Revaccination for Hepatitis B in Previous Nonresponders Following Hepatitis C Eradication.

BACKGROUND: Patients with chronic hepatitis C virus (HCV) do not respond to hepatitis B virus (HBV) vaccination as efficiently as the general population. We assessed if revaccination after HCV treatment resulted in improved response. METHODS: Previous HBV vaccine nonresponders were prospectively recruited for revaccination after HCV eradication. Hepatitis B surface antibody (HBsAb) testing was performed 1 month after series completion. RESULTS: Follow-up HBsAb testing was performed in 31 of 34 enrolled patients with 21 (67.7%) reactive results. There were no significant differences in HBsAb reactivity based on age, sex, race, or advanced fibrosis presence. CONCLUSIONS: HBV vaccine nonresponders should be considered for revaccination following HCV cure.

End-of-life in Hepatocellular Carcinoma: How Palliative Care and Social Factors Impact Care and Cost.

OBJECTIVE: Investigate the impacts of palliative care consults, race, and socioeconomic status on the prevalence of invasive procedures in patients with hepatocellular carcinoma (HCC). BACKGROUND: Palliative care, race, and socioeconomic status can all influence end-of-life care preferences, but their roles in HCC have not been adequately explored. MATERIALS AND METHODS: This is a cross-sectional study of patients with HCC from 2016 to 2019 using the National Inpatient Sample. Terminal and nonterminal hospitalizations were assessed with logistical regression evaluating associations between palliative care, race, income, and procedures along with do-not-resuscitate orders and cost. Procedures included mechanical ventilation, tracheostomy, and cardiopulmonary resuscitation (CPR) among others. RESULTS: A total of 217,060 hospitalizations in patients with HCC were included, 18.1% of which included a palliative care encounter. The mean age was 65.0 years (SD = 11.3 y), 73.9% were males and 55.5% were white. Procedures were increased in terminal hospitalizations in black [CPR adjusted odds ratio (aOR) = 2.57, P < 0.001] and Hispanic patients (tracheostomy aOR = 3.64, P = 0.018) compared with white patients. Palliative care encounters were associated with reduced procedures during terminal hospitalizations (mechanical ventilation aOR = 0.47, P < 0.001, CPR aOR = 0.24, P < 0.001), but not in nonterminal hospitalizations. No association between income and end-of-life procedures was found. Palliative care was associated with decreased mean cost in terminal ($23,608 vs $31,756, P < 0.001) and nonterminal hospitalizations ($15,786 vs $19,914, P < 0.001). CONCLUSIONS: Palliative care is associated with less aggressive end-of-life care and decreased costs in patients with HCC. Black and Hispanic race were both associated with more aggressive end-of-life care.

Critical care outcomes in decompensated cirrhosis: a United States national inpatient sample cross-sectional study.

BACKGROUND: Prior assessments of critical care outcomes in patients with cirrhosis have shown conflicting results. We aimed to provide nationwide generalizable results of critical care outcomes in patients with decompensated cirrhosis. METHODS: This is a retrospective study using the National Inpatient Sample from 2016 to 2019. Adults with cirrhosis who required respiratory intubation, central venous catheter placement or both (n = 12,945) with principal diagnoses including: esophageal variceal hemorrhage (EVH, 24%), hepatic encephalopathy (58%), hepatorenal syndrome (HRS, 14%) or spontaneous bacterial peritonitis (4%) were included. A comparison cohort of patients without cirrhosis requiring intubation or central line placement for any principal diagnosis was included. RESULTS: Those with cirrhosis were younger (mean 58 vs. 63 years, p < 0.001) and more likely to be male (62% vs. 54%, p < 0.001). In-hospital mortality was higher in the cirrhosis cohort (33.1% vs. 26.6%, p < 0.001) and ranged from 26.7% in EVH to 50.6% HRS. Mortality when renal replacement therapy was utilized (n = 1580, 12.2%) was 46.5% in the cirrhosis cohort, compared to 32.3% in other hospitalizations (p < 0.001), and was lowest in EVH (25.7%) and highest in HRS (51.5%). Mortality when cardiopulmonary resuscitation was used was increased in the cirrhosis cohort (88.0% vs. 72.1%, p < 0.001) and highest in HRS (95.7%). CONCLUSIONS: One-third of patients with cirrhosis requiring critical care did not survive to discharge in this U.S. nationwide assessment. While outcomes were worse than in patients without cirrhosis, the results do suggest better outcomes compared to previous studies.

Endoscopic Management of Pancreaticobiliary Injuries: A Level 1 US Trauma Center Experience.

Background: Traumatic pancreaticobiliary injuries are challenging to diagnose and manage. Endoscopic retrograde cholangiopancreatography (ERCP) has potential diagnostic and therapeutic utility in cases of traumatic pancreaticobiliary injuries. Methods: In this single-center retrospective study, we assessed 25 cases of abdominal trauma in which the patients underwent ERCP for management of suspected pancreaticobiliary injuries. We analyzed basic patient demographics, mechanism of trauma, method of diagnosis, ERCP results, surgical treatments, and outcomes. Results: Of the 25 assessed patients, 12 (48%) had pancreatic injuries, 12 (48%) had biliary injuries, and 1 (4%) patient had both. The median age was 28 years [IQR 25-35], and 84% of patients were males. Fifty-six percent of injuries were from blunt trauma, while 44% were from penetrating trauma. In cases of ERCP-confirmed biliary leaks (n=11), 100% of leaks were resolved in the 8 patients who underwent repeat ERCP after initial ERCP with stenting. In cases of ERCP-confirmed pancreatic duct leaks (n=10), 57% of duct leaks were resolved in the 7 patients who underwent repeat ERCP after initial ERCP with stenting. One patient in the biliary trauma cohort developed post-ERCP pancreatitis and sepsis. Conclusion: ERCP was a useful diagnostic and therapeutic intervention in this population of patients with pancreaticobiliary trauma.

Outcomes of Liver Transplant Recipients Hospitalized With COVID-19: A Nationwide Analysis From the United States.

Introduction: Currently available data regarding the impact of liver transplantation on the outcomes of patients hospitalized with COVID-19 is conflicting. This study aims to compare the outcomes and resource utilization between patients with and without a history of liver transplant hospitalized with COVID-19. Methods and materials: This is a retrospective study using the National Inpatient Sample. All adults hospitalized with COVID-19 in the year 2020 were included. Mortality was the primary outcome, while endotracheal intubation, length of hospital stay, and total hospital charges were the secondary outcomes. Results: Out of 1,050,720 adults admitted with COVID-19 as the primary diagnosis, 1,455 had a secondary diagnosis of liver transplant. Mortality was not significantly increased in transplant recipients (OR adjusted = 0.69, 95% CI: 0.46-1.03, P = 0.07). Intubation rates and total hospital charges did not differ significantly between liver transplant recipients and patients without a history of liver transplant receipt. LOS was shorter by a coefficient of almost two days in patients with a history of LT (P < 0.001). Conclusion: Liver transplant recipients do not appear to be at increased risk of severe COVID-19 and COVID-19 mortality.

Risk of Aspiration Pneumonitis After Elective Esophagogastroduodenoscopy in Patients on Glucagon-Like Peptide-1 Receptor Agonists.

Background Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are gaining popularity in the management of diabetes mellitus and obesity. It has been suggested that this class of medications causes delayed gastric emptying which raised concerns about the potential for aspiration of gastric contents in patients undergoing sedation. This led to a statement by the American Society of Anesthesiologists about their preoperative use. Nevertheless, there is minimal evidence regarding the effects of GLP-1RAs on the risk of aspiration post-esophagogastroduodenoscopy (EGD). In this study, we sought to evaluate the incidence of aspiration and pneumonia in patients receiving GLP-1RAs who underwent EGD. Methodology We performed a retrospective cohort study in TriNetX, a global federated research network of electronic health records. The primary outcome was the development of aspiration post-EGD. Secondary outcomes were the development of aspiration pneumonia and requiring antibiotics post-EGD. One-to-one propensity score matching was performed for age, sex, diabetes mellitus, obesity, and other comorbidities between the cohorts. Results Our analysis showed a small but significant risk of aspiration pneumonitis in patients on GLP-1RAs undergoing elective EGD compared to non-GLP-1RA-receiving patients. However, there was no increased risk of the composite outcome of respiratory failure or intensive care unit (ICU) admission; however, this did not reach statistical significance. Conclusions GLP-1RA use was associated with an increased risk of aspiration in patients undergoing elective upper endoscopy. However, this did not translate to an increased risk of respiratory failure or ICU admission. Our findings highlight the importance of following an individualized approach to preoperative management that takes into consideration GLP-1RA indications and other aspiration risk factors, including advanced age, impaired gag reflex, and gastrointestinal symptoms such as nausea and abdominal distention.

Statin Utilization Among Individuals Infected With Hepatitis C Virus: A Retrospective Cohort Study.

Introduction and Objectives Statin use for primary prevention of coronary artery disease (CAD) has historically been limited in patients with chronic liver disease due to concerns for increased adverse events with statin use in this population. We aimed to quantify the underutilization of statins among individuals with a history of HCV infection in a community health system to understand the clinical implications of statin underutilization in a diverse, generalizable population of patients infected with HCV. Materials and Methods We performed a single-center retrospective study of individuals with a history of HCV infection aged 40-75 years from 2019-2021. Statin eligibility was determined using the 2019 American College of Cardiology/American Heart Association (ACC/AHA) guidelines with the 2013 Pooled Cohort Equation used to determine atherosclerotic cardiovascular disease (ASCVD) risk. Baseline characteristics and adverse events of statin and non-statin users were compared, and factors associated with statin use were determined using multivariable logistical regression. Results Based on 2019 ACC/AHA guidelines, 752/1,077 (69.8%) subjects had an indication for a statin, 280/752 (37.2%) of which were treated with a statin. Cirrhosis was independently associated with statin underutilization. Diabetes, anti-hypertensive use, and Black race were all independently associated with statin use in subjects with an indication for therapy. Statin use was not associated with adverse events. Conclusions Statins were underutilized and well tolerated in the cohort of individuals with a history of HCV infection. This high-risk population would benefit from increased CAD screening and utilization of statins for the primary prevention of CAD.

The Effect of Pass/Fail Exam Grading on Exam Performance in a Pediatric Clerkship.

OBJECTIVE: Clerkship grades are a component of determining a residency candidate's competitiveness. In 2017, the University of Minnesota Medical School's pediatric clerkship transitioned its standardized multiple-choice exam, the Aquifer Pediatrics Examination, to pass/fail with eligibility for honors being determined by clinical performance, not exam performance. We assessed the effect this change had on Aquifer exam performance and evaluated for correlation between Aquifer exam performance and clinical evaluation scores in order to gather insight into the validity of each type of assessment with respect to one another. METHODS: We analyzed de-identified data from 750 medical students between the academic years of 2016 to 2017 and 2019 to 2020. Individual Aquifer exam scores were compared to individual clinical performance scores. Differences in exam performance before and after the transition to pass/fail were investigated with a two-sample t-test and Cohen's d for effect size. RESULTS: No correlation was found between Aquifer exam scores and clinical performance scores. The mean Aquifer exam score prior to the transition to pass/fail was 80.02 ± 7.51 while the mean after the exam was made pass/fail was 77.8 ± 7.42. This difference was statistically significant (P < .001) with a Cohen's d (effect size) of 0.297. CONCLUSIONS: A lack of correlation between the Aquifer exam scores and clinical performance scores was found. There was a small yet statistically significant decrease in Aquifer exam scores after the change to pass/fail; it is not clear if this represents a meaningful decrease in learning by students.