinetics of patients who experienced moderate to severe hepatotoxicity (Common Terminology Criteria for Adverse Events grades 2-4). We applied these criteria to a retrospective cohort of 682 patients diagnosed with hepatocellular carcinoma and treated with ICI. All patients were required to have baseline laboratory measurements before and after the initiation of ICI. RESULTS A set of 63 equally sampled patients were reviewed by two blinded, clinical adjudicators. Disagreements were reviewed and consensus was taken to be the ground truth. Of these, 25 patients with irAEs were identified, 16 were determined to be hepatic irAEs, 36 patients were nonadverse events, and two patients were of indeterminant status. Reviewers agreed in 44 of 63 patients, including 19 patients with irAEs (0.70 concordance, Fleiss' kappa: 0.43). By comparison, the algorithm achieved a sensitivity and specificity of identifying hepatic irAEs of 0.63 and 0.81, respectively, with a test efficiency (percent correctly classified) of 0.78 and outcome-weighted F1 score of 0.74. CONCLUSION The algorithm achieves greater concordance with the ground truth than either individual clinical adjudicator for the detection of irAEs.
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Affiliation(s)
- Theodore C Feldman
- VA Boston Healthcare System, Boston, MA
- Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, PA
| | - David E Kaplan
- Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, PA
- Perelman School of Medicine at the University of Pennsylvania Medical School, Philadelphia, PA
| | - Albert Lin
- VA Palo Alto Healthcare System, Palo Alto, CA
- Stanford University School of Medicine, Stanford, CA
| | - Jennifer La
- VA Boston Healthcare System, Boston, MA
- Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, PA
| | - Jerry S H Lee
- Ellison Institute of Technology, Los Angeles, CA
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Chemical Engineering and Materials Sciences, Viterbi School of Engineering, University of Southern California, Los Angeles, CA
- Department of Quantitative and Computational Biology, Dornsife College of Letters, Arts and Sciences, University of Southern California, Los Angeles, CA
| | | | - David P Tuck
- VA Boston Healthcare System, Boston, MA
- Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, PA
| | - Mary T Brophy
- VA Boston Healthcare System, Boston, MA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Nathanael R Fillmore
- VA Boston Healthcare System, Boston, MA
- Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, PA
- Dana-Farber Cancer Institute, Boston, MA
| | - Nhan V Do
- VA Boston Healthcare System, Boston, MA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA
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Kaplan DE, Ripoll C, Thiele M, Fortune BE, Simonetto DA, Garcia-Tsao G, Bosch J. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024; 79:1180-1211. [PMID: 37870298 DOI: 10.1097/hep.0000000000000647] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023]
Affiliation(s)
- David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA USA
| | - Cristina Ripoll
- Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Brett E Fortune
- Department of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS) and CIBERehd, University of Barcelona, Spain
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Ghouse J, Sveinbjörnsson G, Vujkovic M, Seidelin AS, Gellert-Kristensen H, Ahlberg G, Tragante V, Rand SA, Brancale J, Vilarinho S, Lundegaard PR, Sørensen E, Erikstrup C, Bruun MT, Jensen BA, Brunak S, Banasik K, Ullum H, Verweij N, Lotta L, Baras A, Mirshahi T, Carey DJ, Kaplan DE, Lynch J, Morgan T, Schwantes-An TH, Dochtermann DR, Pyarajan S, Tsao PS, Laisk T, Mägi R, Kozlitina J, Tybjærg-Hansen A, Jones D, Knowlton KU, Nadauld L, Ferkingstad E, Björnsson ES, Ulfarsson MO, Sturluson Á, Sulem P, Pedersen OB, Ostrowski SR, Gudbjartsson DF, Stefansson K, Olesen MS, Chang KM, Holm H, Bundgaard H, Stender S. Integrative common and rare variant analyses provide insights into the genetic architecture of liver cirrhosis. Nat Genet 2024:10.1038/s41588-024-01720-y. [PMID: 38632349 DOI: 10.1038/s41588-024-01720-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 03/18/2024] [Indexed: 04/19/2024]
Abstract
We report a multi-ancestry genome-wide association study on liver cirrhosis and its associated endophenotypes, alanine aminotransferase (ALT) and γ-glutamyl transferase. Using data from 12 cohorts, including 18,265 cases with cirrhosis, 1,782,047 controls, up to 1 million individuals with liver function tests and a validation cohort of 21,689 cases and 617,729 controls, we identify and validate 14 risk associations for cirrhosis. Many variants are located near genes involved in hepatic lipid metabolism. One of these, PNPLA3 p.Ile148Met, interacts with alcohol intake, obesity and diabetes on the risk of cirrhosis and hepatocellular carcinoma (HCC). We develop a polygenic risk score that associates with the progression from cirrhosis to HCC. By focusing on prioritized genes from common variant analyses, we find that rare coding variants in GPAM associate with lower ALT, supporting GPAM as a potential target for therapeutic inhibition. In conclusion, this study provides insights into the genetic underpinnings of cirrhosis.
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Affiliation(s)
- Jonas Ghouse
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
- Cardiac Genetics Group, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | | | - Marijana Vujkovic
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anne-Sofie Seidelin
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Helene Gellert-Kristensen
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gustav Ahlberg
- Cardiac Genetics Group, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Søren A Rand
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Cardiac Genetics Group, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Joseph Brancale
- Section of Digestive Diseases, Department of Internal Medicine, and Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Silvia Vilarinho
- Section of Digestive Diseases, Department of Internal Medicine, and Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Pia Rengtved Lundegaard
- Cardiac Genetics Group, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Erik Sørensen
- Department of Clinical Immunology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Erikstrup
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Mie Topholm Bruun
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | | | - Søren Brunak
- Translational Disease Systems Biology, Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Karina Banasik
- Department of Obstetrics and Gynaecology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | | | - Niek Verweij
- Regeneron Genetics Center, Regeneron Pharmaceuticals Inc, Tarrytown, NY, USA
| | - Luca Lotta
- Regeneron Genetics Center, Regeneron Pharmaceuticals Inc, Tarrytown, NY, USA
| | - Aris Baras
- Regeneron Genetics Center, Regeneron Pharmaceuticals Inc, Tarrytown, NY, USA
| | - Tooraj Mirshahi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA, USA
| | - David J Carey
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA, USA
| | - David E Kaplan
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Julie Lynch
- VA Informatics and Computing Infrastructure (VINCI), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Timothy Morgan
- Gastroenterology Section, Veterans Affairs Long Beach Healthcare System, Long Beach, CA, USA
- Department of Medicine, University of California, Irvine, CA, USA
| | - Tae-Hwi Schwantes-An
- Gastroenterology Section, Veterans Affairs Long Beach Healthcare System, Long Beach, CA, USA
- Department of Medical and Molecular Genetics, Indiana University, Indianapolis, IN, USA
| | - Daniel R Dochtermann
- Center for Data and Computational Sciences, VA Boston Healthcare System, Boston, MA, USA
| | - Saiju Pyarajan
- Center for Data and Computational Sciences, VA Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Brigham Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Philip S Tsao
- Palo Alto Epidemiology Research and Information Center for Genomics, VA Palo Alto, Palo Alto, CA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Triin Laisk
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Reedik Mägi
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Julia Kozlitina
- Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anne Tybjærg-Hansen
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - David Jones
- Precision Genomics, Intermountain Healthcare, Saint George, UT, USA
| | - Kirk U Knowlton
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, UT, USA
- University of Utah, School of Medicine, Salt Lake City, UT, USA
| | - Lincoln Nadauld
- Precision Genomics, Intermountain Healthcare, Saint George, UT, USA
- Stanford University, School of Medicine, Stanford, CA, USA
| | | | - Einar S Björnsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Internal Medicine and Emergency Services, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - Magnus O Ulfarsson
- deCODE Genetics/Amgen, Reykjavik, Iceland
- Faculty of Electrical and Computer Engineering, University of Iceland, Reykjavik, Iceland
| | | | | | - Ole B Pedersen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Immunology, Zealand University Hospital, Køge, Denmark
| | - Sisse R Ostrowski
- Department of Clinical Immunology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel F Gudbjartsson
- deCODE Genetics/Amgen, Reykjavik, Iceland
- School of Engineering and Natural Sciences, University of Iceland, Reykjavik, Iceland
| | | | - Morten Salling Olesen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Cardiac Genetics Group, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kyong-Mi Chang
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Hilma Holm
- deCODE Genetics/Amgen, Reykjavik, Iceland
| | - Henning Bundgaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Stefan Stender
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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Garcia-Tsao G, Kaplan DE. Reply: On the use of nonselective beta blockers in cirrhosis. Hepatology 2024:01515467-990000000-00845. [PMID: 38626347 DOI: 10.1097/hep.0000000000000889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/18/2024]
Affiliation(s)
- Guadalupe Garcia-Tsao
- Department of Medicine, Yale University, New Haven, Connecticut, USA
- Department of Medicine, VA-CT Healthcare System, West Haven, Connecticut, USA
| | - David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Garcia-Tsao G, Kaplan DE. Reply: Endoscopy for potential variceal bleeding within 12 hours-Not so fast! Hepatology 2024:01515467-990000000-00838. [PMID: 38607742 DOI: 10.1097/hep.0000000000000881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 04/14/2024]
Affiliation(s)
- Guadalupe Garcia-Tsao
- Department of Medicine, Yale University, New Haven, Connecticut, USA
- Department of Medicine, VA-CT Healthcare System, West Haven, Connecticut, USA
| | - David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Chin A, Bastaich DR, Dahman B, Kaplan DE, Taddei TH, John BV. Refractory hepatic hydrothorax is associated with increased mortality with death occurring at lower MELD-Na compared to cirrhosis and refractory ascites. Hepatology 2024; 79:844-856. [PMID: 37625139 DOI: 10.1097/hep.0000000000000577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND AND AIMS Although refractory hepatic hydrothorax (RH) is a serious complication of cirrhosis, waitlisted patients do not receive standardized Model for End-stage Liver Disease (MELD) exemption because of inadequate evidence suggesting mortality above biochemical MELD. This study aimed to examine liver-related death (LRD) associated with RH compared to refractory ascites (RA). APPROACH AND RESULTS This was a retrospective cohort study of Veterans with cirrhosis. Eligibility criteria included participants with RH or RA, followed from their first therapeutic thoracentesis/second paracentesis until death or transplantation. The primary outcome was LRD with non-LRD or transplantation as competing risk. Of 2552 patients with cirrhosis who underwent therapeutic thoracentesis/paracentesis, 177 met criteria for RH and 422 for RA. RH was associated with a significantly higher risk of LRD (adjusted HR [aHR] 4.63, 95% CI 3.31-6.48) than RA overall and within all MELD-sodium (MELD-Na) strata (<10 aHR 4.08, 95% CI 2.30-7.24, 10-14.9 aHR 5.68, 95% CI 2.63-12.28, 15-24.9 aHR 4.14, 95% CI 2.34-7.34, ≥25 aHR 7.75, 95% CI 2.99-20.12). LRD was higher among participants requiring 1 (aHR 3.54, 95% CI 2.29-5.48), 2-3 (aHR 4.39, 95% CI 2.91-6.63), and ≥4 (aHR 7.89, 95% CI 4.82-12.93) thoracenteses relative to RA. Although participants with RH and RA had similar baseline MELD-Na, LRD occurred in RH versus RA at a lower MELD-Na (16.5 vs. 21.82, p =0.002) but higher MELD 3.0 (27.85 vs. 22.48, p <0.0001). CONCLUSIONS RH was associated with higher risk of LRD than RA at equivalent MELD-Na. By contrast, MELD 3.0 may better predict risk of LRD in RH.
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Affiliation(s)
- Allison Chin
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Dustin R Bastaich
- Department of Biostatistics, Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Tamar H Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Binu V John
- Division of Gastroenterology and Hepatology, Miami VA Medical System, Miami, Florida, USA
- Division of Medical Education, University of Miami Miller School of Medicine, Miami, Florida, USA
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John BV, Dang Y, Kaplan DE, Jou JH, Taddei TH, Spector SA, Martin P, Bastaich DR, Chao HH, Dahman B. Liver Stiffness Measurement and Risk Prediction of Hepatocellular Carcinoma After HCV Eradication in Veterans With Cirrhosis. Clin Gastroenterol Hepatol 2024; 22:778-788.e7. [PMID: 38061410 PMCID: PMC10960676 DOI: 10.1016/j.cgh.2023.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/05/2023] [Accepted: 11/17/2023] [Indexed: 01/04/2024]
Abstract
BACKGROUND & AIMS Patients with cirrhosis secondary to chronic hepatitis C virus (HCV) are at risk for hepatocellular carcinoma (HCC) despite a sustained virological response (SVR). We examined whether post-SVR liver stiffness measurement (LSM) could be used to stratify HCC risk. METHODS This was a retrospective cohort study of 1850 participants identified from the Veterans Health Administration, with HCV cirrhosis and SVR, followed up over 5099 person-years, from the time of post-SVR elastography until death, HCC, or the end of the study. RESULTS The risk of HCC increased by 3% with every 1-kPa increase in LSM (adjusted hazard ratio [aHR], 1.03, 95% confidence interval [CI], 1.01-1.04; P < .001) and decreased with the number of years from SVR (aHR, 0.79; 95% CI, 0.70-0.90; P = .0003). The adjusted annual risk of HCC was 2.03% among participants with post-SVR LSM <10 kPa, 2.48% in LSM 10-14.9 kPa (aHR, 1.71; 95% CI, 1.01-2.88; P = .046), 3.22% for LSM 15-19.9 kPa (aHR, 1.59; 95% CI, 0.78-3.20; P = .20), 5.07% among LSM 20-24.9 kPa (aHR, 2.55; 95% CI, 1.30-5.01; P = .01), and 5.44% in LSM ≥25 kPa (aHR, 3.03; 95% CI, 1.74-5.26; P < .0001). The adjusted annual risk of HCC was < 0.4% in participants with LSM <5 kPa and without diabetes mellitus. CONCLUSIONS LSM predicts rates of HCC in patients with HCV cirrhosis after SVR at multiple cutoff levels and offers a single test to predict portal hypertension-related complications and HCC. Patients with LSM <5 kPa in the absence of diabetes mellitus had a low risk of HCC in which surveillance could be discontinued.
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Affiliation(s)
- Binu V John
- Division of Gastroenterology and Hepatology, Miami VA Medical System, Miami, Florida; Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida.
| | - Yangyang Dang
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania and Philadelphia VA Medical Center, Philadelphia, Pennsylvania
| | - Janice H Jou
- Division of Gastroenterology and Hepatology, Portland VA Medical Center and Oregon Health University, Portland, Oregon
| | - Tamar H Taddei
- Section of Digestive Diseases, Yale School of Medicine and VA Connecticut Healthcare System, West Haven, Connecticut
| | - Seth A Spector
- Department of Surgery, Miami VA Medical System, University of Miami Miller School of Medicine, Miami, Florida
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Dustin R Bastaich
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Hann-Hsiang Chao
- Department of Radiation Oncology, Central Virginia Health System and Virginia Commonwealth University, Richmond, Virginia
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
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Tang H, Kaplan DE, Mahmud N. The Impact of Weight Loss Programs on BMI Trajectory in Patients with Metabolic Dysfunction-Associated Steatotic Liver Disease: A Veterans Health Administration Study. Am J Gastroenterol 2024:00000434-990000000-01097. [PMID: 38534167 DOI: 10.14309/ajg.0000000000002785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/22/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Weight loss is the mainstay of management for patients with metabolic dysfunction-associated steatotic liver disease. We studied the impact of referral to MOVE!, a nationally-implemented behavioral weight loss program, on weight in MASLD patients. METHODS This retrospective cohort study included 102,294 MASLD patients from 125 Veterans Health Administration centers from 2008-2022. RESULTS Most patients lost no significant weight or gained weight. Increased engagement with MOVE! was associated with greater hazard of significant weight loss compared to no engagement. CONCLUSION A minority of patients experienced significant weight loss through 5 years using lifestyle interventions alone.
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Affiliation(s)
- Helen Tang
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Ebadi R, Kaplan DE, Rajendran S, Walsworth RL. GALILEO: Galactic Axion Laser Interferometer Leveraging Electro-Optics. Phys Rev Lett 2024; 132:101001. [PMID: 38518313 DOI: 10.1103/physrevlett.132.101001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 11/08/2023] [Accepted: 02/05/2024] [Indexed: 03/24/2024]
Abstract
We propose a novel experimental method for probing light dark matter candidates. We show that an electro-optical material's refractive index is modified in the presence of a coherently oscillating dark matter background. A high-precision resonant Michelson interferometer can be used to read out this signal. The proposed detection scheme allows for the exploration of an uncharted parameter space of dark matter candidates over a wide range of masses-including masses exceeding a few tens of microelectronvolts, which is a challenging parameter space for microwave cavity haloscopes.
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Affiliation(s)
- Reza Ebadi
- Department of Physics, University of Maryland, College Park, Maryland 20742, USA
- Quantum Technology Center, University of Maryland, College Park, Maryland 20742, USA
| | - David E Kaplan
- The William H. Miller III Department of Physics and Astronomy, The Johns Hopkins University, Baltimore, Maryland 21218, USA
| | - Surjeet Rajendran
- The William H. Miller III Department of Physics and Astronomy, The Johns Hopkins University, Baltimore, Maryland 21218, USA
| | - Ronald L Walsworth
- Department of Physics, University of Maryland, College Park, Maryland 20742, USA
- Quantum Technology Center, University of Maryland, College Park, Maryland 20742, USA
- Department of Electrical and Computer Engineering, University of Maryland, College Park, Maryland 20742, USA
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Wang L, Rahimi Larki N, Dobkin J, Salgado S, Ahmad N, Kaplan DE, Yang W, Yang YX. A Clinical Prediction Model to Assess Risk for Pancreatic Cancer Among Patients With Acute Pancreatitis. Pancreas 2024; 53:e254-e259. [PMID: 38266222 DOI: 10.1097/mpa.0000000000002295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
OBJECTIVES We aimed to develop and validate a prediction model as the first step in a sequential screening strategy to identify acute pancreatitis (AP) individuals at risk for pancreatic cancer (PC). MATERIALS AND METHODS We performed a population-based retrospective cohort study among individuals 40 years or older with a hospitalization for AP in the US Veterans Health Administration. For variable selection, we used least absolute shrinkage and selection operator regression with 10-fold cross-validation to identify a parsimonious logistic regression model for predicting the outcome, PC diagnosed within 2 years after AP. We evaluated model discrimination and calibration. RESULTS Among 51,613 eligible study patients with AP, 801 individuals were diagnosed with PC within 2 years. The final model (area under the receiver operating curve, 0.70; 95% confidence interval, 0.67-0.73) included histories of gallstones, pancreatic cyst, alcohol use, smoking, and levels of bilirubin, triglycerides, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, and albumin. If the predicted risk threshold was set at 2% over 2 years, 20.3% of the AP population would undergo definitive screening, identifying nearly 50% of PC associated with AP. CONCLUSIONS We developed a prediction model using widely available clinical factors to identify high-risk patients with PC-associated AP, the first step in a sequential screening strategy.
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Affiliation(s)
| | | | | | - Sanjay Salgado
- Division of Gastroenterology and Hepatology, New York Presbyterian Hospital/Weill Cornell Medical College, New York, NY
| | - Nuzhat Ahmad
- Division of Gastroenterology and Hepatology, Perelman School of Medicine
| | | | - Wei Yang
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, Philadelphia, PA
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11
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Pulaski M, Bittermann T, Taddei TH, Kaplan DE, Mahmud N. The Association Between Homelessness and Key Liver-Related Outcomes in Veterans With Cirrhosis. Am J Gastroenterol 2024; 119:297-305. [PMID: 37782293 DOI: 10.14309/ajg.0000000000002535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/06/2023] [Indexed: 10/03/2023]
Abstract
INTRODUCTION Homelessness adversely affects patient outcomes in broad cohort studies; however, its impact on key liver-related outcomes in patients with cirrhosis is understudied. We aimed to address this knowledge gap using data from the Veterans Health Administration, a cohort disproportionately affected by homelessness. METHODS This was a retrospective cohort study of the Veterans Health Administration patients with incident cirrhosis diagnosis between January 2008 and February 2022. Homeless status was classified at baseline and as time-updating variable during follow-up. Inverse probability treatment weighted Cox regression was performed to evaluate the association between homelessness and outcomes of all-cause mortality, cirrhosis decompensation, and hepatocellular carcinoma. RESULTS A total of 117,698 patients were included in the cohort, of whom 14,243 (12.1%) were homeless at baseline. In inverse probability treatment weighted Cox regression, homelessness was associated with a 24% higher hazard of all-cause mortality (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.22-1.26, P < 0.001). However, in competing risk regression models, homelessness was associated with a reduced subhazard of decompensation (subhazard ratio 0.86, 95% CI 0.84-0.88, P < 0.001) and hepatocellular carcinoma (subhazard ratio 0.86, 95% CI 0.83-0.89, P < 0.001). In cause-specific mortality analysis, homeless patients had significantly increased non-liver-related and liver-related mortality; however, the magnitude of effect size was greater for non-liver-related mortality (csHR 1.38, 95% CI 1.35-1.40, P < 0.001). DISCUSSION Homelessness in veterans with cirrhosis is associated with increased all-cause mortality; however, this is likely mediated primarily through non-liver-related factors. Future studies are needed to explore drivers of mortality and improve mitigation strategies in these patients.
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Affiliation(s)
- Marya Pulaski
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Therese Bittermann
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tamar H Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Wang RX, Vizzutti F, Celsa C, Schepis F, Kaplan DE, Mahmud N. Evaluating the predictive performance of the elderly patient calculator TIPS score in a North American cohort. Hepatol Commun 2024; 8:e0346. [PMID: 38251888 PMCID: PMC10805419 DOI: 10.1097/hc9.0000000000000346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/07/2023] [Indexed: 01/23/2024] Open
Affiliation(s)
- Roy X. Wang
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Ciro Celsa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, Gastroenterology and Hepatology Unit, University of Palermo, Palermo, Italy
| | - Filippo Schepis
- Department of Medicine, Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - David E. Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nadim Mahmud
- Department of Medicine, Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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13
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Scorletti E, Saiman Y, Jeon S, Schneider CV, Buyco DG, Lin C, Himes BE, Mesaros CA, Vujkovic M, Creasy KT, Furth EE, Billheimer JT, Hand NJ, Kaplan DE, Chang KM, Tsao PS, Lynch JA, Dempsey JL, Harkin J, Bayen S, Conlon D, Guerraty M, Phillips MC, Rader DJ, Carr RM. A missense variant in human perilipin 2 ( PLIN2 Ser251Pro) reduces hepatic steatosis in mice. JHEP Rep 2024; 6:100902. [PMID: 38074507 PMCID: PMC10701134 DOI: 10.1016/j.jhepr.2023.100902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 08/01/2023] [Accepted: 08/24/2023] [Indexed: 01/23/2024] Open
Abstract
Background & Aims Non-alcoholic fatty liver disease (NAFLD) is characterised by the accumulation of lipid droplets (LDs) within hepatocytes. Perilipin 2 (PLIN2) is the most abundant protein in hepatic LDs and its expression correlates with intracellular lipid accumulation. A recently discovered PLIN2 coding variant, Ser251Pro (rs35568725), was found to promote the accumulation of small LDs in embryonic kidney cells. In this study, we investigate the role of PLIN2-Ser251Pro (PLIN2-Pro251) on hepatic LD metabolism in vivo and research the metabolic phenotypes associated with this variant in humans. Methods For our animal model, we used Plin2 knockout mice in which we expressed either human PLIN2-Pro251 (Pro251 mice) or wild-type human PLIN2-Ser251 (Ser251 mice) in a hepatocyte-specific manner. We fed both cohorts a lipogenic high-fat, high-cholesterol, high-fructose diet for 12 weeks. Results Pro251 mice were associated with reduced liver triglycerides (TGs) and had lower mRNA expression of fatty acid synthase and diacylglycerol O-acyltransferase-2 compared with Ser251 mice. Moreover, Pro251 mice had a reduction of polyunsaturated fatty acids-TGs and reduced expression of epoxygenase genes. For our human study, we analysed the Penn Medicine BioBank, the Million Veteran Program, and UK Biobank. Across these databases, the minor allele frequency of PLIN2-Pro251 was approximately 5%. There was no association with the clinical diagnosis of NAFLD, however, there was a trend toward reduced liver fat in PLIN2-Pro251 carriers by MRI-spectroscopy in UK Biobank subjects. Conclusions In mice lacking endogenous Plin2, expression of human PLIN2-Pro251 attenuated high-fat, high-fructose, high-cholesterol, diet-induced hepatic steatosis compared with human wild-type PLIN2-Ser251. Moreover, Pro251 mice had lower polyunsaturated fatty acids-TGs and epoxygenase genes expression, suggesting less liver oxidative stress. In humans, PLIN2-Pro251 is not associated with NAFLD. Impact and Implications Lipid droplet accumulation in hepatocytes is the distinctive characteristic of non-alcoholic fatty liver disease. Perilipin 2 (PLIN2) is the most abundant protein in hepatic lipid droplets; however, little is known on the role of a specific polymorphism PLIN2-Pro251 on hepatic lipid droplet metabolism. PLIN2-Pro251 attenuates liver triglycerides accumulation after a high-fat-high-glucose-diet. PLIN2-Pro251 may be a novel lipid droplet protein target for the treatment of liver steatosis.
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Affiliation(s)
- Eleonora Scorletti
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Yedidya Saiman
- Department of Hepatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Sookyoung Jeon
- Department of Food Science and Nutrition, Hallym University, Chuncheon, Gangwon-do, Republic of Korea
| | - Carolin V. Schneider
- Department of Medicine III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Delfin G. Buyco
- Department of Biomedical Engineering, Northwestern University, Evanston, IL, USA
| | - Chelsea Lin
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Blanca E. Himes
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Clementina A. Mesaros
- Department of Systems Pharmacology and Translational Therapeutics (SPATT) University of Pennsylvania, Philadelphia, PA, USA
| | - Marijana Vujkovic
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kate Townsend Creasy
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Emma E. Furth
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey T. Billheimer
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nicholas J. Hand
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kyong-Mi Chang
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Philip S. Tsao
- Precision Medicine, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Julie A. Lynch
- VA Informatics & Computing Infrastructure, VA Salt Lake City Utah & University of Utah, School of Medicine, Salt Lake City, UT, USA
| | - Joseph L. Dempsey
- Division of Gastroenterology, Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Julia Harkin
- Division of Gastroenterology, Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Susovon Bayen
- Division of Gastroenterology, Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Donna Conlon
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, PA, USA
| | - Marie Guerraty
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, PA, USA
| | - Michael C. Phillips
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel J. Rader
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Rotonya M. Carr
- Division of Gastroenterology, Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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Mezzacappa C, Mahmud N, Serper M, John BV, Taddei TH, Kaplan DE. HCC is associated with diabetes and longitudinal blood glucose control in a national cohort with cirrhosis. Hepatol Commun 2023; 7:e0344. [PMID: 38055642 PMCID: PMC10984661 DOI: 10.1097/hc9.0000000000000344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/05/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Diabetes is associated with HCC; however, the impact of longitudinal blood glucose (BG) control on HCC risk in cirrhosis is not well known. We investigated this knowledge gap in a cohort of United States Veterans with cirrhosis from 2015 to 2021. METHODS We used repeated hemoglobin A1c measurements to categorize follow-up time according to BG control (defined as hemoglobin A1c < 7%) state over time: uncontrolled, nonsustained control (≤2 y), or sustained control (>2 y). We performed a sensitivity analysis using hemoglobin A1c < 8% to define BG control. We used Fine and Gray Cox proportional hazards regression with death and transplant as competing events to compare rates of incident HCC. RESULTS Our study included 81,907 individuals, 56.2% of whom had diabetes at baseline. There were 8,002 incident HCCs. The rate of HCC was 18% higher in diabetes (95% CI: 13% - 24%), and the relative increase in the rate of HCC varied by etiology of cirrhosis from nonsignificant (HCV) to an increase of 120% (HBV). Uncontrolled and nonsustained BG control was associated with 1.80 (95% CI: 1.70-1.91) and 2.34 (95% CI: 2.21-2.48) times the rate of HCC compared to sustained BG control, respectively. Using Hgb A1c < 8% to define BG control, HCC rates in uncontrolled and nonsustained BG control were 2.43 (2.28-2.58) and 2.23 (2.11-2.36) times that observed in sustained BG control. CONCLUSIONS Associations between diabetes and HCC in cirrhosis vary according to the longitudinal BG control state. Inadequate BG control is consistently associated with a higher risk of HCC, and long-term BG control should be considered in comprehensive cirrhosis care.
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Affiliation(s)
- Catherine Mezzacappa
- Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, Department of Internal Medicine West Haven, Connecticut, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Binu V. John
- University of Miami School of Medicine, Miami, Florida, USA
- Bruce W Carter VA Medical Center, Miami, Florida, USA
| | - Tamar H. Taddei
- Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, Department of Internal Medicine West Haven, Connecticut, USA
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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15
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Arif-Tiwari H, Porter KK, Kamel IR, Bashir MR, Fung A, Kaplan DE, McGuire BM, Russo GK, Smith EN, Solnes LB, Thakrar KH, Vij A, Wahab SA, Wardrop RM, Zaheer A, Carucci LR. ACR Appropriateness Criteria® Abnormal Liver Function Tests. J Am Coll Radiol 2023; 20:S302-S314. [PMID: 38040457 DOI: 10.1016/j.jacr.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
Liver function tests are commonly obtained in symptomatic and asymptomatic patients. Various overlapping lab patterns can be seen due to derangement of hepatocytes and bile ducts function. Imaging tests are pursued to identify underlying etiology and guide management based on the lab results. Liver function tests may reveal mild, moderate, or severe hepatocellular predominance and can be seen in alcoholic and nonalcoholic liver disease, acute hepatitis, and acute liver injury due to other causes. Cholestatic pattern with elevated alkaline phosphatase with or without elevated γ-glutamyl transpeptidase can be seen with various causes of obstructive biliopathy. Acute or subacute cholestasis with conjugated or unconjugated hyperbilirubinemia can be seen due to prehepatic, intrahepatic, or posthepatic causes. We discuss the initial and complementary imaging modalities to be used in clinical scenarios presenting with abnormal liver function tests. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Hina Arif-Tiwari
- University of Arizona, Banner University Medical Center, Tucson, Arizona.
| | | | - Ihab R Kamel
- Panel Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Alice Fung
- Oregon Health & Science University, Portland, Oregon
| | - David E Kaplan
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; American Association for the Study of Liver Diseases
| | - Brendan M McGuire
- University of Alabama at Birmingham, Birmingham, Alabama, Primary care physician
| | | | - Elainea N Smith
- University of Alabama at Birmingham Medical Center, Birmingham, Alabama
| | - Lilja Bjork Solnes
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Abhinav Vij
- New York University Langone Medical Center, New York, New York
| | - Shaun A Wahab
- University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Richard M Wardrop
- Cleveland Clinic, Cleveland, Ohio; American College of Physicians, Hospital Medicine
| | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Thanawala SU, Kaplan DE, Falk GW, Beveridge CA, Schaubel D, Serper M, Yang YX. Antibiotic Exposure is Associated With a Risk of Esophageal Adenocarcinoma. Clin Gastroenterol Hepatol 2023; 21:2817-2824.e4. [PMID: 36967101 PMCID: PMC10518027 DOI: 10.1016/j.cgh.2023.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 03/02/2023] [Accepted: 03/10/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND & AIMS Antibiotic exposure leads to changes in the gut microbiota. Our objective was to evaluate the association between antibiotic exposure and esophageal adenocarcinoma (EAC) risk. METHODS We performed a nested case-control study using data from the Veterans Health Administration from 2004 through 2020. The case group consisted of patients who received an incident diagnosis of EAC. For each case, up to 20 matched controls were selected using incidence density sampling. Our primary exposure of interest was any oral or intravenous antibiotic use. Our secondary exposures included cumulative number of days of exposure and classification of antibiotics by various subgroups. Conditional logistic regression was used to estimate the crude and adjusted odds ratios (aORs) for the risk of EAC associated with antibiotic exposure. RESULTS The case-control analysis included 8226 EAC cases and 140,670 matched controls. Exposure to any antibiotic was associated with an aOR for EAC of 1.74 (95% confidence interval [CI], 1.65-1.83) vs no antibiotic exposure. Compared with no antibiotic exposure, the aOR for EAC was 1.63 (95% CI, 1.52-1.74; P < .001) for cumulative exposure to any antibiotic for 1 to 15 days; 1.77 (95% CI, 1.65-1.89; P < 0 .001) for 16 to 47 days; and 1.87 (95% CI, 1.75-2.01; P < .001) for ≥48 days, respectively (P for trend < .001). CONCLUSION Exposure to any antibiotic is associated with an increased risk of EAC, and this risk increases as the cumulative days of exposure increase. This novel finding is hypothesis-generating for potential mechanisms that may play a role in the development or progression of EAC.
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Affiliation(s)
- Shivani U Thanawala
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology, Veterans Health Administration, Philadelphia, Pennsylvania
| | - Gary W Falk
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Claire A Beveridge
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Douglas Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology, Veterans Health Administration, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yu-Xiao Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology, Veterans Health Administration, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
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John BV, Bastaich DR, Ferreira RD, Doshi A, Taddei TH, Kaplan DE, Spector S, Deng Y, Dahman B. COVID-19 vaccine effectiveness and community prevalence of Alpha, Delta and Omicron variants in patients with cirrhosis. Gut 2023; 72:1800-1802. [PMID: 36562753 DOI: 10.1136/gutjnl-2022-327799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 08/29/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Binu V John
- Gastroenterology and Hepatology, University of Miami, Miami, Florida, USA
- Gastroenterology and Hepatology, Miami VA Healthcare System, Miami, Florida, USA
| | - Dustin R Bastaich
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Raphaella D Ferreira
- Gastroenterology and Hepatology, Miami VA Healthcare System, Miami, Florida, USA
| | - Akash Doshi
- Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Tamar H Taddei
- Medicine, VA Connecticut Health System West Haven Campus, West Haven, Connecticut, USA
| | - David E Kaplan
- Gastroenterology and Hepatology, Hospital of the Inversity of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Seth Spector
- Department of Surgery, University of Miami, Coral Gables, Florida, USA
- Department of Surgery, Bruce W Carter Department of Veterans Affairs Medical Center, Miami, Florida, USA
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
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Hsu CC, Gopalakrishna H, Mironova M, Lee MH, Chen CJ, Yang HI, Wiese M, Chang KM, Wright EC, Abijo T, Feld JJ, Kaplan DE. Risk of Hepatocellular Carcinoma After Spontaneous Clearance of Hepatitis C Virus and in Noncirrhosis Chronic Hepatitis C Patients With Sustained Virological Response: A Systematic Review. Clin Infect Dis 2023; 77:S245-S256. [PMID: 37579210 PMCID: PMC10425144 DOI: 10.1093/cid/ciad380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
In a hepatitis C virus (HCV)-controlled human infection model (CHIM), healthy volunteers are inoculated with HCV and then treated. Residual hepatocellular carcinoma (HCC) risk after viral clearance is an important consideration when evaluating the CHIM. We estimate HCC risk in spontaneously cleared HCV and in noncirrhosis after sustained virological response (SVR) to HCV treatment in a systematic review and using data from 3 cohorts: German anti-D, Taiwan, and US Veterans Affairs (VA). For noncirrhosis SVR, the overall HCC rate is 0.33 per 100 patient-years in meta-analysis. HCC rates for the German, Taiwan, and US Veterans Affairs cohorts are 0, 0.14, and 0.02 per 100 patient-years, respectively. Past hepatitis B virus exposure was not accounted for in the Taiwan cohort, while VA patients were likely tested based on liver disease/risk factors, which may confound HCC outcomes. The German cohort with no HCC after 44 years is most comparable to the CHIM participants. Although it is difficult to precisely estimate HCC risk from an HCV CHIM, the data suggest the risk to be very low or negligible.
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Affiliation(s)
- Christine C Hsu
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Harish Gopalakrishna
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Maria Mironova
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Mei-Hsuan Lee
- Institute of Clinical Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Jen Chen
- Genomics Research Center, Academia Sinica, Taipei, Taiwan
| | - Hwai-I Yang
- Genomics Research Center, Academia Sinica, Taipei, Taiwan
| | - Manfred Wiese
- Department of Hepatology, University Hospital Leipzig, East German HCV Study Group, Leipzig, Germany
| | - Kyong-Mi Chang
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Elizabeth C Wright
- Office of the Director, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Tomilowo Abijo
- Office of the Director, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Jordan J Feld
- Department of Medicine, Division of Gastroenterology, Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
- Toronto Viral Hepatitis Care Network, Toronto, Canada
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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O'Leary C, Nadolski G, Kovach SJ, Zheng J, Cohen A, Kaplan DE, Itkin M. Thoracic Duct-Venous Junction Obstruction as Unknown Cause of Abdominal Pain: Diagnosis and Treatment. Radiology 2023; 308:e230380. [PMID: 37526547 DOI: 10.1148/radiol.230380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Affiliation(s)
- Cathal O'Leary
- From the Division of Interventional Radiology (C.O., G.N., M.I.), Division of Plastic Surgery (S.J.K.), Department of Physical Medicine and Rehabilitation (J.Z.), and Division of Gastroenterology and Hepatology (D.E.K.), University of Pennsylvania Health System, Philadelphia, PA 19104; and Department of Interventional Radiology, Rabin Medical Center, Petah Tikva, Israel (A.C.)
| | - Gregory Nadolski
- From the Division of Interventional Radiology (C.O., G.N., M.I.), Division of Plastic Surgery (S.J.K.), Department of Physical Medicine and Rehabilitation (J.Z.), and Division of Gastroenterology and Hepatology (D.E.K.), University of Pennsylvania Health System, Philadelphia, PA 19104; and Department of Interventional Radiology, Rabin Medical Center, Petah Tikva, Israel (A.C.)
| | - Stephen J Kovach
- From the Division of Interventional Radiology (C.O., G.N., M.I.), Division of Plastic Surgery (S.J.K.), Department of Physical Medicine and Rehabilitation (J.Z.), and Division of Gastroenterology and Hepatology (D.E.K.), University of Pennsylvania Health System, Philadelphia, PA 19104; and Department of Interventional Radiology, Rabin Medical Center, Petah Tikva, Israel (A.C.)
| | - Jasmine Zheng
- From the Division of Interventional Radiology (C.O., G.N., M.I.), Division of Plastic Surgery (S.J.K.), Department of Physical Medicine and Rehabilitation (J.Z.), and Division of Gastroenterology and Hepatology (D.E.K.), University of Pennsylvania Health System, Philadelphia, PA 19104; and Department of Interventional Radiology, Rabin Medical Center, Petah Tikva, Israel (A.C.)
| | - Aenov Cohen
- From the Division of Interventional Radiology (C.O., G.N., M.I.), Division of Plastic Surgery (S.J.K.), Department of Physical Medicine and Rehabilitation (J.Z.), and Division of Gastroenterology and Hepatology (D.E.K.), University of Pennsylvania Health System, Philadelphia, PA 19104; and Department of Interventional Radiology, Rabin Medical Center, Petah Tikva, Israel (A.C.)
| | - David E Kaplan
- From the Division of Interventional Radiology (C.O., G.N., M.I.), Division of Plastic Surgery (S.J.K.), Department of Physical Medicine and Rehabilitation (J.Z.), and Division of Gastroenterology and Hepatology (D.E.K.), University of Pennsylvania Health System, Philadelphia, PA 19104; and Department of Interventional Radiology, Rabin Medical Center, Petah Tikva, Israel (A.C.)
| | - Maxim Itkin
- From the Division of Interventional Radiology (C.O., G.N., M.I.), Division of Plastic Surgery (S.J.K.), Department of Physical Medicine and Rehabilitation (J.Z.), and Division of Gastroenterology and Hepatology (D.E.K.), University of Pennsylvania Health System, Philadelphia, PA 19104; and Department of Interventional Radiology, Rabin Medical Center, Petah Tikva, Israel (A.C.)
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20
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Durkin C, Schaubel DE, Xu Y, Mahmud N, Kaplan DE, Abt PL, Bittermann T. Induction Immunosuppression Does Not Worsen Tumor Recurrence After Liver Transplantation for Hepatocellular Carcinoma. Transplantation 2023; 107:1524-1534. [PMID: 36695564 DOI: 10.1097/tp.0000000000004487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Prior studies are inconsistent regarding the impact of antibody induction therapy on outcomes after liver transplantation (LT) for hepatocellular carcinoma (HCC). METHODS Adults transplanted with HCC exception priority were identified from February 27, 2002, to March 31, 2019, using the United Network for Organ Sharing database. Time-to-event analyses evaluated the association of antibody induction therapy (none, nondepleting induction [NDI], depleting induction [DI]) with overall post-LT patient survival and HCC recurrence. Separate multivariable models adjusted for tumor characteristics on either last exception or on explant. The interaction of induction and maintenance regimen at LT discharge was investigated. RESULTS Among 22 535 LTs for HCC, 17 688 (78.48%) received no antibody induction, 2984 (13.24%) NDI, and 1863 (8.27%) DI. Minimal differences in patient and tumor characteristics were noted between induction groups, and there was significant center variability in practices. NDI was associated with improved survival, particularly when combined with a calcineurin inhibitor (CNI) and antimetabolite (hazard ratio [HR] 0.73 versus no induction plus 3-drug therapy in the last exception model [ P < 0.001]; HR 0.64 in the explant model [ P = 0.011]). The combination of DI with CNI alone was also protective (HR 0.43; P = 0.003). Neither NDI nor DI was associated with tumor recurrence (all P > 0.1). However, increased HCC recurrence was observed with no induction plus CNI monotherapy (HR 1.47, P = 0.019; versus no induction plus 3-drug therapy). CONCLUSIONS In conclusion, induction immunosuppression was not associated with worse post-LT outcomes in patients transplanted with HCC exception priority. An improvement in survival was possibly observed with NDI.
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Affiliation(s)
- Claire Durkin
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Yuwen Xu
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
- Section of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Section of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Peter L Abt
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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21
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Serper M, Agha A, Garren PA, Taddei TH, Kaplan DE, Groeneveld PW, Werner RM, Shea JA. Multidisciplinary teams, efficient communication, procedure services, and telehealth improve cirrhosis care: A qualitative study. Hepatol Commun 2023; 7:e0157. [PMID: 37219845 PMCID: PMC10208700 DOI: 10.1097/hc9.0000000000000157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/29/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Cirrhosis care and outcomes are improved with access to subspecialty gastroenterology and hepatology care. In qualitative interviews, we investigated clinicians' perceptions of factors that optimize or impede cirrhosis care. METHODS We conducted 24 telephone interviews with subspecialty clinicians at 7 Veterans Affairs medical centers with high- and low-complexity services. Purposive sampling stratified Veterans Affairs medical centers on timely post-hospitalization follow-up, a quality measure. We asked open-ended questions about facilitators and barriers of care coordination, access to appointments, procedures, transplantation, management of complications, keeping up to date with medical knowledge, and telehealth use. RESULTS Key themes that facilitated care were structural: multidisciplinary teams, clinical dashboards, mechanisms for appointment tracking and reminders, and local or virtual access to transplant and liver cancer specialists through the "specialty care access network extension for community health care outcomes" program. Coordination and efficient communication between transplant and non-transplant specialists and between transplant and primary care facilitated timely care. Same-day access to laboratory, procedural, and clinical services is an indicator of high-quality care. Barriers included lack of on-site procedural services, clinician turnover, patient social needs related to transportation, costs, and patient forgetfulness due to HE. Telehealth enabled lower complexity sites to obtain recommendations for complex patient cases. Barriers to telehealth included lack of credit (eg, VA billing equivalent), inadequate staff, lack of audiovisual technology support, and patient and staff discomfort with technology. Telehealth was optimal for return visits, cases where physical examination was nonessential, and where distance and transportation precluded in-person care. Rapid telehealth uptake during the COVID-19 pandemic was a positive disruptor and facilitated use. CONCLUSIONS We identify multi-level factors related to structure, staffing, technology, and care organization to optimize cirrhosis care delivery.
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Affiliation(s)
- Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard David Institute of Health Economics, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Aneeza Agha
- Corporal Michael J. Crescenz VA Medical Center, VA Center for Health Equity Research and Promotion (CHERP), Philadelphia, Pennsylvania, USA
| | - Patrik A. Garren
- School of Nursing, NewCourtland Center for Transitions in Health, Department of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, Department of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, Department of Medicine, West Haven, Connecticut, USA
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Peter W. Groeneveld
- Leonard David Institute of Health Economics, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, VA Center for Health Equity Research and Promotion (CHERP), Philadelphia, Pennsylvania, USA
- Department of Medicine, Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cardiovascular Outcomes, Quality, and Evaluation Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel M. Werner
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard David Institute of Health Economics, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Medicine, Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Judy A. Shea
- Department of Medicine, Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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22
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Choi DT, Sada YH, Sansgiry S, Kaplan DE, Taddei TH, Aguilar JK, Strayhorn M, Hernaez R, Davila JA. Using Telemedicine to Facilitate Patient Communication and Treatment Decision-Making Following Multidisciplinary Tumor Board Review for Patients with Hepatocellular Carcinoma. J Gastrointest Cancer 2023; 54:623-631. [PMID: 35773376 PMCID: PMC9247952 DOI: 10.1007/s12029-022-00844-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND AIMS A rapid increase in the use of telemedicine for delivering healthcare has occurred since the onset of the Covid-19 pandemic. There is evidence for using telemedicine to facilitate cancer care delivery for patients with hepatocellular carcinoma (HCC). Examining how telemedicine can be used to communicate multidisciplinary tumor board (MTB) recommendations for HCC has not been studied. This study has two specific aims: (1) to evaluate the patient perspective of the MTB review process and identify best strategies for communicating treatment recommendations for HCC and (2) to pilot test a telemedicine intervention following MTB review to assess patient feasibility and satisfaction with using telemedicine to facilitate treatment decision-making and treatment referral. METHODS We conducted a mixed-methods study. First, semi-structured qualitative interviews were conducted among patients diagnosed with HCC who were discussed in MTB review at one of three VA Medical Centers (VAMC). We collected information about the MTB process from the patient perspective and identified strategies for improving communication and delivery of care. Rapid qualitative analysis was used to inform intervention development. Using our qualitative data, a MTB telemedicine pilot intervention was developed and implemented to assess the feasibility of using this approach for patients with HCC. RESULTS Almost all patients (94%) in the pilot study would recommend telemedicine to other patients with HCC, and half of the patients (50%) preferred telemedicine over in-person visits. Many patients (81%) found communication through telemedicine an acceptable platform to deliver difficult cancer information. Overall, patients felt they understood their treatment recommendations and found them clear and useful. Further, patients reported that they enjoyed being included in the decision-making process and appreciated being able to have family members easily join them for the telemedicine visit. CONCLUSIONS Using telemedicine to communicate treatment recommendations following MTB review was found to be feasible and an acceptable alternative to an in-person visit for patient with HCC. Future studies could include expanding this approach for communicating MTB recommendations to patients with other types of cancers.
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Affiliation(s)
- Debra T Choi
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA.
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Yvonne H Sada
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Section of Hematology and Oncology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Shubhada Sansgiry
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Veterans Affairs South Central Mental Illness Research Education and Clinical Center, Houston, TX, USA
| | - David E Kaplan
- Department of Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Tamar H Taddei
- VA Connecticut Healthcare System, West Haven, CT, USA
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jason K Aguilar
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Michael Strayhorn
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ruben Hernaez
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Jessica A Davila
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Chapin S, Kaplan DE, Taddei T, Mahmud N. Association between statin exposure and short-term mortality in patients with high-grade acute-on-chronic liver failure. JHEP Rep 2023; 5:100740. [PMID: 37215188 PMCID: PMC10193237 DOI: 10.1016/j.jhepr.2023.100740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 05/24/2023] Open
Abstract
Background & Aims Acute-on-chronic liver failure (ACLF) carries a high short-term mortality for patients with cirrhosis. Prior literature suggests that statin exposure may reduce the likelihood of ACLF events. However, it is unclear if statin exposure is associated with ACLF-related mortality. This study sought to determine the association between statin use and short-term mortality among patients hospitalised with ACLF. Methods This was a retrospective cohort study of Veterans Health Administration (VHA) patients diagnosed with cirrhosis between 2008 and 2021 and hospitalised with high-grade (2 or 3) ACLF. Patients were stratified into those with and without continuous statin exposure for at least 90 days prior to hospitalisation. Multivariable logistic regression models were created to determine the adjusted association between statin exposure and 28-day and 90-day mortality. Categorical statin dose exposure, converted to simvastatin equivalents, was also explored. Results A total of 11,731 patients with cirrhosis hospitalised with Grade 2 or 3 ACLF were included in the analytic cohort, 26% of whom had statin exposure. In adjusted logistic regression models, statin use was associated with 18% lower odds of ACLF-related 28-day mortality (odds ratio [OR] 0.82, 95% CI 0.73-0.93, p = 0.001) and 24% lower odds of 90-day mortality (OR 0.76, 95% CI 0.68-0.86, p <0.001). Increasing statin dose exposure was also associated with further reductions in 90-day mortality (e.g. OR 0.81, 95% CI 0.70-0.93 for 10-40 mg vs. 0 mg and OR 0.72, 95% CI 0.60-0.87 for 80 mg vs. 0 mg, p <0.001). Conclusions In this large, retrospective cohort study, statin exposure before high-grade ACLF hospitalisation was associated with reduced odds of 28-day and 90-day mortality in patients with cirrhosis. A statin dose-dependent reduction in 90-day ACLF-related mortality was also observed. Impact and Implications Statins have been identified as a class of medications with potential beneficial effects for patients with cirrhosis. In this large, retrospective cohort study of patients with cirrhosis who seek care at the Veterans Health Administration, statin use was associated with a decrease in short term (28-day and 90-day) mortality as a result of acute-on-chronic liver failure. Future prospective studies are needed to further clarify the relative safety and efficacy of statin therapy in reducing morbidity and mortality associated with acute-on-chronic liver failure in patients with cirrhosis.
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Affiliation(s)
- Sara Chapin
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Tamar Taddei
- VA Connecticut-Healthcare System, West Haven, CT, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard David Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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24
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Kaplan DE. Statins in Cirrhosis: Trial Data Are in but the Jury Is Still Out. Dig Dis Sci 2023:10.1007/s10620-023-07970-w. [PMID: 37213002 DOI: 10.1007/s10620-023-07970-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 05/08/2023] [Indexed: 05/23/2023]
Affiliation(s)
- David E Kaplan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
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25
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Broz J, You B, Khan S, Häffner H, Kaplan DE, Rajendran S. Test of Causal Nonlinear Quantum Mechanics by Ramsey Interferometry with a Trapped Ion. Phys Rev Lett 2023; 130:200201. [PMID: 37267574 DOI: 10.1103/physrevlett.130.200201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 04/06/2023] [Indexed: 06/04/2023]
Abstract
Quantum mechanics requires the time evolution of the wave function to be linear. While this feature has been associated with the preservation of causality, a consistent causal nonlinear theory was recently developed. Interestingly, this theory is unavoidably sensitive to the full physical spread of the wave function, rendering existing experimental tests for nonlinearities inapplicable. Here, using well-controlled motional superpositions of a trapped ion, we set a stringent limit of 5.4×10^{-12} on the magnitude of the unitless scaling factor ε[over ˜]_{γ} for the predicted causal nonlinear perturbation.
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Affiliation(s)
- Joseph Broz
- Department of Physics, University of California, Berkeley, California 94720, USA and Challenge Institute for Quantum Computation, University of California, Berkeley, California 94720, USA
| | - Bingran You
- Department of Physics, University of California, Berkeley, California 94720, USA and Challenge Institute for Quantum Computation, University of California, Berkeley, California 94720, USA
| | - Sumanta Khan
- Department of Physics, University of California, Berkeley, California 94720, USA and Challenge Institute for Quantum Computation, University of California, Berkeley, California 94720, USA
| | - Hartmut Häffner
- Department of Physics, University of California, Berkeley, California 94720, USA and Challenge Institute for Quantum Computation, University of California, Berkeley, California 94720, USA
| | - David E Kaplan
- Department of Physics and Astronomy, The Johns Hopkins University, Baltimore, Maryland 21218, USA
| | - Surjeet Rajendran
- Department of Physics and Astronomy, The Johns Hopkins University, Baltimore, Maryland 21218, USA
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26
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John BV, Bastaich D, Webb G, Brevini T, Moon A, Ferreira RD, Chin AM, Kaplan DE, Taddei TH, Serper M, Mahmud N, Deng Y, Chao HH, Sampaziotis F, Dahman B. Ursodeoxycholic acid is associated with a reduction in SARS-CoV-2 infection and reduced severity of COVID-19 in patients with cirrhosis. J Intern Med 2023; 293:636-647. [PMID: 37018129 DOI: 10.1111/joim.13630] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND AND AIMS Studies have demonstrated that reducing farnesoid X receptor activity with ursodeoxycholic acid (UDCA) downregulates angiotensin-converting enzyme in human lung, intestinal and cholangiocytes organoids in vitro, in human lungs and livers perfused ex situ, reducing internalization of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) into the host cell. This offers a potential novel target against coronavirus disease 2019 (COVID-19). The objective of our study was to compare the association between UDCA exposure and SARS-CoV-2 infection, as well as varying severities of COVID-19, in a large national cohort of participants with cirrhosis. METHODS In this retrospective cohort study among participants with cirrhosis in the Veterans Outcomes and Costs Associated with Liver cohort, we compared participants with exposure to UDCA, with a propensity score (PS) matched group of participants without UDCA exposure, matched for clinical characteristics, and vaccination status. The outcomes included SARS-CoV-2 infection, symptomatic, at least moderate, severe, or critical COVID-19, and COVID-19-related death. RESULTS We compared 1607 participants with cirrhosis who were on UDCA, with 1607 PS-matched controls. On multivariable logistic regression, UDCA exposure was associated with reduced odds of developing SARS-CoV-2 infection (adjusted odds ratio [aOR] 0.54, 95% confidence interval [CI] 0.41-0.71, p < 0.0001). Among patients who developed COVID-19, UDCA use was associated with reduced disease severity, including symptomatic COVID-19 (aOR 0.54, 95% CI 0.39-0.73, p < 0.0001), at least moderate COVID-19 (aOR 0.51, 95% CI 0.32-0.81, p = 0.005), and severe or critical COVID-19 (aOR 0.48, 95% CI 0.25-0.94, p = 0.03). CONCLUSIONS In participants with cirrhosis, UDCA exposure was associated with both a decrease in SARS-CoV-2 infection, and reduction in symptomatic, at least moderate, and severe/critical COVID-19.
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Affiliation(s)
- Binu V John
- Division of Gastroenterology and Hepatology, Miami VA Medical System, Miami, Florida, USA
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Dustin Bastaich
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Gwilym Webb
- Cambridge Liver Unit, Cambridge University Hospital, NHS Foundation Trust, Cambridge, UK
| | - Teresa Brevini
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
| | - Andrew Moon
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Raphaella D Ferreira
- Division of Gastroenterology and Hepatology, Miami VA Medical System, Miami, Florida, USA
| | - Allison M Chin
- Herbert Wertheim Florida International University, Miami, Florida, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Section of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Tamar H Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- Section of Gastroenterology, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Hann-Hsiang Chao
- Department of Radiation Oncology, Central Virginia Health System, Richmond, Virginia, USA
| | - Fotios Sampaziotis
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
- Cambridge Liver Unit, Cambridge University Hospital, NHS Foundation Trust, Cambridge, UK
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
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27
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Shaffer LR, Kaplan DE, Taddei TH, Mahmud N. The association between mental illness and all-cause mortality in patients with cirrhosis: a Veterans Affairs retrospective cohort study. Hepatol Commun 2023; 7:e0129. [PMID: 36996031 PMCID: PMC10069831 DOI: 10.1097/hc9.0000000000000129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/24/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Mental health diagnoses are common and known to impact key outcomes in patients with chronic illnesses including cirrhosis. However, the independent impact of psychiatric comorbidities on mortality in these patients and potential mitigating effects of outpatient mental health-related care has not been well characterized. METHODS This was a retrospective cohort study of patients with cirrhosis in the Veterans Health Administration between 2008 and 2021. Adjusted Cox regression was performed to evaluate the association between mental health-related diagnoses [groups: alcohol use disorder (AUD)/substance use disorder (SUD) alone, non-AUD/SUD alone, and any mental health diagnosis (AUD/SUD or non-AUD/SUD)] and all-cause mortality. In subgroup analyses, the impact of regular outpatient mental health visits was also assessed. RESULTS We identified 115,409 patients, 81.7% of whom had any mental health diagnosis at baseline. During the study window there was a significant increase in the number of mental health clinic visits per person-year (β=0.078, 95% CI: 0.065-0.092, p < 0.001), but a decrease in AUD/SUD clinic utilization (p < 0.001). In regression models, there was a 54% increased hazard in all-cause mortality for any mental health diagnosis, 11% for non-AUD/SUD, and 44% for AUD/SUD (each p < 0.001). Regular mental health visits resulted in a 21% decreased risk in all-cause mortality for AUD/SUD diagnosis, compared with 3% and 9% for any mental health diagnosis and non-AUD/SUD diagnosis, respectively (each p < 0.001). CONCLUSIONS Mental illness is associated with an increased risk of all-cause mortality in veterans with cirrhosis. Regular outpatient mental health care may be protective against all-cause mortality, particularly among patients with AUD/SUD. Future studies should focus on relevant clinical practice changes, including implementing integrated care programs.
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Affiliation(s)
- Lauren R. Shaffer
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Rabiee A, Mahmud N, Falker C, Garcia-Tsao G, Taddei T, Kaplan DE. Medications for alcohol use disorder improve survival in patients with hazardous drinking and alcohol-associated cirrhosis. Hepatol Commun 2023; 7:e0093. [PMID: 36972386 PMCID: PMC10043587 DOI: 10.1097/hc9.0000000000000093] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Medications for alcohol use disorder (MAUD) are highly effective in achieving and maintaining abstinence in patients with alcohol use disorder (AUD). Our aim was to evaluate the effect of MAUD on all-cause mortality in patients with alcohol-associated cirrhosis and active alcohol use. METHODS This was a retrospective cohort study of patients with alcohol-associated cirrhosis and high-risk alcohol use disorder in the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) database. Propensity score matching for exposure to MAUD (acamprosate or naltrexone) within a year after cirrhosis diagnosis was performed to account for potential confounders, and the association between MAUD and all-cause mortality was subsequently evaluated using Cox regression analysis. RESULTS A total of 9131 patients were included, of whom 886 (9.7%) were exposed to MAUD (naltrexone: 520, acamprosate: 307, both medications: 59). The duration of MAUD exposure was >3 months in 345 patients (39%). The strongest positive predictor of MAUD prescription was an inpatient diagnosis code for AUD, followed by a concurrent diagnosis of depression; the strongest negative predictor was a history of cirrhosis decompensation. After propensity score matching (866 patients in each group) with excellent covariate balance (absolute standardized mean differences <0.1), MAUD exposure was associated with improved survival, with an HR of 0.80 relative to no MAUD exposure (95% CI: 0.67-0.97, p = 0.024). CONCLUSION MAUD are underutilized in patients with alcohol-associated cirrhosis with high-risk alcohol use behavior but are associated with improved survival after adjustment for confounders such as the severity of liver disease, age, and engagement in the healthcare system.
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Affiliation(s)
- Anahita Rabiee
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Caroline Falker
- VA Connecticut Healthcare System, New Haven, Connecticut, USA
- Department of Internal Medicine & Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, New Haven, Connecticut, USA
| | - Tamar Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, New Haven, Connecticut, USA
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Mahmud N, Reddy KR, Taddei TH, Kaplan DE. Type of Infection Is Associated with Prognosis in Acute-on-Chronic Liver Failure: A National Veterans Health Administration Study. Dig Dis Sci 2023; 68:1632-1640. [PMID: 36083379 PMCID: PMC9995592 DOI: 10.1007/s10620-022-07680-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 08/21/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a syndrome in patients with cirrhosis with high short-term mortality. Infection is a frequent precipitant of ACLF; however, it is unclear if prognosis varies by difference infectious sources. To address this knowledge gap, we utilized a large national database of patients with cirrhosis. METHODS This was a retrospective cohort study of patients with cirrhosis in the Veterans Health Administration between 2008 and 2016. First ACLF hospitalizations were identified and infections were classified using validated algorithms, categorized as bacteremia, fungal, spontaneous bacterial peritonitis (SBP), pyelonephritis/urinary tract infection, or skin and soft tissue/musculoskeletal infection (SST/MSK). Inverse probability treatment weighing for infection-associated ACLF followed by multivariable logistic regression was used to evaluate the association between infection type and 90-day mortality. RESULTS A total 22,589 ACLF hospitalizations were included, 3998 (17.7%) of which had ACLF grade 3. Infection was associated with 12,405 (54.9%) of ACLF hospitalizations. In regression models, SBP was associated with a 1.79-fold increased odds of 90-day mortality vs. no infection (95% confidence interval [CI] 1.58-2.02, p < 0.001), whereas SST/MSK infections had a lower relative odds of mortality (odds ratio 0.48, 95% CI 0.42-0.53, p < 0.001). There was a significant interaction between infection category and ACLF grade on the outcome of 90-day mortality (p < 0.001). CONCLUSIONS The impact of infection on short-term mortality in ACLF varies depending on the source of infection. This has relevance for ACLF prognostication and challenges previous notions that bacterial infection invariably worsens prognosis among all patients with ACLF.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tamar H Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
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Mahmud N, Panchal S, Abu-Gazala S, Serper M, Lewis JD, Kaplan DE. Association Between Bariatric Surgery and Alcohol Use-Related Hospitalization and All-Cause Mortality in a Veterans Affairs Cohort. JAMA Surg 2023; 158:162-171. [PMID: 36515960 PMCID: PMC9856780 DOI: 10.1001/jamasurg.2022.6410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Bariatric surgery procedures, in particular Roux-en-Y gastric bypass (RYGB), have been associated with subsequent alcohol-related complications. However, previous studies lack data to account for changes in body mass index (BMI) or alcohol use over time, which are key potential confounders. Objective To evaluate the association between RYGB, sleeve gastrectomy, or gastric banding on subsequent alcohol use disorder (AUD)-related hospitalization and all-cause mortality as compared with referral to a weight management program alone. Design, Setting, and Participants This cohort study included 127 Veterans Health Administration health centers in the US. Patients who underwent RYGB, sleeve gastrectomy, or gastric banding or who were referred to MOVE!, a weight management program, and had a BMI (calculated as weight in kilograms divided by height in meters squared) of 30 or greater between January 1, 2008, and December 31, 2021, were included in the study. Exposures RYGB, sleeve gastrectomy, or gastric banding or referral to the MOVE! program. Main Outcomes and Measures The primary outcome was time to AUD-related hospitalization from the time of bariatric surgery or MOVE! referral. The secondary outcome was time to all-cause mortality. Separate propensity scores were created for each pairwise comparison (RYGB vs MOVE! program, RYGB vs sleeve gastrectomy, sleeve gastrectomy vs MOVE!). Sequential Cox regression approaches were used for each pairwise comparison to estimate the relative hazard of the primary outcome in unadjusted, inverse probability treatment weighting (IPTW)-adjusted (generated from the pairwise logistic regression models), and IPTW-adjusted approaches with additional adjustment for time-updating BMI and categorical Alcohol Use Disorders Identification Test-Concise scores. Results A total of 1854 patients received RYGB (median [IQR] age, 53 [45-60] years; 1294 men [69.8%]), 4211 received sleeve gastrectomy (median [IQR] age, 52 [44-59] years; 2817 men [66.9%]), 265 received gastric banding (median [IQR] age, 55 [46-61] years; 199 men [75.1%]), and 1364 were referred to MOVE! (median [IQR] age, 59 [49-66] years; 1175 men [86.1%]). In IPTW Cox regression analyses accounting for time-updating alcohol use and BMI, RYGB was associated with an increased hazard of AUD-related hospitalization vs MOVE! (hazard ratio [HR], 1.70; 95% CI, 1.20-2.41; P = .003) and vs sleeve gastrectomy (HR, 1.98; 95% CI, 1.55-2.53; P < .001). There was no significant difference between sleeve gastrectomy and MOVE! (HR, 0.76; 95% CI, 0.56-1.03; P = .08). While RYGB was associated with a reduced mortality risk vs MOVE! (HR, 0.63; 95% CI, 0.49-0.81; P < .001), this association was mitigated by increasing alcohol use over time. Conclusions and Relevance This cohort study found that RYGB was associated with an increased risk of AUD-related hospitalizations vs both sleeve gastrectomy and the MOVE! program. The mortality benefit associated with RYGB was diminished by increased alcohol use, highlighting the importance of careful patient selection and alcohol-related counseling for patients undergoing this procedure.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Department of Medicine, Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania,Leonard David Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sarjukumar Panchal
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Samir Abu-Gazala
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Department of Medicine, Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania,Leonard David Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - James D. Lewis
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Leonard David Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Department of Medicine, Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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Serper M, Tapper EB, Kaplan DE, Taddei TH, Mahmud N. Patterns of Care Utilization and Hepatocellular Carcinoma Surveillance: Tracking Care Across the Pandemic. Am J Gastroenterol 2023; 118:294-303. [PMID: 36114778 PMCID: PMC9898115 DOI: 10.14309/ajg.0000000000002011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/09/2022] [Indexed: 02/06/2023]
Abstract
INTRODUCTION We studied longitudinal trends in mortality, outpatient, and inpatient care for cirrhosis in a national cohort in the first 2 years of the coronavirus disease-2019 pandemic. We evaluated trends in hepatocellular carcinoma (HCC) surveillance and factors associated with completion. METHODS Within the national cirrhosis cohort in the Veterans Administration from 2020 to 2021, we captured mortality, outpatient primary care provider, gastroenterology/hepatology (GI/HEP) visits, and hospitalizations. HCC surveillance was computed as percentage of time up to date with surveillance every 6 months (PTUDS). Multivariable models for PTUDS were adjusted for patient demographics, clinical factors, and facility-level variables. RESULTS The total cohort was 68,073; 28,678 were eligible for HCC surveillance. Outpatient primary care provider and GI/HEP appointment rates initially dropped from 30% to 7% with a rebound 1 year into the pandemic and steady subsequent use. Telemedicine monthly visit rates rose from less than 10% to a peak of 20% with a steady gradual decline. Nearly 70% of Veterans were up to date with HCC surveillance before the pandemic with an early pandemic nadir of approximately 50% and 60% PTUDS 2 years into the pandemic. In adjusted models, use of a population-based cirrhosis dashboard (β 8.5, 95% CI 6.9-10.2) and GI/HEP visits both in-person (β 3.2, 95% CI 2.9-3.6) and telemedicine (β 2.1, 95% CI 1.9-2.4) were associated with a higher PTUDS. DISCUSSION Outpatient utilization and HCC surveillance rates have rebounded but remain below at baseline. Population-based approaches and specialty care for cirrhosis were associated with a higher completion of HCC surveillance.
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Affiliation(s)
- Marina Serper
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, USA
- Gastroenterology Section, Ann Arbor Healthcare System, Ann Arbor, VA, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Tamar H. Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Serper M, Kaplan DE, Taddei TH, Tapper EB, Cohen JB, Mahmud N. Nonselective beta blockers, hepatic decompensation, and mortality in cirrhosis: A national cohort study. Hepatology 2023; 77:489-500. [PMID: 35984731 PMCID: PMC9877112 DOI: 10.1002/hep.32737] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND AIMS Little is known about the effectiveness of nonselective beta blockers (NSBBs) in preventing hepatic decompensation in routine clinical settings. We investigated whether NSBBs are associated with hepatic decompensation or liver-related mortality in a national cohort of veterans with Child-Turcotte-Pugh (CTP) A cirrhosis with no prior decompensations. APPROACH AND RESULTS In an active comparator, new user (ACNU) design, we created a cohort of new users of carvedilol ( n = 123) versus new users of selective beta blockers (SBBs) ( n = 561) and followed patients for up to 3 years. An inverse probability treatment weighting (IPTW) approach balanced demographic and clinical confounders. The primary analysis simulated intention-to-treat ("pseudo-ITT") with IPTW-adjusted Cox models; secondary analyses were pseudo-as-treated, and both were adjusted for baseline and time-updating drug confounders. Subgroup analyses evaluated NSBB effects by HCV viremia status, CTP class, platelet count, alcohol-associated liver disease (ALD) etiology, and age. In pseudo-ITT analyses of carvedilol versus SBBs, carvedilol was associated with a lower hazard of any hepatic decompensation (HR 0.59, 95% CI 0.42-0.83) and the composite outcome of hepatic decompensation/liver-related mortality (HR 0.56, 95% CI 0.41-0.76). Results were similar in pseudo-as-treated analyses (hepatic decompensation: HR 0.55, 95% CI 0.33-0.94; composite outcome: HR 0.62, 95% 0.38-1.01). In subgroup analyses, carvedilol was associated with lower hazard of primary outcomes in the absence of HCV viremia, higher CTP class and platelet count, younger age, and ALD etiology. CONCLUSIONS There is an ongoing need to noninvasively identify patients who may benefit from NSBBs for the prevention of hepatic decompensation.
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Affiliation(s)
- Marina Serper
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, 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
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, USA
- Gastroenterology Section, Ann Arbor Healthcare System, Ann Arbor, VA, USA
| | - Jordana B. Cohen
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Polkovnikov M, Gramolin AV, Kaplan DE, Rajendran S, Sushkov AO. Experimental Limit on Nonlinear State-Dependent Terms in Quantum Theory. Phys Rev Lett 2023; 130:040202. [PMID: 36763446 DOI: 10.1103/physrevlett.130.040202] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 10/20/2022] [Accepted: 01/03/2023] [Indexed: 06/18/2023]
Abstract
Linear time evolution is one of the fundamental postulates of quantum theory. Past theoretical attempts to introduce nonlinearity into quantum evolution have violated causality. However, a recent theory has introduced nonlinear state-dependent terms in quantum field theory, preserving causality [D. E. Kaplan and S. Rajendran, Phys. Rev. D 105, 055002 (2022)PRVDAQ2470-001010.1103/PhysRevD.105.055002]. We report the results of an experiment that searches for such terms. Our approach, inspired by the Everett many-worlds interpretation of quantum theory, correlates a binary macroscopic classical voltage with the outcome of a projective measurement of a quantum bit, prepared in a coherent superposition state. Measurement results are recorded in a bit string, which is used to control a voltage switch. Presence of a nonzero voltage reading in cases of no applied voltage is the experimental signature of a nonlinear state-dependent shift of the electromagnetic field operator. We implement blinded measurement and data analysis with three control bit strings. Control of systematic effects is realized by producing one of the control bit strings with a classical random-bit generator. The other two bit strings are generated by measurements performed on a superconducting qubit in an IBM Quantum processor and on a ^{15}N nuclear spin in a nitrogen-vacancy center in diamond. Our measurements find no evidence for electromagnetic quantum state-dependent nonlinearity. We set a bound on the parameter that quantifies this nonlinearity |ε_{γ}|<4.7×10^{-11}, at 90% confidence level.
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Affiliation(s)
| | | | - David E Kaplan
- Department of Physics and Astronomy, The Johns Hopkins University, Baltimore, Maryland 21218, USA
| | - Surjeet Rajendran
- Department of Physics and Astronomy, The Johns Hopkins University, Baltimore, Maryland 21218, USA
| | - Alexander O Sushkov
- Department of Physics, Boston University, Boston, Massachusetts 02215, USA
- Department of Electrical and Computer Engineering, Boston University, Boston, Massachusetts 02215, USA
- Photonics Center, Boston University, Boston, Massachusetts 02215, USA
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Mahmud N, Panchal S, Turrentine FE, Kaplan DE, Zaydfudim VM. Performance of risk prediction models for post-operative mortality in patients undergoing liver resection. Am J Surg 2023; 225:198-205. [PMID: 35985849 PMCID: PMC9994627 DOI: 10.1016/j.amjsurg.2022.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/22/2022] [Accepted: 07/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Liver resection is commonly performed for hepatic tumors, however preoperative risk stratification remains challenging. We evaluated the performance of contemporary prediction models for short-term mortality after liver resection in patients with and without cirrhosis. METHODS This retrospective cohort study examined National Surgical Quality Improvement Program data. We included patients who underwent liver resections from 2014 to 2019. VOCAL-Penn, MELD, MELD-Na, ALBI, and Mayo risk scores were evaluated in terms of model discrimination and calibration for 30-day post-operative mortality. RESULTS A total 15,198 patients underwent liver resection, of whom 249 (1.6%) experienced 30-day post-operative mortality. The VOCAL-Penn score had the highest discrimination (area under the ROC curve [AUC] 0.74) compared to all other models. The VOCAL-Penn score similarly outperformed other models in patients with (AUC 0.70) and without (AUC 0.74) cirrhosis. CONCLUSION The VOCAL-Penn score demonstrated superior predictive performance for 30-day post-operative mortality after liver resection as compared to existing clinical standards.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Sarjukumar Panchal
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Florence E Turrentine
- Department of Surgery, Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Victor M Zaydfudim
- Department of Surgery, Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
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John BV, Doshi A, Ferreira RD, Taddei TH, Kaplan DE, Spector SA, Deng Y, Bastaich D, Dahman B. Comparison of infection-induced and vaccine-induced immunity against COVID-19 in patients with cirrhosis. Hepatology 2023; 77:186-196. [PMID: 35712794 DOI: 10.1002/hep.32619] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/27/2022] [Accepted: 06/13/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS Immunity to SARS-CoV-2 can be infection or vaccine-induced. Cirrhosis is associated with vaccine hyporesponsiveness, but whether there is decreased immunity after SARS-CoV-2 infection in unvaccinated patients with cirrhosis is unknown.The objective of our study was to compare infection-induced and vaccine-induced immunity against COVID-19 among patients with cirrhosis. METHODS This was a retrospective cohort study among US Veterans with cirrhosis between November 27, 2020, and November 16, 2021, comparing a vaccine-induced immunity group, defined as participants without a documented SARS-CoV-2 infection but fully vaccinated with two doses of an mRNA vaccine, and infection-associated immunity group, defined as unvaccinated participants who had a positive SARS-CoV-2 polymerase chain reaction (PCR). Both groups were propensity score matched for observed characteristics, including location, and the date of the immunity acquiring event, to control for the community prevalence of COVID-19 variants. The outcome was a positive SARS-CoV-2 PCR more than 60 days after previous infection in the infection-induced, or after full vaccination in the vaccine-induced immunity group. RESULTS We compared 634 participants in the infection-induced immunity group with 27,131 participants in the vaccine-induced immunity group using inverse propensity of treatment weighting. Vaccine-induced immunity was associated with a reduced odds of developing SARS-CoV-2 infection (adjusted hazard ratio [aHR], 0.18; 95% confidence interval [CI], 0.16-0.20, p < 0.0001). On multivariable logistic regression, vaccine-induced immunity was associated with reduced odds of developing symptomatic (adjusted odds ratio [aOR], 0.36; 95% CI, 0.33-0.41, p < 0.0001), moderate/severe/critical (aOR, 0.27; 95% CI, 0.22-0.31, p < 0.0001), and severe or critical COVID-19 (aOR, 0.20; 95% CI, 0.16-0.26, p < 0.001), compared with infection-induced immunity. CONCLUSIONS In participants with cirrhosis, vaccine-induced immunity is associated with reduced risk of developing COVID-19, compared with infection-induced immunity.
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Affiliation(s)
- Binu V John
- Division of Gastroenterology and Hepatology , Miami VA Medical System , Miami , Florida , USA
- Division of Digestive Health and Liver Diseases , Department of Medicine , University of Miami Miller School of Medicine , Miami , Florida , USA
| | - Akash Doshi
- Division of Gastroenterology and Hepatology , Miami VA Medical System , Miami , Florida , USA
- University of Miami Miller School of Medicine , Miami , Florida , USA
| | - Raphaella D Ferreira
- Division of Gastroenterology and Hepatology , Miami VA Medical System , Miami , Florida , USA
| | - Tamar H Taddei
- Section of Digestive Diseases , Yale School of Medicine , New Haven , Connecticut , USA
- VA Connecticut Healthcare System , West Haven , Connecticut , USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology , University of Pennsylvania , Philadelphia , Pennsylvania , USA
- Division of Gastroenterology and Hepatology , Corporal Michael J. Crescenz VA Medical Center , Philadelphia , Pennsylvania , USA
| | - Seth A Spector
- Division of Surgery , Miami VA Medical System , Miami , Florida , USA
- Division of Surgery , University of Miami Miller School of Medicine , Miami , Florida , USA
| | - Yangyang Deng
- Department of Health Behavior and Policy , Virginia Commonwealth University , Richmond , Virginia , USA
| | - Dustin Bastaich
- Department of Health Behavior and Policy , Virginia Commonwealth University , Richmond , Virginia , USA
| | - Bassam Dahman
- Department of Health Behavior and Policy , Virginia Commonwealth University , Richmond , Virginia , USA
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Block T, Zezulinski D, Kaplan DE, Lu J, Zanine S, Zhan T, Doria C, Sayeed A. Circulating messenger RNA variants as a potential biomarker for surveillance of hepatocellular carcinoma. Front Oncol 2022; 12:963641. [PMID: 36582804 PMCID: PMC9793749 DOI: 10.3389/fonc.2022.963641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 11/18/2022] [Indexed: 12/15/2022] Open
Abstract
Background and rationale Liver derived messenger ribonucleic acid (mRNA) transcripts were reported to be elevated in the circulation of hepatocellular carcinoma (HCC) patients. We now report the detection of high-risk mRNA variants exclusively in the circulation of HCC patients. Numerous genomic alleles such as single nucleotide polymorphisms (SNPs), nucleotide insertions and deletions (called Indels), splicing variants in many genes, have been associated with elevated risk of cancer. Our findings potentially offer a novel non-invasive platform for HCC surveillance and early detection. Approach RNAseq analysis was carried out in the plasma of 14 individuals with a diagnosis of HCC, 8 with LC and no HCC, and 6 with no liver disease diagnosis. RNA from 6 matching tumors and 5 circulating extracellular vesicle (EV) samples from 14 of those with HCC was also analyzed. Specimens from two cholangiocarcinoma (CCA) patients were also included in our study. HCC specific SNPs and Indels referred as "variants" were identified using GATK HaplotypeCaller and annotated by SnpEff to filter out high risk variants. Results The variant calling on all RNA samples enabled the detection of 5.2 million SNPs, 0.91 million insertions and 0.81 million deletions. RNAseq analyses in tumors, normal liver tissue, plasma, and plasma derived EVs led to the detection of 5480 high-risk tumor specific mRNA variants in the circulation of HCC patients. These variants are concurrently detected in tumors and plasma samples or tumors and EVs from HCC patients, but none of these were detected in normal liver, plasma of LC patients or normal healthy individuals. Our results demonstrate selective detection of concordant high-risk HCC-specific mRNA variants in free plasma, plasma derived EVs and tumors of HCC patients. The variants comprise of splicing, frameshift, fusion and single nucleotide alterations and correspond to cancer and tumor metabolism pathways. Detection of these high-risk variants in matching specimens from same subjects with an enrichment in circulating EVs is remarkable. Validation of these HCC selective ctmRNA variants in larger patient cohorts is likely to identify a predictive set of ctmRNA with high diagnostic performance and thus offer a novel non-invasive serology-based biomarker for HCC.
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Affiliation(s)
- Timothy Block
- Department of Translational Medicine, Baruch S. Blumberg Institute, Doylestown, PA, United States
| | - Daniel Zezulinski
- Department of Translational Medicine, Baruch S. Blumberg Institute, Doylestown, PA, United States
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine and The Corporal Michael J. Crescenz Veterans Administration Hospital, Philadelphia, PA, United States
| | - Jingqiao Lu
- Ray Biotech Life Inc., Peachtree Corners, GA, United States
| | - Samantha Zanine
- Department of Mechanical Engineering, Pennsylvania State University, PA, United States
| | - Tingting Zhan
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia PA, United States
| | - Cataldo Doria
- CHS Liver and Pancreas Centers of Excellence, Capital Health Cancer Center, One Capital Way, Pennington, NJ, United States
| | - Aejaz Sayeed
- Department of Translational Medicine, Baruch S. Blumberg Institute, Doylestown, PA, United States,*Correspondence: Aejaz Sayeed,
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Wang LL, Dobkin J, Salgado S, Kaplan DE, Yang YX. Development and validation of case-finding algorithms to identify acute pancreatitis in the Veterans Health Administration. Pharmacoepidemiol Drug Saf 2022; 31:1294-1299. [PMID: 36222554 PMCID: PMC9729430 DOI: 10.1002/pds.5549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 09/19/2022] [Accepted: 10/07/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Acute pancreatitis (AP) is a frequently encountered adverse drug reaction. However, the validity of diagnostic codes for AP is unknown. We aimed to determine the positive predictive value (PPV) of a diagnostic code-based algorithm for identifying patients with AP within the US Veterans Health Administration and evaluate the value of adding readily available structured laboratory information. METHODS We identified patients with possible AP events first based on the presence of a single hospital discharge ICD-9 or ICD-10 diagnosis of AP (Algorithm 1). We then expanded Algorithm 1 by including relevant laboratory test results (Algorithm 2). Specifically, we considered amylase or lipase serum values obtained between 2 days before admission and the end of the hospitalization. Medical records of a random sample of patients identified by the respective algorithms were reviewed by two separate gastroenterologists to adjudicate AP events. The PPV (95% confidence interval [CI]) for the algorithms were calculated. RESULTS Algorithm 2, consisting of one ICD-9 or ICD-10 hospital discharge diagnosis of AP and the addition of lipase serum value ≥200 U/L, had a PPV 89.1% (95% CI 83.0%-95.2%), improving from the PPV of algorithm 1 (57.9% [95% CI 46.8-69.0]). CONCLUSIONS An algorithm consisting of an ICD-9 or ICD-10 diagnosis of AP with a lipase value ≥200 U/L achieved high PPV. This simple algorithm can be readily implemented in any electronic health records (EHR) systems and could be useful for future pharmacoepidemiologic studies on AP.
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Affiliation(s)
- Louise L. Wang
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jane Dobkin
- Department of Medicine, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sanjay Salgado
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David E. Kaplan
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Medicine Services, GI Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Yu-Xiao Yang
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Medicine Services, GI Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Mahmud N, Serper M, Kaplan DE. Reply. Gastroenterology 2022; 163:1718-1719. [PMID: 36030972 PMCID: PMC10002149 DOI: 10.1053/j.gastro.2022.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, and, Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, and, Leonard David Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, and, Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, and, Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, and, Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, and, Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Chang JH, Kaplan DE, Rajendran S, Ramani H, Tanin EH. Dark Solar Wind. Phys Rev Lett 2022; 129:211101. [PMID: 36461962 DOI: 10.1103/physrevlett.129.211101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 06/17/2023]
Abstract
We study the solar emission of light dark sector particles that self-interact strongly enough to self-thermalize. The resulting outflow behaves like a fluid which accelerates under its own thermal pressure to highly relativistic bulk velocities in the solar system. Compared to the ordinary noninteracting scenario, the local outflow has at least ∼10^{3} higher number density and correspondingly at least ∼10^{3} lower average energy per particle. We show how this generic phenomenon arises in a dark sector composed of millicharged particles strongly self-interacting via a dark photon. The millicharged plasma wind emerging in this model has novel yet predictive signatures that encourages new experimental directions. This phenomenon demonstrates how a small step away from the simplest models can lead to radically different outcomes and thus motivates a broader search for dark sector particles.
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Affiliation(s)
- Jae Hyeok Chang
- Department of Physics and Astronomy, Johns Hopkins University, Baltimore, Maryland 21218, USA
- Maryland Center for Fundamental Physics, Department of Physics, University of Maryland, College Park, Maryland 20742, USA
| | - David E Kaplan
- Department of Physics and Astronomy, Johns Hopkins University, Baltimore, Maryland 21218, USA
| | - Surjeet Rajendran
- Department of Physics and Astronomy, Johns Hopkins University, Baltimore, Maryland 21218, USA
| | - Harikrishnan Ramani
- Stanford Institute for Theoretical Physics, Stanford University, Stanford, California 94305, USA
| | - Erwin H Tanin
- Department of Physics and Astronomy, Johns Hopkins University, Baltimore, Maryland 21218, USA
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Knavel Koepsel EM, Smolock AR, Pinchot JW, Kim CY, Ahmed O, Chamarthy MRK, Hecht EM, Hwang GL, Kaplan DE, Luh JY, Marrero JA, Monroe EJ, Poultsides GA, Scheidt MJ, Hohenwalter EJ. ACR Appropriateness Criteria® Management of Liver Cancer: 2022 Update. J Am Coll Radiol 2022; 19:S390-S408. [PMID: 36436965 DOI: 10.1016/j.jacr.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
The treatment and management of hepatic malignancies can be complex because it encompasses a variety of primary and metastatic malignancies and an assortment of local and systemic treatment options. When to use each of these treatments is critical to ensure the most appropriate care for patients. Interventional radiologists have a key role to play in the delivery of a variety of liver directed treatments including percutaneous ablation, transarterial embolization with bland embolic particles alone, transarterial chemoembolization (TACE) with injection of a chemotherapeutic emulsion, and transarterial radioembolization (TARE). Based on 9 clinical variants, the appropriateness of each treatment is described in this document. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Amanda R Smolock
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Charles Y Kim
- Panel Vice-Chair, Duke University Medical Center, Durham, North Carolina
| | - Osmanuddin Ahmed
- Vice-Chair of Wellness, Director of Venous Interventions, University of Chicago, Chicago, Illinois
| | - Murthy R K Chamarthy
- Vascular Institute of North Texas, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging
| | - Elizabeth M Hecht
- Vice-Chair of Academic Affairs, Professor of Radiology, Weill Cornell Medicine, New York, New York; RADS Committee; Member of Appropriateness Subcommittees on Hepatobiliary Topics; Member of LI-RADS
| | - Gloria L Hwang
- Associate Chair of Clinical Performance Improvement, Stanford Radiology, Stanford Medical Center, Stanford, California
| | - David E Kaplan
- Section Chief of Hepatology at the University of Pennsylvania Division of Gastroenterology and Hepatology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; American Association for the Study of Liver Diseases
| | - Join Y Luh
- Providence Health Radiation Oncology Focus Group Chair, Providence St. Joseph Health, Eureka, California; Commission on Radiation Oncology; ACR CARROS President; ACR Council Steering Committee; California Radiological Society Councilor to ACR
| | - Jorge A Marrero
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; American Gastroenterological Association
| | | | - George A Poultsides
- Chief of Surgical Oncology and Professor of Surgery, Stanford University School of Medicine, Stanford, California; Society of Surgical Oncology
| | - Matthew J Scheidt
- Program Director of Independent IR Residency, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Eric J Hohenwalter
- Specialty Chair; Chief, MCW VIR, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
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John BV, Ferreira RD, Doshi A, Kaplan DE, Taddei TH, Spector SA, Paulus E, Deng Y, Bastaich D, Dahman B. Third dose of COVID-19 mRNA vaccine appears to overcome vaccine hyporesponsiveness in patients with cirrhosis. J Hepatol 2022; 77:1349-1358. [PMID: 36181987 PMCID: PMC9519143 DOI: 10.1016/j.jhep.2022.07.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Cirrhosis is associated with immune dysregulation and hyporesponsiveness to several vaccines including those against COVID-19. Our aim was to compare outcomes between patients with cirrhosis who received 3 doses of either the Pfizer BNT162b2 mRNA or Moderna mRNA-1273 vaccines to a propensity-matched control group of patients at similar risk of infection who received 2 doses. METHODS This was a retrospective cohort study of patients with cirrhosis who received 2 or 3 doses of a COVID-19 mRNA vaccine at the Veterans Health Administration. Participants who received 3 doses of the vaccine (n = 13,041) were propensity score matched with 13,041 controls who received 2 doses, and studied between July 18, 2021 and February 11, 2022, when B.1.617.2 (delta) and B.1.1.529 (omicron) were the predominant variants. Outcomes were aggregated as all cases with COVID-19, symptomatic COVD-19, with at least moderate COVID-19, or severe or critical COVID-19. RESULTS Receipt of the third dose of a COVID-19 mRNA vaccine was associated with an 80.7% reduction in COVID-19 (95% CI 39.2-89.1, p <0.001), an 80.4% reduction in symptomatic COVID-19, an 80% reduction in moderate, severe or critical COVID-19, (95% CI 34.5-87.6%, p = 0.005), a 100% reduction in severe or critical COVID-19 (95% CI 99.2-100.0, p = 0.01), and a 100% reduction in COVID-19-related death (95% CI 99.8-100.0, p = 0.007). The magnitude of reduction in COVID-19 was greater with the third dose of BNT 162b2 than mRNA-1273 and among participants with compensated rather than decompensated cirrhosis. CONCLUSIONS Administration of a third dose of a COVID-19 mRNA vaccine was associated with a more significant reduction in COVID-19 in patients with cirrhosis than in the general population, suggesting that the third dose can overcome vaccine hyporesponsiveness in this population. LAY SUMMARY Cirrhosis is associated with decreased responsiveness to several vaccines, including those against COVID-19. In this study of 26,082 participants with cirrhosis during the delta and omicron surge, receipt of the third dose of the vaccine was associated with an 80% reduction in COVID-19, a 100% reduction in severe/critical COVID-19, and a 100% reduction in COVID-19-related death. These findings support the importance of a third dose of mRNA vaccine among patients with cirrhosis.
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Affiliation(s)
- Binu V John
- Division of Gastroenterology and Hepatology, Miami VA Medical System, Miami, FL, USA; Division of Digestive Health and Liver Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Raphaella D Ferreira
- Division of Gastroenterology and Hepatology, Miami VA Medical System, Miami, FL, USA
| | - Akash Doshi
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA; Division of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Tamar H Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Seth A Spector
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Department of Surgery, Miami VA Medical System, Miami, FL, USA
| | - Elizabeth Paulus
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Department of Surgery, Miami VA Medical System, Miami, FL, USA
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA
| | - Dustin Bastaich
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA
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John BV, Sidney Barritt A, Moon A, Taddei TH, Kaplan DE, Dahman B, Doshi A, Deng Y, Mansour N, Ioannou G, Martin P, Chao HH. Effectiveness of COVID-19 Viral Vector Ad.26.COV2.S Vaccine and Comparison with mRNA Vaccines in Cirrhosis. Clin Gastroenterol Hepatol 2022; 20:2405-2408.e3. [PMID: 35716904 PMCID: PMC9212810 DOI: 10.1016/j.cgh.2022.05.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 05/24/2022] [Accepted: 05/24/2022] [Indexed: 12/26/2022]
Affiliation(s)
- Binu V John
- Division of Hepatology, Miami VA Medical System, Miami, Florida, and, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida.
| | - A Sidney Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Andrew Moon
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Tamar H Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, and, VA Connecticut Healthcare System, West Haven, Connecticut
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, and, Division of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Akash Doshi
- University of Miami Miller School of Medicine, Miami, Florida
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Natalie Mansour
- Division of Hepatology, Miami VA Medical System, Miami, Florida
| | - George Ioannou
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, and, Division of Gastroenterology and Hepatology, Puget Sound VA Medical Center, Seattle, Washington
| | - Paul Martin
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Hann-Hsiang Chao
- Department of Radiation Oncology, Central Virginia VA Medical System, Richmond, Virginia
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Kaplan DE, Serper M, Kaushik A, Durkin C, Raad A, El-Moustaid F, Smith N, Yehoshua A. Cost-effectiveness of direct-acting antivirals for chronic hepatitis C virus in the United States from a payer perspective. J Manag Care Spec Pharm 2022; 28:1138-1148. [PMID: 36125059 PMCID: PMC10373042 DOI: 10.18553/jmcp.2022.28.10.1138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND: Direct-acting antivirals (DAAs) have been a breakthrough therapeutic innovation in the treatment of chronic hepatitis C virus (HCV) with significantly improved efficacy, safety, and tolerability. OBJECTIVE: To evaluate the cost-effectiveness of treating patients with HCV with DAAs compared with pre-DAAs or no treatment over a lifetime horizon from the perspective of the US Veterans Affairs (VA) health care system. METHODS: A hybrid decision-tree and Markov model simulated the health outcomes of a cohort of 142,147 patients with HCV with an average age of 63 years. Demographic data, treatment rates and distribution, treatment efficacy by subpopulation, and health state costs were sourced from VA data. Treatment costs and utility values were sourced from publicly available databases and prior publications for older regimens. RESULTS: Over a lifetime horizon, the use of DAAs results in a significant reduction in advanced liver disease events compared with pre-DAA and no treatment. Total cost savings of $7 and $9 billion over a lifetime horizon (50 years) were predicted for patients who received DAA treatments compared with patients treated with pre-DAA treatments and those who were untreated, respectively. Cost savings were achieved quickly after treatment, with DAAs being inexpensive when compared with both the pre-DAA and untreated scenarios within 5 years. The DAA intervention dominated (ie, more effective and less costly) for both the pre-DAA and untreated strategies on both a per-patient and cohort basis. CONCLUSIONS: The use of DAA-based treatments in patients with HCV in the VA system significantly reduced long-term HCV-related morbidity and mortality, while providing cost savings within only 5 years of treatment. DISCLOSURES: This work was supported by Gilead Inc. Health Economic Outcomes Research group, grant number GS-US-18-HCV003. Drs Yehoshua and Kaushik are employees of Gilead in the Health Economic Outcome Research group. These individuals reviewed the manuscript but did not contribute to input or output of the Markov model. Maple Health Group (Dr El-Moustaid, Ms Raad, and Dr Smith) are consultants hired by Gilead for Markov modeling expertise. The model used in this study was previously published and peer reviewed. Data inputted into the model related to patient demographic, treatment outcomes, clinical outcomes, and costs were completely independent in derivation by Drs Kaplan, Serper, and Durkin and were not influenced by the funding sponsor. Dr Kaplan reports grants from Gilead Inc. during the conduct of the study and grants from Gilead Inc., other from Glycotest Inc., other from AstraZeneca, other from Exact Sciences, and other from Bayer outside the submitted work.
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Affiliation(s)
- David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Gastroenterology Section, Philadelphia VA Medical Center, PA
| | - Marina Serper
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Gastroenterology Section, Philadelphia VA Medical Center, PA
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, PA
| | | | - Claire Durkin
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Howell J, Samani A, Mannan B, Hajiev S, Motedayen Aval L, Abdelmalak R, Tam VC, Bettinger D, Thimme R, Taddei TH, Kaplan DE, Seidensticker M, Sharma R. Impact of NAFLD on clinical outcomes in hepatocellular carcinoma treated with sorafenib: an international cohort study. Therap Adv Gastroenterol 2022; 15:17562848221100106. [PMID: 36199289 PMCID: PMC9527996 DOI: 10.1177/17562848221100106] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/21/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The impact of nonalcoholic fatty liver disease (NAFLD) on overall survival (OS), treatment response and toxicity in patients with hepatocellular carcinoma (HCC) treated with sorafenib is unknown. We examined the impact of NAFLD on survival and toxicity in an international cohort of patients receiving sorafenib. METHODS Clinical and demographic data were collected from patients consecutively treated at specialist centres in Europe and North America. The impact of NAFLD on OS, sorafenib-specific survival and toxicity compared with other aetiologies of liver disease using multivariable Cox-proportional hazards and logistic regression modelling was assessed. RESULTS A total of 5201 patients received sorafenib; 183 (3.6%) had NAFLD-associated HCC. NAFLD-associated HCC patients were more likely to be older women (median age 65.8 versus 63.0 years, p < 0.01 and 10.4% versus 2.3%, < 0.01), with a median body mass index (BMI) of 29.4. After controlling for known prognostic factors, no difference in OS in patients with or without NAFLD was observed [hazard ratio (HR): 0.99, 95% confidence interval (CI): 0.84-1.18, p = 0.98]. NAFLD-associated patients had more advanced stage HCC when they commenced sorafenib [Barcelona Clinic Liver Class (BCLC) C/D 70.9% versus 58.9%, p < 0.01] and were more likely to be commenced on a lower starting dose of sorafenib (51.4 versus 36.4%, p < 0.01). There was no difference in sorafenib-specific survival between NAFLD and other aetiologies (HR: 0.96, 95% CI: 0.79-1.17, p = 0.96). Adverse events were similar between NAFLD and non-NAFLD HCC groups, including rates of greater than grade 2 hypertension (6.3% versus 5.8%, p = 1.00). CONCLUSION Survival in HCC does not appear to be influenced by the presence of NAFLD. NAFLD-associated HCC derive similar clinical benefit from sorafenib compared with other aetiologies.
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Affiliation(s)
- Jessica Howell
- Department of Medicine, The University of Melbourne, St Vincent’s Hospital, Melbourne, VIC, Australia,Disease Elimination Program, Macfarlane-Burnet Institute, Melbourne, VIC, Australia,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Amit Samani
- Department of Medical Oncology, Hammersmith Hospital, Imperial College Hospital NHS Trust, London, UK
| | - Binish Mannan
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Saur Hajiev
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | | | - Vincent C. Tam
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Dominik Bettinger
- University Medical Center Freiburg and Department of Medicine II, University of Freiburg, Freiburg, Germany,Berta-Ottenstein Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- University Medical Center Freiburg and Department of Medicine II, University of Freiburg, Freiburg, Germany
| | - Tamar H. Taddei
- Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - David E. Kaplan
- Perelman School of Medicine, University of Pennsylvania and Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Max Seidensticker
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, LMU München, Munchen, Germany
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Mahmud N, Goldberg DS, Abu-Gazala S, Lewis JD, Kaplan DE. Modeling Optimal Clinical Thresholds for Elective Abdominal Hernia Repair in Patients With Cirrhosis. JAMA Netw Open 2022; 5:e2231601. [PMID: 36098965 PMCID: PMC9471978 DOI: 10.1001/jamanetworkopen.2022.31601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Patients with cirrhosis have increased risk of postoperative mortality. Several models have been developed to estimate this risk; however, current risk estimation scores cannot compare surgical risk with the risk of not operating. OBJECTIVE To identify clinical optimal thresholds to favor operative or nonoperative management for a common cirrhosis surgical scenario, the symptomatic abdominal hernia. DESIGN, SETTING, AND PARTICIPANTS This was a Markov cohort decision analytical modeling study evaluating elective surgery vs nonoperative management for a symptomatic abdominal hernia in a patient with cirrhosis. Transition probabilities and utilities were derived from the literature and from data using an established cirrhosis cohort in the Veterans Health Administration. Participants included patients who were referred to a surgery clinic for a symptomatic abdominal hernia. Data were obtained from patients diagnosed with cirrhosis between January 1, 2008 and December 31, 2018. Data were analyzed from January 1 to May 1, 2022. MAIN OUTCOMES AND MEASURES Expected quality-adjusted life-years (QALYs) were estimated for each pathway and iterated over baseline model for end-stage liver disease-sodium (MELD-Na) scores ranging from 6 to 25. Markov models were cycled over a 5-year time horizon. RESULTS A total 2740 patients with cirrhosis (median [IQR] age, 62 [56-66] years; 2699 [98.5%] men) were referred to a surgery clinic for a symptomatic abdominal hernia; 1752 patients (63.9%) did not receive surgery. The median (IQR) follow-up was 42.1 (25.3-70.0) months. Using this cohort to estimate the mortality risk of operative and nonoperative pathways, an initial MELD-Na threshold of 21.3 points, below which surgery was associated with maximized QALYs was identified. Nonoperative management was associated with increased QALYs above this MELD-Na threshold. Although more patients experienced death with a surgical treatment decision across all initial MELD-Na values, this was counterbalanced by increased time spent in a resolved hernia state associated with increased utility. Model results were sensitive to the probability of hernia recurrence and hernia incarceration and utility decrement in the symptomatic hernia state. CONCLUSIONS AND RELEVANCE This decision analytical model study found that elective surgical treatment for a symptomatic abdominal hernia was favored even in the setting of relatively high MELD-Na scores. Patient symptoms, hernia-specific characteristics, and surgeon and center expertise may potentially impact the optimal strategy, emphasizing the importance of shared decision-making.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Samir Abu-Gazala
- Division of Transplant Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - James D. Lewis
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Chapin SE, Goldberg DS, Kaplan DE, Mahmud N. External Validation of the FIPS Score for Post-TIPS Mortality in a National Veterans Affairs Cohort. Dig Dis Sci 2022; 67:4581-4589. [PMID: 34797445 PMCID: PMC9117561 DOI: 10.1007/s10620-021-07307-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/25/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Freiburg index of post-TIPS survival (FIPS) score was recently demonstrated to improve prediction of post-TIPS mortality relative to existing standards. As this score was derived from a German cohort over an extended time period, it is unclear if performance will translate well to other settings. This study aimed to externally validate the FIPS score in a large Veterans Affairs (VA) cohort over two separate eras of TIPS-related care. METHODS This was a retrospective cohort study of patients with cirrhosis who underwent TIPS placement in the VA from 2008 to 2020. Cox regression models for post-TIPS survival were constructed using FIPS, MELD, MELD-Na, or CTP scores as predictors. Discrimination (Harrell's C) and calibration (joint tests of calibration curve slope and intercept) were evaluated for each score. A stratified analysis was performed for time periods between 2008-2013 and 2014-2020. RESULTS The cohort of 1,274 patients was 97.3% male with mean age 60.9 years and mean MELD-Na 14. The FIPS score demonstrated the highest overall discrimination versus MELD, MELD-Na, and CTP (0.634 vs. 0.585, 0.626, 0.612, respectively). However, in the modern treatment era (2014-2020), the FIPS score performed similarly to MELD-Na. Additionally, the FIPS score demonstrated poor calibration at one-month and six-month post-TIPS timepoints (joint p = 0.04 and 0.004, respectively). MELD, MELD-Na, and CTP were well-calibrated at each timepoint (each joint p > 0.05). CONCLUSION The FIPS score performed similarly to MELD-Na in the modern TIPS treatment era and demonstrated regions of poor calibration. Future models derived with contemporary data may improve prediction of post-TIPS mortality.
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Affiliation(s)
- Sara E Chapin
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA.
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Panchal SA, Kaplan DE, Goldberg DS, Mahmud N. Algorithms to Identify Alcoholic Hepatitis Hospitalizations in Patients with Cirrhosis. Dig Dis Sci 2022; 67:4395-4402. [PMID: 35022905 PMCID: PMC9276834 DOI: 10.1007/s10620-021-07321-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/08/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Alcoholic hepatitis (AH) is a clinically diagnosed syndrome with high short-term mortality for which liver transplantation may be curative. A lack of validated algorithms to identify AH hospitalizations has hindered clinical epidemiology research. METHODS This was a retrospective cohort study of patients with cirrhosis using Veterans Health Administration (VHA) data from 2008 to 2015. We randomly sampled hospitalizations based upon abnormal liver tests and administrative codes for acute hepatitis or alcohol-associated liver disease (ALD). Hospitalizations were manually adjudicated for AH per society guidelines. A priori algorithms were evaluated to compute positive predicted value (PPV) and positive likelihood ratio (LR+), and were tested in an external University of Pennsylvania Health System (UPHS) cohort. RESULTS Of 368 hospitalizations, 142 (38.6%) were adjudicated as AH. AH patients were younger (55 vs. 58 years, p < 0.001), less likely to have prior cirrhosis decompensation (57% vs. 73.9%, p < 0.001), and had higher AST-to-ALT ratios (median 2.9 vs. 1.9 mg/dL, p < 0.001) and higher bilirubin levels (median 2.9 vs. 1.9 mg/dL, p < 0.001). Algorithms combining clinical laboratory criteria (AST > 85 U/L but < 450 U/L, AST-to-ALT ratio > 2, total bilirubin > 5 mg/dL) and administrative coding criteria yielded the highest PPV (96.4%, 95% CI 87.7-99.6) and the highest LR+ (43.0, 95% CI 10.6-173.5). Several algorithms demonstrated 100% PPV for definite AH in the UPHS external cohort. CONCLUSION We have identified algorithms for AH hospitalizations with excellent PPV and LR+. These high-specificity algorithms may be used in VHA datasets to identify patients with high likelihood of AH, but should not be used to study AH incidence.
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Affiliation(s)
- Sarjukumar A Panchal
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA.
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA.
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Mahmud N, Goldberg DS, Kaplan DE, Serper M. Major Shifts in Outpatient Cirrhosis Care Delivery Attributable to the COVID-19 Pandemic: A National Cohort Study. Hepatol Commun 2022; 6:3186-3193. [PMID: 36321766 PMCID: PMC9592756 DOI: 10.1002/hep4.1638] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has disrupted health care delivery in the United States, with increased reliance on telemedicine visits as opposed to in-person outpatient appointments. We used national data to evaluate shifts in modes of hepatology outpatient care for patients with cirrhosis during the pandemic. This was a retrospective cohort study among U.S. veterans with cirrhosis. We used linear regression to evaluate absolute and percentage changes from baseline in hepatology in-person visits and telemedicine visits from January 1, 2020, to August 11, 2020. The proportion of in-person and telemedicine visits were plotted geographically to demonstrate state-level shifts in care delivery over time. Patient-level characteristics in the pre-COVID and during-COVID periods were also compared. We identified 5,618 in-person and 6,210 telemedicine hepatology visits among patients with cirrhosis. In-person visits significantly declined (-16.0% per week; 95% confidence interval [CI] -20.7, -11.2; P < 0.001), while telemedicine visits significantly increased (61.3% per week; 95% CI 45.1, 77.5; P < 0.001) in the early during-COVID period. At the U.S. state level, we found that nearly all states experienced a significant shift toward telemedicine over the course of several weeks. Patients over the age of 70 years and Black patients were less likely to receive telemedicine visits in the pre-COVID period (each P < 0.05), although these differences were eliminated in the during-COVID periods. Conclusion: Among patients with cirrhosis, hepatology outpatient care delivery has shifted heavily toward telemedicine due to COVID-19. This occurred across the United States, and changes have been sustained through August 2020. Expanded telemedicine visits among older patients and Black patients may reflect dedicated efforts to increased access to care among these groups.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and HepatologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA,Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - David S. Goldberg
- Division of Digestive Health and Liver DiseasesUniversity of Miami Miller School of MedicineMiamiFLUSA
| | - David E. Kaplan
- Division of Gastroenterology and HepatologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA,Department of MedicineCorporal Michael J. Crescenz VA Medical CenterPhiladelphiaPAUSA
| | - Marina Serper
- Division of Gastroenterology and HepatologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA,Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPAUSA,Department of MedicineCorporal Michael J. Crescenz VA Medical CenterPhiladelphiaPAUSA
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John BV, Deng Y, Schwartz KB, Taddei TH, Kaplan DE, Martin P, Chao H, Dahman B. Postvaccination COVID-19 infection is associated with reduced mortality in patients with cirrhosis. Hepatology 2022; 76:126-138. [PMID: 35023206 PMCID: PMC9015228 DOI: 10.1002/hep.32337] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 12/12/2021] [Accepted: 01/08/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS Patients develop breakthrough COVID-19 infection despite vaccination. The aim of this study was to identify outcomes in patients with cirrhosis who developed postvaccination COVID-19. METHODS We performed a retrospective cohort study among US veterans with cirrhosis and postvaccination or unvaccinated COVID-19. Patients were considered fully vaccinated if COVID-19 was diagnosed 14 days after the second dose of either the Pfizer BNT162b2, the Moderna 1273-mRNA, or the single-dose Janssen Ad.26.COV2.S vaccines and partially vaccinated if COVID-19 was diagnosed 7 days after the first dose of any vaccine but prior to full vaccination. We investigated the association of postvaccination COVID-19 with mortality. RESULTS We identified 3242 unvaccinated and 254 postvaccination COVID-19 patients with cirrhosis (82 after full and 172 after partial vaccination). In a multivariable analysis of a 1:2 propensity-matched cohort including vaccinated (n = 254) and unvaccinated (n = 508) participants, postvaccination COVID-19 was associated with reduced risk of death (adjusted HR [aHR], 0.21; 95% CI, 0.11-0.42). The reduction was observed after both full (aHR, 0.22; 95% CI, 0.08-0.63) and partial (aHR, 0.19; 95% CI, 0.07-0.54) vaccination, following the 1273-mRNA (aHR, 0.12; 95% CI 0.04-0.37) and BNT162b2 (aHR, 0.27; 95% CI, 0.10-0.71) vaccines and among patients with compensated (aHR, 0.19; 95% CI, 0.08-0.45) and decompensated (aHR, 0.27; 95% CI, 0.08-0.90) cirrhosis. Findings were consistent in a sensitivity analysis restricted to participants who developed COVID-19 after vaccine availability. CONCLUSIONS Though patients with cirrhosis can develop breakthrough COVID-19 after full or partial vaccination, these infections are associated with reduced mortality.
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Affiliation(s)
- Binu V. John
- Division of HepatologyMiami VA Health SystemMiamiFloridaUSA
- Division of Digestive Health and Liver DiseasesUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Yangyang Deng
- Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | | | - Tamar H. Taddei
- Section of Digestive DiseasesYale School of MedicineNew HavenConnecticutUSA
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
| | - David E. Kaplan
- Division of Gastroenterology and HepatologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Division of Gastroenterology and HepatologyCorporal Michael J. Crescenz VA Medical CenterPhiladelphiaPennsylvaniaUSA
| | - Paul Martin
- Division of HepatologyMiami VA Health SystemMiamiFloridaUSA
- Division of Digestive Health and Liver DiseasesUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Hann‐Hsiang Chao
- Department of Radiation OncologyCentral Virginia VA Health Care SystemRichmondVirginiaUSA
| | - Bassam Dahman
- Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVirginiaUSA
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Mahmud N, Serper M, Taddei TH, Kaplan DE. The Association Between Proton Pump Inhibitor Exposure and Key Liver-Related Outcomes in Patients With Cirrhosis: A Veterans Affairs Cohort Study. Gastroenterology 2022; 163:257-269.e6. [PMID: 35398042 PMCID: PMC10020994 DOI: 10.1053/j.gastro.2022.03.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/24/2022] [Accepted: 03/29/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS The impact of proton pump inhibitory (PPI) medications on adverse outcomes in cirrhosis remains controversial. We aimed to evaluate the association between PPI exposure and all-cause mortality, infection, and decompensation in a large national cohort. METHODS This was a retrospective study of patients with cirrhosis in the Veterans Health Administration. PPI exposure was classified as a time-updating variable from the index time of the cirrhosis diagnosis. Inverse probability treatment weighting-adjusted Cox regression was performed with additional adjustment for key time-varying covariates, including cardiovascular comorbidities, gastrointestinal bleeding (GIB), and statin exposure. RESULTS The study included 76,251 patients, 23,628 of whom were on a PPI at baseline. In adjusted models, binary (yes/no) PPI exposure was associated with reduced hazard of all-cause mortality in patients with hospitalization for GIB (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.84-0.91; P < .001) but had no significant association in all others (HR, 0.99; 95% CI, 0.97-1.02; P = .58). However, cumulative PPI exposure was associated with increased mortality in patients without hospitalization for GIB (HR, 1.07 per 320 mg-months [omeprazole equivalents]; 95% CI, 1.06-1.08; P < .001). PPI exposure was significantly associated with severe infection (HR, 1.21; 95% CI, 1.18-1.24; P < .001) and decompensation (HR, 1.64; 95% CI, 1.61-1.68; P < .001). In a cause-specific mortality analysis, PPI exposure was associated with increased liver-related mortality (HR, 1.23; 95% CI, 1.19-1.28) but with decreased nonliver-related mortality (HR, 0.88; 95% CI, 0.85-0.91). CONCLUSIONS PPI exposure is associated with increased risk of infection and decompensation in cirrhosis, which may mediate liver-related mortality. However, PPI use was associated with reduced all-cause mortality in those with prior GIB, suggesting benefit in the presence of an appropriate indication.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania; Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania; Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Tamar H Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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