Opioid and benzodiazepine prescription among patients with cirrhosis compared to other forms of chronic disease.

OBJECTIVE: Data on patterns and correlates of opioid and benzodiazepines prescriptions among patients with chronic conditions are limited. Given a diminished capacity for hepatic clearance, patients with cirrhosis represent a high risk group for use. The aim of this study was to characterise the patterns and correlates of prescription opioid, benzodiazepine and dual drug prescriptions among individuals with common chronic diseases. DESIGN: Analysis of Truven Marketscan database to evaluate individuals with drug coverage with cirrhosis (n=169,181), chronic hepatitis C without cirrhosis (n=210 191), congestive heart failure (n=766 840) or chronic obstructive pulmonary disease (n=1 438 798). Pharmacy files were examined for outpatient prescriptions. RESULTS: Patients with cirrhosis had a significantly higher prevalence of opioid prescriptions (37.1 per 100 person-years vs 24.3-26.0, p≤0.001) and benzodiazepine prescriptions (21.3 per 100 person-years vs 12.1-12.9, p<0.001). High dose opioid prescription (>90 daily oral morphine equivalents) (29.1% vs 14.4%, p<0.001) and dual opioid and benzodiazepine prescription (17.5% vs 9.6%-10.5 %, p<0.001) were also significantly more prevalent in cirrhosis. High dose opioid prescription was greater in men, individuals ages 40-59, in the Western USA, and among those with a mental health or substance abuse condition. Dual opioid and benzodiazepine prescription were highest among those with alcoholic cirrhosis and middle aged-adults. CONCLUSION: Persons with cirrhosis have significantly higher rates of prescription opioid and benzodiazepine prescription compared to others with chronic diseases despite their high risk for adverse drug reactions. Demographics and mental health or substance abuse history can help identify high risk groups to target interventions.

Prevalence of Hepatitis B Virus, Hepatitis C Virus, and HIV Infection Among Patients With Newly Diagnosed Cancer From Academic and Community Oncology Practices.

IMPORTANCE: Universal screening of patients with newly diagnosed cancer for hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV is not routine in oncology practice, and experts disagree about whether universal screening should be performed. OBJECTIVE: To estimate the prevalence of HBV, HCV, and HIV infection among persons with newly diagnosed cancer. DESIGN, SETTING, AND PARTICIPANTS: Multicenter prospective cohort study of patients with newly diagnosed cancer (ie, identified within 120 days of cancer diagnosis) at 9 academic and 9 community oncology institutions affiliated with SWOG (formerly the Southwest Oncology Group) Cancer Research Network, a member of the National Clinical Trials Network, with enrollment from August 29, 2013, through February 15, 2017. The data analysis was conducted using data available through August 17, 2017. MAIN OUTCOMES AND MEASURES: The accrual goal was 3000 patients and the primary end point was the presence of HBV infection (previous or chronic), HCV infection, or HIV infection at enrollment. Patients with previous knowledge of infection as well as patients with unknown viral viral status were evaluated. RESULTS: Of 3092 registered patients, 3051 were eligible and evaluable. Median (range) age was 60.6 (18.2-93.7) years, 1842 (60.4%) were female, 553 (18.1%) were black, and 558 (18.3%) were Hispanic ethnicity. Screened patients had similar clinical and demographic characteristics compared with those registered. The observed infection rate for previous HBV infection was 6.5% (95% CI, 5.6%-7.4%; n = 197 of 3050 patients); chronic HBV, 0.6% (95% CI, 0.4%-1.0%; n = 19 of 3050 patients); HCV, 2.4% (95% CI, 1.9%-3.0%; n = 71 of 2990 patients); and HIV, 1.1% (95% CI, 0.8%-1.6%; n = 34 of 3045). Among those with viral infections, 8 patients with chronic HBV (42.1%; 95% CI, 20.3%-66.5%), 22 patients with HCV (31.0%; 95% CI, 20.5%-43.1%), and 2 patients with HIV (5.9%; 95% CI, 0.7%-19.7%) were newly diagnosed through the study. Among patients with infections, 4 patients with chronic HBV (21.1%; 95% CI, 6.1%-45.6%), 23 patients with HCV (32.4%; 95% CI, 21.8%-44.5%), and 7 patients with HIV (20.6%; 95% CI, 8.7%-37.9%) had no identifiable risk factors. CONCLUSIONS AND RELEVANCE: Results of this study found that a substantial proportion of patients with newly diagnosed cancer and concurrent HBV or HCV are unaware of their viral infection at the time of cancer diagnosis, and many had no identifiable risk factors for infection. Screening patients with cancer to identify HBV and HCV infection before starting treatment may be warranted to prevent viral reactivation and adverse clinical outcomes. The low rate of undiagnosed HIV infection may not support universal screening of newly diagnosed cancer patients.

Machine learning models to predict disease progression among veterans with hepatitis C virus.

BACKGROUND: Machine learning (ML) algorithms provide effective ways to build prediction models using longitudinal information given their capacity to incorporate numerous predictor variables without compromising the accuracy of the risk prediction. Clinical risk prediction models in chronic hepatitis C virus (CHC) can be challenging due to non-linear nature of disease progression. We developed and compared two ML algorithms to predict cirrhosis development in a large CHC-infected cohort using longitudinal data. METHODS AND FINDINGS: We used national Veterans Health Administration (VHA) data to identify CHC patients in care between 2000-2016. The primary outcome was cirrhosis development ascertained by two consecutive aspartate aminotransferase (AST)-to-platelet ratio indexes (APRIs) > 2 after time zero given the infrequency of liver biopsy in clinical practice and that APRI is a validated non-invasive biomarker of fibrosis in CHC. We excluded those with initial APRI > 2 or pre-existing diagnosis of cirrhosis, hepatocellular carcinoma or hepatic decompensation. Enrollment was defined as the date of the first APRI. Time zero was defined as 2 years after enrollment. Cross-sectional (CS) models used predictors at or closest before time zero as a comparison. Longitudinal models used CS predictors plus longitudinal summary variables (maximum, minimum, maximum of slope, minimum of slope and total variation) between enrollment and time zero. Covariates included demographics, labs, and body mass index. Model performance was evaluated using concordance and area under the receiver operating curve (AuROC). A total of 72,683 individuals with CHC were analyzed with the cohort having a mean age of 52.8, 96.8% male and 53% white. There are 11,616 individuals (16%) who met the primary outcome over a mean follow-up of 7 years. We found superior predictive performance for the longitudinal Cox model compared to the CS Cox model (concordance 0.764 vs 0.746), and for the longitudinal boosted-survival-tree model compared to the linear Cox model (concordance 0.774 vs 0.764). The accuracy of the longitudinal models at 1,3,5 years after time zero also showed superior performance compared to the CS model, based on AuROC. CONCLUSIONS: Boosted-survival-tree based models using longitudinal information are statistically superior to cross-sectional or linear models for predicting development of cirrhosis in CHC, though all four models were highly accurate. Similar statistical methods could be applied to predict outcomes in other non-linear chronic disease states.

Frequency and Outcomes of Abnormal Imaging in Patients With Cirrhosis Enrolled in a Hepatocellular Carcinoma Surveillance Program.

There are limited data on the downstream effects of hepatocellular carcinoma (HCC) surveillance, including the frequency of false-positive results. We aimed to quantify the incidence of indeterminate nodules (INs) and the follow-up testing needed to resolve these findings among patients enrolled in a structured HCC surveillance program. We retrospectively analyzed adult patients with cirrhosis enrolled in a structured HCC surveillance program in a large tertiary care center. Outcomes included surveillance benefits, defined as early HCC detection, and harm, defined as INs prompting additional diagnostic evaluation. Among 999 patients followed for a median of 2.2 years, HCC surveillance imaging was consistently completed every 6, 9, and 12 months in 46%, 51%, and 68% of patients, respectively. Of 256 (25.6%) patients with abnormal imaging, 69 (27.0%) were diagnosed with HCC and 187 (73.0%) with INs. Most HCC (n = 54, 78.3%) were found within Milan criteria. Among those with an IN, 78.1% returned to ultrasound surveillance after a median of 2 (interquartile range [IQR], 1-3) negative computed tomography (CT)/magnetic resonance imaging (MRI) scans, and 21.9% continued CT/MRI imaging (median, 1; IQR, 1-2). Eleven patients underwent diagnostic liver biopsy. Hypoalbuminemia, thrombocytopenia, and larger nodule size were independently associated with HCC diagnosis. In conclusion, 1 in 4 patients enrolled in an HCC surveillance program had abnormal surveillance imaging, but three-fourths of the lesions were INs, resulting in downstream harm. Improved risk-stratification tools are needed to identify nodules that are benign to reduce follow-up diagnostic evaluation.

Impact of a structured lifestyle programme on patients with metabolic syndrome complicated by non-alcoholic fatty liver disease.

BACKGROUND: Lifestyle interventions are first-line therapy for non-alcoholic fatty liver disease (NAFLD). AIMS: To examine the prevalence of NAFLD among participants of the University of Michigan Metabolic Fitness (MetFit) Programme and to assess the impact of this programme on weight, metabolic and liver-related parameters among patients with and without NAFLD. METHODS: Adults who completed the programme between 2008 and 2016 were included. Clinical and laboratory data were collected at enrolment, and at 12 and 24 weeks. NAFLD was defined based on liver biopsy, imaging or clinical diagnosis. RESULTS: The cohort (N = 403; 253 12-week, 150 24-week) consisted primarily of middle-aged (median 54 years) white (88%) men (63%) with severe obesity (median BMI 37.4). 47.6% met criteria for NAFLD. At baseline, NAFLD patients were younger (52 vs 55 years), had higher weights and more metabolic derangements (higher fasting insulin and triglyceride, lower high-density lipoprotein-cholesterol). At programme completion, 30% achieved weight reduction ≥5%, 62% resolution of hypertriglyceridaemia, 33% resolution of low HDL, 27% resolution of impaired fasting glucose and 43% normalisation of alanine aminotransferase. Endpoints were unaffected by NAFLD. Longer programme duration (OR 6.7, 95% CI 3.6-12.3) and white race (OR 3.83, 95% CI 1.04-1.76) were independent predictors of ≥5% weight loss. CONCLUSIONS: Nearly half of the patients referred to a structured lifestyle programme for metabolic syndrome had NAFLD. Although baseline metabolic derangements were more pronounced among NAFLD patients, the programme was equally efficacious in achieving weight loss and resolving metabolic syndrome components. Programme duration was the most important predictor of response.

Long-term outcomes following completion of a structured nutrition and exercise lifestyle intervention program for patients with metabolic syndrome.

INTRODUCTION: Metabolic syndrome is associated with an increased risk of cardiovascular disease and multiple other chronic health conditions. Studies have demonstrated the effectiveness of structured diet and exercise programs to improve the components of metabolic syndrome. The durability of these benefits after program completion is unclear. The aim of this study was to evaluate trends in cardiovascular risk factors 12 months post completion of a 12- or 24-week structured lifestyle intervention program. METHODS: Individuals with metabolic syndrome were referred to the Metabolic Fitness program, a 12- or 24-week lifestyle intervention program consisting of weekly exercise and nutrition education sessions. Patients were assessed at baseline, 12 weeks, and 24 weeks for those in the 24-week program. Data collection included weight, body mass index, waist circumference, body composition percentage, sBP, dBP, fasting blood glucose, total cholesterol, triglycerides, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol. Unstructured follow-up data were obtained by retrospective chart review for up to 12 months post program completion. RESULTS: Two-hundred twenty-five patients were enrolled in the 12-week program and 121 in the 24-week program. At the conclusion of the 12-week program, patients showed significant improvement in sBP and dBP. At the conclusion of the 24-week program, patients showed significant improvement in body mass index, weight, sBP, dBP, fasting blood glucose, total cholesterol, and triglycerides. However, 12 months after program completion, while the majority of parameters were still improved compared with baseline, only change in low-density lipoprotein cholesterol remained significantly improved compared with the end of 12-week program, and sBP had increased back above baseline in both programs. CONCLUSION: Patients with metabolic syndrome participating in a structured lifestyle intervention program show significant improvement in their cardiovascular risk and metabolic profile at program completion. The durability of these improvements appears to wane over time, however, stressing the need for programs that can facilitate maintenance of long-term behavior change.

Pharmacotherapy for NASH: Current and emerging.

Non-alcoholic fatty liver disease (NAFLD) has become one of the most prominent forms of chronic liver disease worldwide, reflecting the epidemic of global obesity. Those with the progressive variant of NAFLD, non-alcoholic steatohepatitis (NASH), are at significantly increased risk of multisystem morbidity and mortality. However, there are currently no approved pharmacologic therapies for NASH. Given the disease burden, there is an important unmet need for pharmacologic treatment options for this patient population. The underlying pathophysiologic mechanisms that contribute to the development and progression of NAFLD and NASH are complex and reflected by the myriad of therapies, with different targets, currently under investigation. In broad strokes, drug development has focused on modulation of metabolic pathways, inflammatory cascades, and/or mechanisms impacting fibrosis. Although much progress has been made in enhancing our understanding of NAFLD pathogenesis, development of pharmacologic treatments has been hindered by challenges in clinical trial enrollment and complexities in clinical trial design. The compounds in phase IIa have provided promising results in terms of potential benefits on various aspects of histopathology. Agents in later stages of development have shown fairly modest results in terms of reduction of hepatic steatosis, necroinflammation and fibrosis. If longer term safety and efficacy are established among heterogeneous cohorts, these medications may help mitigate potential morbidity and mortality for this burgeoning patient population.

Assessing risk of fibrosis progression and liver-related clinical outcomes among patients with both early stage and advanced chronic hepatitis C.

OBJECTIVE: Assessing risk of adverse outcomes among patients with chronic liver disease has been challenging due to non-linear disease progression. We previously developed accurate prediction models for fibrosis progression and clinical outcomes among patients with advanced chronic hepatitis C (CHC). The primary aim of this study was to validate fibrosis progression and clinical outcomes models among a heterogeneous patient cohort. DESIGN: Adults with CHC with ≥3 years follow-up and without hepatic decompensation, hepatocellular carcinoma (HCC), liver transplant (LT), HBV or HIV co-infection at presentation were analyzed (N = 1007). Outcomes included: 1) fibrosis progression 2) hepatic decompensation 3) HCC and 4) LT-free survival. Predictors included longitudinal clinical and laboratory data. Machine learning methods were used to predict outcomes in 1 and 3 years. RESULTS: The external cohort had a median age of 49.4 years (IQR 44.3-54.3); 61% were male, 80% white, and 79% had genotype 1. At presentation, 73% were treatment naïve and 31% had cirrhosis. Fibrosis progression occurred in 34% over a median of 4.9 years (IQR 3.2-7.6). Clinical outcomes occurred in 22% over a median of 4.4 years (IQR 3.2-7.6). Model performance for fibrosis progression was limited due to small sample size. The area under the receiver operating characteristic curve (AUROC) for 1 and 3-year risk of clinical outcomes was 0.78 (95% CI 0.73-0.83) and 0.76 (95% CI 0.69-0.81). CONCLUSION: Accurate assessments for risk of clinical outcomes can be obtained using routinely collected data across a heterogeneous cohort of patients with CHC. These methods can be applied to predict risk of progression in other chronic liver diseases.

Impact of an electronic health record alert in primary care on increasing hepatitis c screening and curative treatment for baby boomers.

Despite effective treatment for chronic hepatitis C, deficiencies in diagnosis and access to care preclude disease elimination. Screening of baby boomers remains low. The aims of this study were to assess the impact of an electronic health record-based prompt on hepatitis C virus (HCV) screening rates in baby boomers in primary care and access to specialty care and treatment among those newly diagnosed. We implemented an electronic health record-based "best practice advisory" (BPA) that prompted primary care providers to perform HCV screening for patients seen in primary care clinic (1) born between 1945 and 1965, (2) who lacked a prior diagnosis of HCV infection, and (3) who lacked prior documented anti-HCV testing. The BPA had associated educational materials, order set, and streamlined access to specialty care for newly diagnosed patients. Pre-BPA and post-BPA screening rates were compared, and care of newly diagnosed patients was analyzed. In the 3 years prior to BPA implementation, 52,660 baby boomers were seen in primary care clinics and 28% were screened. HCV screening increased from 7.6% for patients with a primary care provider visit in the 6 months prior to BPA to 72% over the 1 year post-BPA. Of 53 newly diagnosed patients, all were referred for specialty care, 11 had advanced fibrosis or cirrhosis, 20 started treatment, and 9 achieved sustained virologic response thus far. CONCLUSION: Implementation of an electronic health record-based prompt increased HCV screening rates among baby boomers in primary care by 5-fold due to efficiency in determining needs for HCV screening and workflow design. Streamlined access to specialty care enabled patients with previously undiagnosed advanced disease to be cured. This intervention can be easily integrated into electronic health record systems to increase HCV diagnosis and linkage to care. (Hepatology 2017;66:1805-1813).

Incidence of and Risk Assessment for Adverse Cardiovascular Outcomes After Liver Transplantation: A Systematic Review.

BACKGROUND: Cardiovascular events represent a major source of morbidity and mortality after liver transplantation and will likely increase given the aging population and nonalcoholic fatty liver disease as a leading indication for transplant. The optimal cardiovascular risk stratification approach in this evolving patient population remains unclear. The aims of this systematic review are to: (1) refine the definition, (2) characterize the incidence, and (3) identify risk factors for cardiovascular events post-liver transplantation. Additionally, we evaluated performance characteristics of different cardiac testing modalities. METHODS: MEDLINE via PubMed, EMBASE, Web of Science, and Scopus were searched for studies published between 2002 and 2016 (model of end-stage liver disease era). Two authors independently reviewed articles to select eligible studies and performed data abstraction. RESULTS: Twenty-nine studies representing 57 493 patients from 26 unique cohorts were included. Definitions of cardiovascular outcomes were highly inconsistent. Incidence rates were widely variable: 1% to 41% for outcomes of 6 months or shorter and 0% to 31% for outcomes longer than 6 months. Multivariate analyses demonstrated that older age and history of cardiac disease were the most consistent predictors of cardiovascular events posttransplant (significant in 8/23 and 7/22, studies, respectively). Predictive capacity of various cardiac imaging modalities was also discrepant. CONCLUSIONS: The true incidence of cardiovascular outcomes post-liver transplant remains unknown in large part due to lack of consensus regarding outcome definition. Overall, poor data quality and gaps in knowledge limit the ability to clearly identify predictors of outcomes, but existing data support a more aggressive risk stratification protocol for patients of advanced age and/or with preexisting cardiac disease.

Endoscopic Ultrasound as a Diagnostic Tool in a Case of Obscure Hemobilia.

Hemobilia represents an uncommon cause of gastrointestinal bleeding that can present both diagnostic and therapeutic challenges. The evaluation of hemobilia typically involves cross-sectional imaging and endoscopic retrograde cholangiopancreatography (ERCP). There is limited data regarding the diagnostic utility of endoscopic ultrasound (EUS) in the evaluation of hemobilia. We present a case of a hepatic artery pseudoaneurysm as the etiology of hemobilia that was detected via EUS only. We conclude that EUS can serve as an important diagnostic tool in the evaluation of obscure hemobilia, especially in cases where imaging, ERCP, and percutaneous transhepatic cholangiography have been unsuccessful or inconclusive.

Interferon Treatment for Hepatitis B.

Chronic hepatitis B virus (HBV) infection has a significant public health impact. There are currently 7 approved therapies for chronic HBV, including standard and pegylated interferon (IFN)-α, and 5 nucleos(t)ide analogs (NUCs). IFN offers benefits over NUCs, including a finite duration of therapy and a higher rate of clearance of hepatitis Be antigen and surface antigen. These benefits need to be weighed against the potential adverse effects of IFN therapy. Some patients should not receive IFN because of advanced liver disease or comorbidities. This article reviews the mechanisms of action, efficacy, and clinical use of IFN therapy for HBV infection.

Hepatitis C Treatment and Barriers to Eradication.

Current treatment for chronic hepatitis C (CHC) is highly efficacious, well-tolerated, and of short duration for the majority of patients. Despite the dramatic advances in therapy, there remain several barriers to disease eradication. These include deficiencies in screening, diagnosis, and access to care, and high cost of the direct-acting antiviral medications. In addition, incident cases and reinfection associated with injection drug use contribute to the persistent worldwide disease burden. This article will review the current CHC treatments, and outline the remaining gaps in therapy and barriers to disease eradication.

Pre-Liver Transplant Transthoracic Echocardiogram Findings and 6-Month Post-Transplant Outcomes: A Case-Control Analysis.

BACKGROUND Cardiopulmonary (CP) outcomes remain a leading cause of morbidity and mortality following liver transplantation (LT). The optimal CP risk stratification of LT candidates remains unclear. The aim of this study was to evaluate the association of pre-LT transthoracic echocardiogram (TTE) findings and 6-month post-LT outcomes. MATERIAL AND METHODS This retrospective review analyzed adults who underwent LT, comparing those who died within 6 months of LT (cases; n=38) with age- and sex-matched patients who survived >6 months (controls; n=38). Cases were categorized by cause of death (COD) defined as either a primary CP process (n=20) or a non-CP process (n=18). Data were analyzed using logistic regression and survival analysis was performed using Kaplan-Meier curves. RESULTS There was a higher odds of death within 6 months of LT with ≥ mild mitral regurgitation (OR 3.44, p=0.03) or an incomplete assessment of right ventricular systolic function (RVSF) (OR 24, p=0.004). On subgroup analysis, these findings only persisted in patients with a CP COD. Patients with CP COD were older (61 vs. 54.5, p=0.04), had longer intervals between TTE and LT (122 vs. 29 days, p=0.05), less complete assessments of RVSF (p=0.009), and lower RV fractional area change (p=0.04) compared to patients with non-CP COD. CONCLUSIONS Multiple TTE parameters were associated with patients who died within 6 months of LT, and in particular patients with a CP COD. Our findings suggest that pre-LT TTEs can convey useful CP risk stratification information and emphasizes the importance of adequately assessing these parameters prior to LT.

Primary Care Physician Perspectives on Hepatitis C Management in the Era of Direct-Acting Antiviral Therapy.

BACKGROUND: Primary care physicians (PCPs) play a critical role in the care cascade for patients with chronic hepatitis C (CHC). AIM: To assess PCP knowledge and perspectives on CHC screening, diagnosis, referral, and treatment. METHODS: An anonymous survey was distributed to PCPs who participated in routine outpatient care at our hospital. RESULTS: Eighty (36 %) eligible PCPs completed the survey. More than half were females (60 %) aged 36-50 (55 %) from family (44 %) or internal (49 %) medicine. Overall, PCPs correctly identified high-risk populations for screening, though 19 % failed to identify baby boomers and 45 % failed to identify hemodialysis patients as populations to screen. Approximately half reported they were able to screen at risk patients <50 % of the time secondary to time constraints and difficulty assessing if patients had already been screened. 71 % of PCPs reported they refer all newly diagnosed patients to specialty care. 70 % of PCPs did not feel up to date with current treatment. The majority grossly underestimated efficacy, tolerability and ease of administration, and overestimated treatment duration. Only 9 % felt comfortable treating CHC, even those without cirrhosis. Practice patterns were influenced by specialty and Veterans Affairs Hospital affiliation. CONCLUSIONS: Although the majority of PCPs are up to date with CHC screening recommendations, few are able to routinely screen in practice. Most PCPs are not up to date with treatment and do not feel comfortable treating CHC. Interventions to overcome screening barriers and expand treatment into primary care settings are needed to maximize access to and use of curative therapies.

Improvement of predictive models of risk of disease progression in chronic hepatitis C by incorporating longitudinal data.

UNLABELLED: Existing predictive models of risk of disease progression in chronic hepatitis C have limited accuracy. The aim of this study was to improve upon existing models by applying novel statistical methods that incorporate longitudinal data. Patients in the Hepatitis C Antiviral Long-term Treatment Against Cirrhosis trial were analyzed. Outcomes of interest were (1) fibrosis progression (increase of two or more Ishak stages) and (2) liver-related clinical outcomes (liver-related death, hepatic decompensation, hepatocellular carcinoma, liver transplant, or increase in Child-Turcotte-Pugh score to ≥7). Predictors included longitudinal clinical, laboratory, and histologic data. Models were constructed using logistic regression and two machine learning methods (random forest and boosting) to predict an outcome in the next 12 months. The control arm was used as the training data set (n = 349 clinical, n = 184 fibrosis) and the interferon arm, for internal validation. The area under the receiver operating characteristic curve for longitudinal models of fibrosis progression was 0.78 (95% confidence interval [CI] 0.74-0.83) using logistic regression, 0.79 (95% CI 0.77-0.81) using random forest, and 0.79 (95% CI 0.77-0.82) using boosting. The area under the receiver operating characteristic curve for longitudinal models of clinical progression was 0.79 (95% CI 0.77-0.82) using logistic regression, 0.86 (95% CI 0.85-0.87) using random forest, and 0.84 (95% CI 0.82-0.86) using boosting. Longitudinal models outperformed baseline models for both outcomes (P < 0.0001). Longitudinal machine learning models had negative predictive values of 94% for both outcomes. CONCLUSIONS: Prediction models that incorporate longitudinal data can capture nonlinear disease progression in chronic hepatitis C and thus outperform baseline models. Machine learning methods can capture complex relationships between predictors and outcomes, yielding more accurate predictions; our models can help target costly therapies to patients with the most urgent need, guide the intensity of clinical monitoring required, and provide prognostic information to patients.

Randomized, controlled pilot study comparing large-volume paracentesis using wall suction and traditional glass vacuum bottle methods.

OBJECTIVES: Large-volume paracentesis (LVP) can be time and labor intensive depending on the amount of ascites removed and the method of drainage. Wall suction has been adopted as the preferred method of drainage at many centers, though the safety and benefits of this technique have not been formally evaluated. The primary objective of this study was to define the cost and time savings of wall suction over the traditional glass vacuum bottle method for ascites drainage. The secondary objective was to compare the safety profile and patient satisfaction using these two techniques. METHODS: We conducted a randomized, controlled pilot study of the wall suction versus vacuum bottle methods for LVP in hospitalized patients. All LVPs were performed under ultrasound guidance by a single proceduralist. Patients with at least 4 liters removed received 25% intravenous albumin, 8 g/liter fluid removed. Demographic, clinical characteristics, and procedure details were recorded. Laboratory and hemodynamic data were recorded for 24 h prior to and 24-48 h post LVP. An electronic chart review was conducted to evaluate procedure-related complications. Data were compared using Fisher's exact test, t test, or Mann-Whitney U test. RESULTS: Thirty-four patients were randomized to wall suction at 200 mmHg (n = 17) or glass vacuum bottle drainage (n = 17). Wall suction was significantly faster and less costly than vacuum bottle drainage (7 versus 15 min, p = 0.002; $4.59 versus $12.73, p < 0.001). There were no differences in outcomes at 24 and 48 h post LVP, or at 60-day follow up. CONCLUSION: Performing LVP using wall suction resulted in significantly shorter procedure time and supply cost savings. There were no differences in outcomes between the groups, suggesting equivalent safety, though larger studies powered to detect small differences are needed. Given its efficiency, convenience, and cost effectiveness, wall suction may be a superior method of ascites drainage for LVP.