Utility of scores to predict alcohol use after liver transplant (lt): take them with a grain of salt.

BACKGROUND AIMS: The Sustained Alcohol use post-Liver Transplant (SALT) and the High-Risk Alcohol Relapse (HRAR) scores were developed to predict return to alcohol use after liver transplant (LT) for alcohol associated liver disease (ALD). METHODS: A retrospective analysis of deceased donor LT 10/2018 to 4/2022 was performed. All patients (pts) underwent careful pre-LT psychosocial evaluation. Data on alcohol use, substance abuse, prior rehabilitation, and legal issues were collected. Post-LT, all were encouraged to participate in rehabilitation programs and underwent interval phosphatidylethanol (PeTH) testing. Pts with ALD were stratified by < or > 6 month sobriety prior to listing. Those with <6 month were further stratified as acute alcoholic hepatitis (AH) by NIAAA criteria and non-AH. The primary outcome was utility of the SALT (<5 vs. ≥5) and HRAR (<3 vs. ≥3) scores to predict return to alcohol use (+PeTH) within 1 year after LT. RESULTS: Of the 365 LT, 86 had > 6 month sobriety and 85 had <6 month sobriety; 41 with AH and 44 non-AH. In those with AH, the mean time of abstinence to LT was 58 days, and 71% failed prior rehabilitation. Following LT, return to drinking was similar in the AH (24%) compared to <6M non-AH (15%) and >6M ALD (22%). Only 4% had returned to heavy drinking. The accuracy of both the SALT and HRAR scores to predict return to alcohol was low (accuracy 61-63%) with poor sensitivity (46% and 37%), specificity (67-68%), positive predictive value (22-26%) with moderate negative predictive value (NPV) (81-83%), respectively with higher NPVs (95%) in predicting return to heavy drinking. CONCLUSIONS: Both SALT and HRAR scores had good NPV in identifying patients at low risk for recidivism.

Part II: Contract Negotiation and Job Preparation-The Gastroenterology Perspective.

GI fellowships do not mandate curricula in career development. Often, fellows resort to peer mentorship for guidance. Fellows should recognize that the path to a successful career varies greatly based on how one defines and measures success. Keywords are preferr Through introspection, fellows will be able to craft their ideal post-fellowship position that balances wants versus needs. In this article, we cover four practical tips for trainees entering the job negotiation process.

Navigating the "First Gastroenterology Job" Search for American and International Medical Graduates.

GI fellowships do not mandate curricula in career development. Often, fellows resort to peer mentorship for guidance. Fellows should recognize that the path to a successful career varies greatly based on how one defines and measures success. Through introspection, fellows will be able to craft their ideal post-fellowship position that balances wants versus needs. In this article, we cover the breadth of post-fellowship opportunities available with a focus on unique considerations for LGBTQ+ and IMG trainees.

Current Pharmacologic Therapies for Hepatorenal Syndrome-Acute Kidney Injury.

BACKGROUND & AIMS: Hepatorenal syndrome (HRS) can occur in patients with cirrhosis and ascites due to splanchnic vasodilation, renal hypoperfusion, and vasoconstriction. HRS is a diagnosis of exclusion and portends a poor prognosis, with upward of 80% mortality at 2 weeks without treatment. This review will highlight randomized controlled trials for HRS pharmacotherapy. METHODS: A PubMed review of randomized controlled trials conducted over the past 25 years was undertaken; 18 studies were included. RESULTS: Initial studies showed that norepinephrine is as effective as terlipressin for HRS reversal. Midodrine with octreotide and albumin is less effective than terlipressin but better than albumin alone at improving 30-day mortality. Recently, terlipressin with albumin led to significantly higher rates of HRS reversal compared to albumin alone. Non-response to terlipressin can predict 90-day mortality in acute-on-chronic-liver failure. CONCLUSIONS: Our current understanding of HRS treatment is improved by recent randomized clinical trials. Previous studies using varying medication doses along with the "old" definition of hepatorenal syndrome (HRS type 1) rather than HRS-AKI means that there is still a need for future multicenter prospective studies further refining the risk-benefit ratio of vasoconstrictors for HRS-AKI patients. The Food and Drug Administration has approved terlipressin for use in September 2022. Because it will take time to adapt into clinical practice, less cost-prohibitive vasoconstrictors should still be considered. Opportunities also exist to clarify the safety, timing of initiation, as well as possible discontinuation of terlipressin.

QuickStroop, a Shortened Version of EncephalApp, Detects Covert Hepatic Encephalopathy With Similar Accuracy Within One Minute.

BACKGROUND & AIMS: Covert hepatic encephalopathy (CHE) is associated with poor outcomes but is often not diagnosed because of the time requirement. Psychometric hepatic encephalopathy score (PHES) is the gold standard against which EncephalApp Stroop has been validated. However, EncephalApp (5 runs each in "Off" and "On" state) can take up to 10 minutes. This study sought to define the smallest number of EncephalApp runs needed for comparable accuracy to the total EncephalApp using CHE on PHES as gold standard. METHODS: A derivation and a validation cohort of outpatients with cirrhosis who underwent PHES (gold standard) and total EncephalApp was recruited. Data were analyzed for individual runs versus total EncephalApp time versus PHES-CHE. The derivation cohort (n = 398) was split into training (n = 299) and test (n = 99) sets. From the training data set a regression model was created with age, gender, education, and various sums of the "Off" settings. After this, a K-fold cross-validation on the test dataset was performed for both total EncephalApp time and individual Off runs and for the validation cohort. RESULTS: In both cohorts, Off runs 1 + 2 had statistically similar area under the receiver operating curve and P value to the total EncephalApp for PHES-CHE prediction. The adjusted (age, gender, education) regression formula from the derivation cohort showed an accuracy of 84% to diagnose PHES-CHE in the validation cohort. Time for CHE diagnosis decreased from 203.7 (67.82) to 36.8 (11.25) seconds in the derivation and from 178.2 (46.19) to 32.9 (9.94) seconds in the validation cohort. CONCLUSIONS: QuickStroop, which is completed within 1 minute, gives an equivalent ability to predict CHE on the gold standard compared with the entire EncephalApp time.

Bowel Movement Frequency Is Not Linked With Cognitive Function in Cirrhosis.

The spectrum of hepatic encephalopathy (HE) ranges from overt HE (OHE) to cognitive impairment (ie, covert) HE (CHE).1 The first-line therapy is lactulose, which is titrated to achieve ~2-3 soft/loose daily bowel movements (BM). This metric is considered dogma for practitioners despite erratic results, GI adverse events, and poor tolerance in Western countries.1 There are logistic barriers for the widespread uptake of rifaximin, the second-line therapy. Moreover, although BM frequency-directed dose titration of lactulose is the usual practice, its impact on objective cognitive performance is unclear. Our aim is to determine the impact of BM frequency on cognition in patients with/without prior OHE.

Reduction in Nosocomial Infections in Patients With Cirrhosis During the COVID-19 Era Compared with Pre-COVID-19: Impact of Masking and Restricting Visitation.

Nosocomial infections (NIs) in critically ill patients with cirrhosis result in higher death and transplant delisting. NIs are promoted by staff, visitors, and the environment, all of which were altered to reduce pathogen transmission after COVID-19. Two cohorts of intensive care unit patients with cirrhosis from March 2019 to February 2020 (pre-COVID, n = 234) and March 2020 to March 2021 (COVID era, n = 296) were included. We found that despite a higher admission MELD-Na, qSOFA, and WBC count and requiring a longer intensive care unit stay, COVID-era patients developed lower NIs (3% vs 10%, P < 0.001) and had higher liver transplant rates vs pre-COVID patients. COVID-era restrictions could reduce NIs in critically ill patients with cirrhosis.

Bristol Stool Scale as a Determinant of Hepatic Encephalopathy Management in Patients With Cirrhosis.

INTRODUCTION: Bowel movement (BM) frequency is used to titrate lactulose for hepatic encephalopathy (HE). However, stool consistency using the Bristol stool scale (BSS, 0-7) is often ignored. METHODS: The study included pre-BSS and post-BSS cohorts. BSS was incorporated into decision-making after training in outpatients with cirrhosis. Two to 3 BMs/d and BSS 3-4 were considered normal, whereas the rest were considered high or low; concordance between the metrics was evaluated. Medication changes and 6-month admissions were compared between this group (post-BSS) and a comparable previous group (pre-BSS). Concordance and regression analyses for all-cause admissions and HE-related admissions were performed, and comparisons were made for HE-related medication stability. In the longitudinal analysis, an outpatient group seen twice was analyzed for BSS and BMs. RESULTS: In the post-BSS cohort, 112 patients were included with only 46% BSS and BMs concordance and modest BSS/BMs correlation (r = 0.27, P = 0.005). Compared with a pre-BSS cohort (N = 114), there was a lower 6-month total (4% vs 0.36%, P < 0.001) or HE-related admission (1% vs 0.12%, P = 0.002). Regression showed model for end-stage liver disease (odds ratio [OR]: 1.10, P = 0.003) and pre-BSS/post-BSS (OR: 0.04, P < 0.001) for all-cause admissions and HE (OR: 3.59, P = 0.04) and preera/postera (OR: 0.16, P = 0.02) for HE-related admissions as significant. HE medication regimens were more stable post-BSS vs pre-BSS (32% vs 20%, P = 0.04), which was due to patients with BSS > BMs (P = 0.02). In the longitudinal analysis, 33 patients without medication changes or underlying clinical status changes were tested 36 ± 24 days apart. No changes in BSS (P = 0.73) or BMs (P = 0.19) were found. DISCUSSION: BSS is complementary and additive to BM frequency, can modulate the risk of readmissions and stabilize HE-related therapy changes in outpatients with cirrhosis, and could help personalize HE management.

Patient- and provider-level factors that underlie alcohol use disorder treatment offer and acceptance in veterans with cirrhosis.

BACKGROUND: Untreated alcohol use disorder (AUD) is associated with poor cirrhosis outcomes. We evaluated factors associated with AUD treatment discussions and initiation in the Veterans Health Administration. METHODS: Chart reviews were conducted for veterans with International Classification of Diseases codes for both cirrhosis and AUD who were receiving care at one of three large medical centers in 2020. Factors associated with a 1-year offer of AUD treatment and its acceptance were assessed using regression models, which included as covariates demographic characteristics, comorbidities, and depression, as measured by the patient health questionnaire (PHQ-2) from the electronic health record. RESULTS: The cohort included 654 veterans, 68 of whom were engaged in AUD treatment at baseline and 174 who were documented as being in AUD remission. Treatment was offered to 264 (64%) of the 412 veterans with opportunities to initiate it. AUD treatment discussions were most often documented by practitioners in primary care (n = 162), hepatology (n = 45), or both (n = 41). Multivariable logistic regression modeling revealed that treatment was significantly more likely to be offered to patients with co-occurring bipolar disorder (OR 2.94, p = 0.03) or depression (1.50, p = 0.05) or who were younger (0.97, p = 0.01). Of the 264 patients offered AUD treatment, 107 (40%) agreed to initiate it. Acceptance of an offer of treatment was significantly associated with hospitalization in the prior year (OR 1.74, p = 0.05), prior AUD treatment (9.92, p < 0.0001), and a higher PHQ-2 depression score (2.85, p = 0.004). CONCLUSIONS: We identified factors associated with an offer of AUD treatment and its initiation among veterans with cirrhosis. Application of these findings could increase the likelihood that veterans with alcoholic cirrhosis initiate AUD treatment.

The impact of the gut microbiome on liver transplantation.

PURPOSE OF REVIEW: Although gut dysbiosis can hasten disease progression in end-stage liver disease and contribute to disease severity, morbidity and mortality, its impact during and after transplant needs further study. RECENT FINDINGS: Changes in the microbiome are associated with hepatic decompensation. Immune homeostasis is further disrupted during transplant and with immunosuppressants required after transplant. There is increasing evidence of the role of microbiota in peri and posttransplant complications. SUMMARY: Although transplant is highly successful with acceptable survival rates, infections, rejection, disease recurrence and death remain important complications. Prognostication and interventions involving the gut microbiome could be beneficial.

How to Become a Competitive Applicant for Gastroenterology Fellowship: Tips and Tricks for Success Part II.

In recent years, gastroenterology has become one of the most competitive subspecialties included in the internal medicine fellowship match, which increases the stressful nature of an already potentially nerve-wracking process for the trainee. Though each applicant has unique strengths and thus the process is somewhat individualized, there are some basic principles that can render an applicant more competitive for a gastroenterology fellowship. These include establishing mentorship, achieving scholarly work, building your resume, honing interpersonal and networking skills, and writing a well-planned application. The goal of this article is to outline some basic principles that will help improve the competitiveness of an applicant, and also highlight some practical tips and tricks for applicants with diverse backgrounds, such as international medical graduates, minority applicants, and women in medicine.

How to Become a Competitive Applicant for Gastroenterology Fellowship: Tips and Tricks for Success Part I.

In recent years, gastroenterology has become one of the most competitive subspecialties included in the internal medicine fellowship match, which increases the stressful nature of an already potentially nerve-wracking process for the trainee. Though each applicant has unique strengths and thus the process is somewhat individualized, there are some basic principles that can render an applicant more competitive for a gastroenterology fellowship. These include establishing mentorship, achieving scholarly work, building your resume, honing interpersonal and networking skills, and a writing a well-planned application. The goal of this article is to outline some basic principles that will help improve the competitiveness of an applicant, and also highlight some practical tips and tricks for applicants with diverse backgrounds, such as international medical graduates, minority applicants, and women in medicine.

Racial disparities in COVID-19 and gastrointestinal diseases-related mortality: analysis from CDC-WONDER databases, 2020-2022.

Background: The COVID-19 pandemic represents an unprecedented global health challenge. Gastrointestinal diseases (GID) have been shown to increase morbidity and mortality in COVID-19 patients, warranting a comprehensive investigation of their combined impact and racial disparities in mortality rates within the United States. Methods: Data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) mortality statistics database were analyzed for the period from January 1, 2020, to December 31, 2022. This study focused on adults, considering all deaths related to COVID-19 and GID. Age-adjusted mortality rates (AAMR) per 100,000 population were reported. Sociodemographic data, including age, sex, race/ethnicity, and region of residence, were collected. Results: Among 9,925,729 total deaths in the US between 2020 and 2022, 3.9% were GID related only, 9.6% were COVID-19 related only, and 0.4% were attributed to both COVID-19 and GID as underlying causes of death. AAMR for COVID-19 was 121.3 per 100,000, significantly higher than the AAMR for GID (50.3 per 100,000). Age-wise, elderly individuals had the highest AAMR for both COVID-19 and GID-related deaths. Stratified by race/ethnicity, Hispanics exhibited the highest AAMR, nearly twice that of Non-Hispanic Black patients and substantially higher than Non-Hispanic White and Asian patients. Conclusion: Our findings reveal substantial disparities in race/ethnicity-specific AAMR associated with both COVID-19 and GID in the US. Further research is crucial to delve deeper into their root causes and develop targeted interventions to strive for health equity for all.

Gut-Liver-Brain Axis and Alcohol Use Disorder: Treatment Potential of Fecal Microbiota Transplantation.

PURPOSE: Chronic alcohol use is a major cause of liver damage and death. In the United States, multiple factors have led to low utilization of pharmacotherapy for alcohol use disorder (AUD), including lack of provider knowledge and comfort in prescribing medications for AUD. Alcohol consumption has direct effects on the gut microbiota, altering the diversity of bacteria and leading to bacterial overgrowth. Growing evidence suggests that alcohol's effects on the gut microbiome may contribute to increased alcohol consumption and progression of alcohol-associated liver disease (ALD). This article reviews human and preclinical studies investigating the role of fecal microbiota transplantation (FMT) in ameliorating alcohol-associated alterations to the liver, gut, and brain resulting in altered behavior; it also discusses the therapeutic potential of FMT. SEARCH METHODS: For this narrative review, a literature search was conducted in September 2022 of PubMed, Web of Science Core Collection, and Google Scholar to identify studies published between January 2012 and September 2022. Search terms used included "fecal microbiota transplantation" and "alcohol." SEARCH RESULTS: Most results of the literature search were review articles or articles on nonalcoholic fatty liver disease; these were excluded. Of the remaining empirical manuscripts, very few described clinical or preclinical studies that were directly investigating the effects of FMT on alcohol drinking or related behaviors. Ultimately, 16 studies were included in the review. DISCUSSION AND CONCLUSIONS: The literature search identified only a few studies that were directly investigating the effect of FMT on ALD or alcohol drinking and related behaviors. Largely proof-of-concept studies, these findings demonstrate that alcohol can alter the gut microbiome and that the microbiome can be transferred between humans and rodents to alter affective behaviors frequently associated with increased alcohol use. Other studies have shown promise of FMT or other probiotic supplementation in alleviating some of the symptoms associated with ALD and drinking. These results show that the implementation of FMT as a therapeutic approach is still in the investigatory stages.

Gastroenterology fellowship application and match trends in the United States over a 12-year period, 2010 to 2022.

Introduction: Gastroenterology has recently gained prominence as a competitive internal medicine subspecialty. The intense competition within the gastroenterology fellowship match (GFM) presents challenges for both applicants and programs, particularly in virtual interviews due to the COVID-19 pandemic. We analyzed the variables impacting GFM competitiveness to provide insights for prospective gastroenterologists and programs to enhance the match process. Methods: We used publicly available National Resident Matching Program (NRMP) data to examine applications and match data for internal medicine subspecialties from 2010 to 2022. We considered factors such as the number of positions, applicants, and programs, utilizing the specialty competitiveness ratio (SCR) to assess competitiveness. Annual growth rates for positions and applications and average annual growth rates were calculated. Correlation coefficients between annual salaries and SCR were computed using various compensation reports. Results: GFM's competitiveness has increased recently, evidenced by substantial growth in positions (4.61%) and applications (3.81%) since 2010. Gastroenterology ranked as the second-fastest growing specialty in positions and applications. In 2022, GFM ranked fourth in applications (974) and positions offered (616). Among internal medicine subspecialties, gastroenterology exhibited the highest SCR (1.58). Correlation analysis highlighted a positive link between SCR and compensation across specialties. Conclusion: The escalating competition within GFM necessitates an expansion of positions to address potential shortages. Complex factors, such as academic interest and financial considerations, require multifaceted strategies to ensure an adequate supply of gastroenterologists. Further research is warranted to examine the long-term consequences of this trend.