HCC EV ECG score: An extracellular vesicle-based protein assay for detection of early-stage hepatocellular carcinoma.

BACKGROUND AND AIMS: The sensitivity of current surveillance methods for detecting early-stage hepatocellular carcinoma (HCC) is suboptimal. Extracellular vesicles (EVs) are promising circulating biomarkers for early cancer detection. In this study, we aim to develop an HCC EV-based surface protein assay for early detection of HCC. APPROACH AND RESULTS: Tissue microarray was used to evaluate four potential HCC-associated protein markers. An HCC EV surface protein assay, composed of covalent chemistry-mediated HCC EV purification and real-time immuno-polymerase chain reaction readouts, was developed and optimized for quantifying subpopulations of EVs. An HCC EV ECG score, calculated from the readouts of three HCC EV subpopulations ( E pCAM + CD63 + , C D147 + CD63 + , and G PC3 + CD63 + HCC EVs), was established for detecting early-stage HCC. A phase 2 biomarker study was conducted to evaluate the performance of ECG score in a training cohort ( n  = 106) and an independent validation cohort ( n  = 72).Overall, 99.7% of tissue microarray stained positive for at least one of the four HCC-associated protein markers (EpCAM, CD147, GPC3, and ASGPR1) that were subsequently validated in HCC EVs. In the training cohort, HCC EV ECG score demonstrated an area under the receiver operating curve (AUROC) of 0.95 (95% confidence interval [CI], 0.90-0.99) for distinguishing early-stage HCC from cirrhosis with a sensitivity of 91% and a specificity of 90%. The AUROCs of the HCC EV ECG score remained excellent in the validation cohort (0.93; 95% CI, 0.87-0.99) and in the subgroups by etiology (viral: 0.95; 95% CI, 0.90-1.00; nonviral: 0.94; 95% CI, 0.88-0.99). CONCLUSION: HCC EV ECG score demonstrated great potential for detecting early-stage HCC. It could augment current surveillance methods and improve patients' outcomes.

The Evolution of Redo Liver Transplantation Over 35 Years: Analysis of 654 Consecutive Adult Liver Retransplants at a Single Center.

OBJECTIVE: To examine liver retransplantation (ReLT) over 35 years at a single center. BACKGROUND: Despite the durability of liver transplantation (LT), graft failure affects up to 40% of LT recipients. METHODS: All adult ReLTs from 1984 to 2021 were analyzed. Comparisons were made between ReLTs in the pre versus post-model for end-stage liver disease (MELD) eras and between ReLTs and primary-LTs in the modern era. Multivariate analysis was used for prognostic modeling. RESULTS: Six hundred fifty-four ReLTs were performed in 590 recipients. There were 372 pre-MELD ReLTs and 282 post-MELD ReLTs. Of the ReLT recipients, 89% had one previous LT, whereas 11% had ≥2. Primary nonfunction was the most common indication in the pre-MELD era (33%) versus recurrent disease (24%) in the post-MELD era. Post-MELD ReLT recipients were older (53 vs 48, P = 0.001), had higher MELD scores (35 vs 31, P = 0.01), and had more comorbidities. However, post-MELD ReLT patients had superior 1, 5, and 10-year survival compared with pre-MELD ReLT (75%, 60%, and 43% vs 53%, 43%, and 35%, respectively, P < 0.001) and lower in-hospital mortality and rejection rates. Notably, in the post-MELD era, the MELD score did not affect survival. We identified the following risk factors for early mortality (≤12 months after ReLT): coronary artery disease, obesity, ventilatory support, older recipient age, and longer pre-ReLT hospital stay. CONCLUSIONS: This represents the largest single-center ReLT report to date. Despite the increased acuity and complexity of ReLT patients, post-MELD era outcomes have improved. With careful patient selection, these results support the efficacy and survival benefit of ReLT in an acuity-based allocation environment.

Management of Patients After Treatment of Severe Alcohol-associated Hepatitis.

Alcohol-associated liver disease is the leading indication for hospitalization among patients with chronic liver disease. Rates of hospitalization for alcohol-associated hepatitis have been rising over the last 2 decades. Patients with alcohol-associated hepatitis carry significant morbidity and mortality, but there is a lack of standardized postdischarge management strategies to care for this challenging group of patients. Patients warrant management of not only their liver disease but also their alcohol use disorder. In this review, we will discuss outpatient management strategies for patients who were recently hospitalized and discharged for alcohol-associated hepatitis. We will discuss short management of their liver disease, long-term follow-up, and review-available treatment options for alcohol use disorder and challenges associated with pursuing treatment for alcohol use disorder.

Role of Biomarkers to Assess the Use of Alcohol.

Alcohol-associated liver disease has seen a significant rise in the last 2 decades, with an associated rise in the need for accurate alcohol use assessment. Alcohol use has been associated with poor outcomes in both the pre-liver transplant and post-liver transplant patients. Patients with alcohol use disorder often under-report their alcohol consumption because of varying factors, highlighting the need for objective assessment of alcohol use. Aside from the available self-report questionnaires, multiple serologic biomarkers are currently available to assist clinicians to assess recent alcohol consumption among patients with chronic liver disease, liver transplant candidates, and recipients. In this review, we will assess some of these alcohol biomarkers, discuss their strengths and weakness, and review-available data to discuss their role in pre-liver transplant and post-liver transplant population.

Role of rifaximin in the management of alcohol-associated hepatitis: A systematic review and meta-analysis.

BACKGROUND AND AIM: Alcohol-associated hepatitis (AAH) is an acute, inflammatory liver disease with severe short-term and long-term morbidity and mortality. AAH can lead to severe complications including hepatic failure, gastrointestinal bleeding, sepsis, and the development or decompensation of cirrhosis. Rifaximin is an antibiotic that reduces bacterial overgrowth and gut translocation, and it may have a role in decreasing systemic inflammation and infection in patients with AAH. Therefore, we conducted a systematic review and meta-analysis to evaluate the role of rifaximin in the management of AAH. METHODS: A comprehensive search strategy was used to identify studies that met our inclusion criteria in Embase, MEDLINE (PubMed), Cochrane Library, Web of Science Core Collection, and Google Scholar. Outcomes of interest included rates of infection, 90-day mortality, and overall mortality between the rifaximin versus non-rifaximin group. Open Meta Analyst software was used to compute the results. RESULTS: Three studies with a total of 162 patients were included in the final meta-analysis. Of the three studies, two were randomized control trials (RCTs), and one was a case-control study. There was a significantly lower rate of infection in the rifaximin group versus the non-rifaximin group (RR: 0.331, 95% CI: 0.159-0.689, I2  = 0%, P = 0.003). There was no significant difference in 90-day mortality in the rifaximin versus non-rifaximin group (RR: 0.743, 95% CI: 0.298-1.850, I2  = 24%, P = 0.523), nor was there a significant difference in overall mortality (RR: 0.624, 95% 95% CI: 0.299-1.3, I2  = 7.1%, P = 0.208). CONCLUSIONS: The use of rifaximin in AAH is associated with a lower rate of infection rate than the non-rifaximin group. Additional research is needed to determine whether this effect is more pronounced in patients concurrently being treated with prednisolone. Differences in 90-day or overall mortality did not reach statistical significance. Further studies, particularly large randomized controlled trials, are needed to establish the role of rifaximin in AAH, especially as an adjunct therapy with prednisolone.

Barriers to Lactulose Adherence in Patients with Cirrhosis and Hepatic Encephalopathy.

BACKGROUND: Hepatic encephalopathy (HE) is a major cause of mortality and morbidity in patients with cirrhosis. Lactulose non-adherence is one of the most frequently reported precipitants of hospital admission for HE. AIMS: We aimed to identify which factors contribute most to lactulose non-adherence and propose strategies to promote greater adherence and utilization of lactulose. METHODS: Participants in this study consisted of patients with cirrhosis who were taking lactulose for prevention of HE. Subjects were administered the Morisky Adherence Scale 8 (MAS-8) and a customized 16-question survey that assessed barriers to lactulose adherence. Results from the MAS-8 were used to stratify subjects into "adherent" and "non-adherent" groups. Survey responses were compared between groups. RESULTS: We enrolled 129 patients in our study, of whom 45 were categorized as "adherent and 72 were categorized as "non-adherent." Barriers to adherence included large volumes of lactulose, high frequency of dosing, difficulty remembering to take the medication, unpleasant taste, and medication side-effects. Most patients (97%) expressed understanding of the importance of lactulose, and 71% of patients felt that lactulose was working to manage their HE. Hospital admission rates for HE was higher in non-adherent patients, although this difference was not statistically significant. CONCLUSION: We identified several factors that contribute to lactulose non-adherence among patients treated for HE. Many of these factors are potentially modifiable. Patient and care-giver education are critical to assure adherence. Pharmacists and nurses are an essential but underutilized aspect of education regarding proper medication use.

Exploratory assessment: Nurse-led community health worker delivered HCV intervention for people experiencing homelessness.

BACKGROUND: Getting and maintaining Hepatitis C Virus (HCV) cure is challenging among people experiencing homelessness (PEH) as a result of critical social determinants of health such as unstable housing, mental health disorders, and drug and alcohol use. OBJECTIVES: The purpose of this exploratory pilot study was to compare a registered nurse/community health worker (RN/CHW)-led HCV intervention tailored for PEH, "I am HCV Free," with a clinic-based standard of care (cbSOC) for treating HCV. Efficacy was measured by sustained virological response at 12 weeks after stopping antivirals (SVR12), and improvement in mental health, drug and alcohol use, and access to healthcare. METHODS: An exploratory randomized controlled trial design was used to assign PEH recruited from partner sites in the Skid Row Area of Los Angeles, California, to the RN/CHW or cbSOC programs. All received direct-acting antivirals. The RN/CHW group received directly observed therapy in community-based settings, incentives for taking HCV medications, and wrap-around services, including connection to additional healthcare services, housing support, and referral to other community services. For all PEH, drug and alcohol use and mental health symptoms were measured at month 2 or 3 and 5 or 6 follow-up, depending on HCV medication type, while SVR12 was measured at month 5 or 6 follow-up. RESULTS: Among PEH in the RN/CHW group, 75% (3 of 4) completed SVR12 and all three attained undetectable viral load. This was compared with 66.7% (n = 4 of 6) of the cbSOC group who completed SVR12; all four attained undetectable viral load. The RN/CHW group, as compared to the cbSOC, also showed greater improvements in mental health, and significant improvement in drug use, and access to healthcare services. DISCUSSION: While this study shows significant improvements in drug use and health service access among the RN/-CHW group, the sample size of the study limits the validity and generalizability of the results. Further studies using larger sample sizes are necessitated.

Circulating Tumor Cell-Based Messenger RNA Scoring System for Prognostication of Hepatocellular Carcinoma: Translating Tissue-Based Messenger RNA Profiling Into a Noninvasive Setting.

Numerous studies in hepatocellular carcinoma (HCC) have proposed tissue-based gene signatures for individualized prognostic assessments. Here, we develop a novel circulating tumor cell (CTC)-based transcriptomic profiling assay to translate tissue-based messenger RNA (mRNA) signatures into a liquid biopsy setting for noninvasive HCC prognostication. The HCC-CTC mRNA scoring system combines the NanoVelcro CTC Assay for enriching HCC CTCs and the NanoString nCounter platform for quantifying the HCC-CTC Risk Score (RS) panel in enriched HCC CTCs. The prognostic role of the HCC-CTC RS was assessed in The Cancer Genome Atlas (TCGA) HCC cohort (n = 362) and validated in an independent clinical CTC cohort (n = 40). The HCC-CTC RS panel was developed through our integrated data analysis framework of 8 HCC tissue-based gene signatures and identified the top 10 prognostic genes (discoidin domain receptor tyrosine kinase 1 [DDR1], enoyl-CoA hydratase and 3-hydroxyacyl CoA dehydrogenase [EHHADH], androgen receptor [AR], lumican [LUM], hydroxysteroid 17-beta dehydrogenase 6[HSD17B6], prostate transmembrane protein, androgen induced 1 [PMEPA1], tsukushi, small leucine rich proteoglycan [TSKU], N-terminal EF-hand calcium binding protein 2 [NECAB2], ladinin 1 [LAD1], solute carrier family 27 member 5 [SLC27A5]) highly expressed in HCC with low expressions in white blood cells. The panel accurately discriminated overall survival in TCGA HCC cohort (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.4-2.9). The combined use of the scoring system and HCC-CTC RS panel successfully distinguished artificial blood samples spiked with an aggressive HCC cell type, SNU-387, from those spiked with PLC/PRF/5 cells (P = 0.02). In the CTC validation cohort (n = 40), HCC-CTC RS remained an independent predictor of survival (HR, 5.7; 95% CI, 1.5-21.3; P = 0.009) after controlling for Model for End-Stage Liver Disease score, Barcelona Clinic Liver Cancer stage, and CTC enumeration count. Our study demonstrates a novel interdisciplinary approach to translate tissue-based gene signatures into a liquid biopsy setting. This noninvasive approach will allow real-time disease profiling and dynamic prognostication of HCC.

Identifying Advanced Fibrosis in NAFLD Using Noninvasive Tests: A Systematic Review of Sequential Algorithms.

BACKGROUND: The utility of noninvasive tests (NITs) for the diagnosis of advanced fibrosis in nonalcoholic fatty liver disease (NAFLD) is limited by indeterminate results and modest predictive values (PVs). Algorithms of sequential NITs may overcome these shortcomings. Thus, we sought to systematically review the accuracy of sequential algorithms for assessing advanced fibrosis in NAFLD. METHODS: A systematic review was performed following guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. A literature search of PubMed and Embase was performed in July of 2020 to identify studies that evaluated diagnostic characteristics of sequential NIT algorithms in NAFLD. RESULTS: Among 8 studies meeting inclusion criteria, 48 algorithms were studied in 6741 patients. The average sensitivity, specificity, positive PV, negative PV, and proportion of indeterminate values for included algorithms were 72%, 92%, 88%, 82%, and 25%, respectively. Six algorithms achieved sensitivities in the top quartile (≥86.3%) with <25% indeterminate values. Four algorithms achieved specificities in the top quartile (≥98.7%) with <25% indeterminate values. The aforementioned algorithms included combinations of Fibrosis-4, NAFLD fibrosis score, and vibration-controlled transient elastography. CONCLUSIONS: Sequential NIT algorithms may reduce indeterminate results while achieving sensitivities comparable to single NITs. Sequential algorithms may also augment the specificities of single NITs, though resulting positive PVs may not be high enough to obviate the need for liver biopsy. Available evidence supports the use of Fibrosis-4, NAFLD fibrosis score, and vibration-controlled transient elastography within sequential algorithms to achieve diagnostic accuracy for advanced fibrosis in NAFLD.

Impact of solid organ transplant status on outcomes of hospitalized patients with COVID-19 infection.

BACKGROUND: The COVID-19 pandemic has caused significant morbidity and mortality in solid organ transplant (SOT) recipients. However, it remains unclear whether the risk factor for SOT patients is the immunosuppression inherent to transplantation versus patient comorbidities. METHODS: We reviewed outcomes in a cohort of SOT (n = 129) and non-SOT (NSOT) patients (n = 708) admitted to the University of California, Los Angeles for COVID-19 infection. Data analyses utilized multivariate logistic regression to evaluate the impact of patient demographics, comorbidities, and transplant status on outcomes. SOT patients were analyzed by kidney SOT (KSOT) versus nonkidney SOT (NKSOT) groups. RESULTS: SOT and NSOT patients with COVID-19 infection differed in terms of patient age, ethnicity, and comorbidities. NKSOT patients were the most likely to experience death, with a mortality rate of 16.2% compared with 1.8% for KSOT and 8.3% for NSOT patients (p = .013). Multivariable analysis of hospitalized patients revealed that patient age (odds ratio [OR] 2.79, p = .001) and neurologic condition (OR 2.66, p < .001) were significantly associated with mortality. Analysis of ICU patients revealed a 2.98-fold increased odds of death in NKSOT compared with NSOT patients (p = .013). CONCLUSIONS: This study demonstrates the importance of transplant status in predicting adverse clinical outcomes in patients hospitalized or admitted to the ICU with COVID-19, especially for NKSOT patients. Transplant status and comorbidities, including age, could be used to risk stratify patients with COVID-19. This data suggests that immunosuppression contributes to COVID-19 disease severity and mortality and may have implications for managing immunosuppression, especially for critically ill patients admitted to the ICU.

Hepatic Encephalopathy-Related Hospitalizations in Cirrhosis: Transition of Care and Closing the Revolving Door.

Cirrhosis is associated with substantial morbidity and mortality. Development of complications of cirrhosis, including hepatic encephalopathy (HE), portends poorer outcomes. HE is associated with hospital readmission, impaired patient and caregiver quality of life, risk of falls, and mortality. Guidelines recommend lactulose as first-line therapy for HE and rifaximin in combination with lactulose for reducing the risk of HE recurrence. Improving post-discharge outcomes, including readmissions, is an important aspect in the management of patients with HE. Approaches focused on improving management and prevention of HE, including properly titrating lactulose dosing, overcoming medication-related nonadherence, and incorporating rifaximin as therapy to reduce the risk of recurrence, as well as incorporating supportive care initiatives, may ease the transition from hospital to home. Strategies to decrease readmission rates include using hospital navigators, who can offer patient/caregiver education, post-discharge planning, and medication review; and involving pharmacists in post-discharge planning. Similarly, telemedicine offers providers the opportunity to monitor patients with HE remotely and improves outcomes. Providers offering transitional care management may be reimbursed when establishing contact with patients within 2 days post-discharge and conducting an outpatient visit within 7 days or 14 days. Several approaches have been shown to improve outcomes broadly in patients post-discharge and may also be effective for improving outcomes specifically in patients hospitalized with cirrhosis and HE, thus closing the revolving door on rehospitalizations in this population.

Autoimmune Hepatitis-Like Syndrome Following COVID-19 Vaccination: A Systematic Review of the Literature.

OBJECTIVES: During the summer of 2021, case reports began to emerge documenting a small number of individuals who developed autoimmune hepatitis (AIH) following COVID-19 vaccination. These cases are rare and novel, and very little is known. In our systematic review, we analyzed every published case of AIH and reviewed their characteristic findings, treatment, and outcomes. METHODS: We searched PubMed, Embase, and Web of Science from December 1, 2019, to November 1, 2021. Two researchers independently extracted information from the articles about vaccine type, patient history, laboratory values, histology results, treatment regimens, and disease course. RESULTS: Thirty-two patients developed AIH-like syndromes after receiving a COVID-19 vaccine. Jaundice was the most frequently reported symptom (81%), and 19% of patients were initially asymptomatic and presented with elevated liver enzymes found during routine bloodwork. Mean alanine transaminase, aspartate transaminase, and total bilirubin were 1231 U/L, 921 U/L, and 14 mg/dL, respectively. Anti-nuclear antibody was positive in 56%, and anti-smooth muscle antibody in 28% of patients. Steroids were used in 75% of patients. Improvement or complete resolution was seen in 97% of patients. One patient died despite aggressive steroid treatment. CONCLUSION: COVID-19 vaccine-induced AIH is an uncommon association with just 32 documented cases in the literature. Clinicians should be vigilant for AIH in patients who present with liver injury following vaccination. These new findings should under not deter individuals from getting vaccinated, as the benefits of vaccination far outweigh the risks. Fortunately, COVID-19 vaccine-induced AIH appears amendable to corticosteroid therapy and appears to have a favorable outcome.

Spontaneous Seroclearance Is Associated with Lower Liver Fibrosis in Treatment-Naïve Chronic Hepatitis B Patients.

BACKGROUND: Chronic hepatitis B virus (HBV) is a major public health concern. Transient elastrography (TE) is a reliable method in assessing hepatic fibrosis in patients with liver disease. We assess the potential clinical associations between HBsAg seroclearance and the severity of liver fibrosis. METHODS: We retrospectively performed a matched analysis of 23 consecutive HBsAg seroclearance patients who underwent TE between March 2008 and August 2021 from a community practice at a 1:3 ratio based on clinic visit date. Baseline laboratory and clinical data were collected. Fisher's exact test and Chi-square test for proportions, and Wilcoxon rank-sum test for median were performed. RESULTS: Twenty-three cases and 69 controls were identified. Median follow up (interquartile range) for the cases and controls was 24,314 (1402) and 2332 (1587) days (p = 0.15), respectively. All patients were Asian. Median age of cases was higher than controls (64 vs 52, p < 0.01, respectively). While most comorbidities were similar, diabetes and hyperlipidemia were more prevalent in cases. Baseline HBV DNA was detectable in 78% of cases and 97% of controls (p < 0.01). More cases had baseline HBsAg titers below 1000 IU/mL than controls (81% vs 8.7%, p < 0.01). Other baseline laboratory values were similar. Few cases had a fibrosis score greater than 1, while control had over a quarter of patients with a fibrosis score of 2 or 3. CONCLUSION: Spontaneous HBsAg seroclearance remains rare in patients with chronic HBV infection. It is associated with low baseline HBsAg, and lower level of liver fibrosis as detected by TE.

AL Lambda Amyloidosis Activates Acute Liver Failure in the Absence of Plasma Cell Dyscrasia.

A patient with systemic amyloidosis developed portal hypertension, acute liver failure and multiorgan dysfunction. Extensive testing was unrevealing for paraproteinemia, plasma cell dyscrasia, infectious, or inflammatory conditions. He was transferred to our institution for orthotopic liver transplant evaluation but was ultimately declined given clinical instability and dysautonomia. Post-mortem evaluation revealed extensive amyloid deposition in multiple organs determined to be AL-lambda amyloidosis.

Rural-Urban Geographical Disparities in Hepatocellular Carcinoma Incidence Among US Adults, 2004-2017.

INTRODUCTION: To evaluate impact of urbanicity and household income on hepatocellular carcinoma (HCC) incidence among US adults. METHODS: HCC incidence was evaluated by rural-urban geography and median annual household income using 2004-2017 Surveillance, Epidemiology, and End Results data. RESULTS: Although overall HCC incidence was highest in large metropolitan regions, average annual percent change in HCC incidence was greatest among more rural regions. Individuals in lower income categories had highest HCC incidence and greatest average annual percent change in HCC incidence. DISCUSSION: Disparities in HCC incidence by urbanicity and income likely reflect differences in risk factors, health-related behaviors, and barriers in access to healthcare services.

The Current Management of Hepatorenal Syndrome-Acute Kidney Injury in the United States and the Potential of Terlipressin.

Acute kidney injury (AKI) in the setting of cirrhosis (hepatorenal syndrome [HRS]-AKI) is a severe and often fatal complication of end-stage liver disease. The goals of treatment are to reverse renal failure and prolong survival in patients who are critically ill. However, interventions have limited efficacy, and mortality rates remain high. In the United States, the mainstay of pharmacologic therapy consists of the off-label use of vasoconstrictive agents in combination with plasma expanders, a strategy that produces modest effects. Liver transplantation is the ultimate solution but is only an option in a minority of patients because contraindications to transplantation are common and organ availability is limited. Renal replacement therapy is a temporary option but is known to confer an extremely poor short-term prognosis in patients with HRS-AKI and at best serves as a bridge to liver transplantation for the minority of patients who are transplantation candidates. The high mortality rate associated with HRS-AKI in the United States is a reflection of the suboptimal standard of care. Improved therapeutic options to treat HRS-AKI are sought. Terlipressin is a drug approved in Europe for treatment of HRS-AKI and supported by recommendations for first-line therapy by some liver societies and experts around the world. This review article will discuss the substantial unmet medical need associated with HRS-AKI and the potential benefits if terlipressin was approved in the United States.

Cost-effectiveness of Universal Hepatitis C Screening in Pregnant Women: A Systematic Review.

BACKGROUND: Hepatitis C virus (HCV) epidemiology has shifted from the baby-boomer generation to young women of childbearing age. The health benefits and cost-effectiveness (CE) of screening pregnant women remain controversial. AIM: To systematically review published studies evaluating the CE of screening pregnant women for HCV in the era of direct-acting antivirals (DAAs). MATERIALS AND METHODS: We conducted a systematic literature search of CE studies evaluating the costs and benefits of screening pregnant women for HCV. Pertinent information including antiviral agent, drug costs, incremental cost-effective ratio (ICER), and infant care was collected. The authors' definition of the threshold price at which screening was deemed CE was also recorded. The quality of studies was assessed using the Consolidated Health Economic Evaluation Reports Standards (CHEERS) checklist. RESULTS: We identified 5 studies that evaluated the ICER of screening pregnant women for HCV. Of these, 2 utilized all oral DAAs, with universal screening CE. The ICER of these 2 studies was $3000 and $41,000 per quality of life-years gained. The remaining studies were interferon-based regimens. Most studies did not include screening of infants. CONCLUSIONS: Universally screening pregnant women for HCV was CE in studies that utilized oral DAAs. Most pharmacoeconomic studies failed to incorporate the impact of vertical transmission on infants.

Older Patients With Hepatocellular Carcinoma Are Less Knowledgeable About Survivorship Issues: Outcomes from a Survey-based Study.

BACKGROUND AND AIMS: As the incidence and survival for hepatocellular carcinoma increase, the number of patients having been treated for liver cancer would be expected to increase as well. Little is known about the experience of the survivors of hepatocellular carcinoma. METHODS: The authors conducted a 3-tool survey of hepatocellular carcinoma survivors at a large, academic, and tertiary referral medical center to assess potential areas of disparities in the survivorship experience. The instruments aimed to assess knowledge of survivorship issues (Perceived Efficacy in Patient-Physician Interactions Questionnaire-1), preparedness for the survivorship experience (Perceived Efficacy in Patient-Physician Interactions Questionnaire-2), and self-efficacy in procuring medical information while navigating the patient-provider relationship (Perceived Efficacy in Patient-Physician Interactions Questionnaire). The authors compared mean test scores for each instrument, with higher scores indicating a more positive response, by patient characteristics and used s linear regression model to examine associations between sociodemographics and survey scores. RESULTS: In total, 110 patients took at least 1 survey. In the multiple linear regression model, the authors found that for every increase in patient age by 10 years, knowledge of survivorship issues decreased by a total score of 1.3 (P=0.02). In this model, the authors found no significant differences between male and female respondents, English and non-English speakers, and liver transplant recipients and nonliver transplant recipients. Survivors who had completed a 4-year college degree had significantly higher knowledge of survivorship issues than those who did not use χ testing, but this finding did not maintain significance in the multiple linear regression model. CONCLUSIONS: In a population of 110 ethnically diverse hepatocellular carcinoma survivors, the authors found older patients had gaps in knowledge of survivorship issues. Particular attention should be paid to older populations during liver cancer treatment.

Disparities in Mortality and Health Care Utilization for 460,851 Hospitalized Patients with Cirrhosis and Hepatic Encephalopathy.

BACKGROUND AND AIMS: Hepatic encephalopathy (HE) is a common cause of hospitalizations and readmissions for patients with decompensated cirrhosis. In this study, we proposed to investigate recent trends in in-hospital mortality and utilization for patients with cirrhosis and HE and to explore the effect of various sociodemographic, hospital, and clinical factors on mortality. METHODS: We performed an observational study using serial cross-sectional data from the 2009-2013 National Inpatient Sample to examine hospitalizations of patients with cirrhosis and HE. We collected data on in-hospital mortality, length of stay, and total hospital costs. We used negative binomial regression and logistic regression to investigate trends in utilization and multilevel modeling to examine the association between sociodemographic, hospital, and clinical factors and in-hospital mortality. RESULTS: The annual total number of hospitalizations from HE has steadily risen from 75,475 in 2009 to 106,915 in 2013 (P < 0.001). Annual in-hospital mortality (11.9-10.2%, P < 0.001) and length of stay (7.5-7.1 days, P = 0.015) have significantly decreased over this timeframe. The presence of septicemia, GI bleeding, and being uninsured were associated with 29.6%, 16.7%, and 15.7% of in-hospital death, respectively. Patients hospitalized in the South, Medicare beneficiaries, and patients hospitalized in the Midwest had a 9.8%, 9.2%, and 8.9% chance of dying in the hospital. CONCLUSION: The number of hospitalizations from HE has increased while in-hospital mortality has concomitantly decreased from 2009 to 2013. Both traditional risk factors (sepsis and GI bleeding) strongly influence the probability of in-hospital death. However, disparities in mortality by sociodemographic factors (insurance status and geography) also exist.

Frailty Does Not Impact Caregiver Burden in Patients with Cirrhosis.

BACKGROUND: Frailty is common and is associated with increased mortality, lower quality of life, and higher readmission rates in cirrhotic patients. Not only are these outcomes important, but further understanding the impact of frailty on a caregiver's life is crucial to better comprehend caregiver burden in cirrhotic patients and develop strategies to improve care for patients and their caregivers. METHODS: A single-center, prospective study was conducted of cirrhotic patients and their caregivers between 4/1/2019 and 11/1/2019. Frailty testing combined aspects from the Fried Frailty Instrument, Short Physical Performance Battery, and activities of daily living. Caregivers completed questionnaires to evaluate caregiver burden using the Zarit Burden Interview (ZBI-12), and perceived social support, using the Interpersonal Support Evaluation List. RESULTS: In total, 94 cirrhotic patients were included, 50% males with a median age of 63.1 years. The most common etiology of cirrhosis was nonalcoholic steatohepatitis. Frailty was prevalent (45.1%). In total, 12.8% of caregivers reported a high burden based on ZBI-12. There was no association between frailty and caregiver burden, hospitalization rates, or death. However, frailty was associated with a higher number of outpatient GI visits (p = 0.002). Lower perceived social support among caregivers was associated with a higher caregiver burden (p < 0.0001). CONCLUSION: Frailty is prevalent in cirrhotic patients but is not associated with higher rates of caregiver burden. Low perceived social support among caregivers, however, was associated with higher caregiver burden. It is important to recognize the impact of caregiver burden on caregivers of cirrhotic patients and ensure caregivers have the appropriate support to mitigate burden.