Surging Liver Transplantation for Nonalcoholic Steatohepatitis from 2000-2022: A National Database Study.

OBJECTIVES: Our aim was to provide an up-to-date, large-scale overview of the trends and clinicodemographics for NASH LTs performed in the United States compared with all other LT indications between 2000 and 2022. We also examined the demographic factors that will predict future demand for NASH LT. METHODS: Our analysis of NASH LT from the Organ Procurement & Transplantation Network database spanning 2000-2022 consisted primarily of descriptive statistics and hypothesis testing with corrections for multiple testing when necessary. Trend lines and linear correlations were also explored. RESULTS: NASH LTs have experienced a remarkable surge, escalating from 0.12% of all LTs in 2000 to a substantial 14.7% in 2022, marking a 100-fold increase. Examining demographic trends, a significant proportion of NASH LTs recipients fall within the 50- to 64-year-old age group. Moreover, 52% of these recipients concurrently exhibit type 2 diabetes mellitus, a notably higher percentage than the 19% observed in all LT recipients. Type 2 diabetes mellitus emerges as a prominent risk factor for NASH progressing to end-stage liver disease. The phenomenon of repeat transplantation is noteworthy; although 6% of all LTs necessitate repeat procedures, this figure dramatically drops to 0.6% for NASH LTs. Ethnic disparities are apparent, with African Americans representing a mere 2% of NASH LT recipients, significantly lower than their representation in the overall population. Regionally, the East Coast has a higher proportion of NASH LT recipients compared with waitlist additions. This trend holds true across demographics. CONCLUSIONS: Our findings underscore the need for increased resources, particularly for minority, uninsured, or noncitizen individuals requiring LT for NASH. This analysis provides valuable insights into the dynamic landscape of LTs in the context of NASH, shaping the trajectory of medical interventions in the 21st century.

Methodology and baseline characteristics of a randomized controlled trial testing a health care professional and peer-support program for patients with chronic obstructive pulmonary disease: The BREATHE2 study.

BACKGROUND: Self-management support (SMS) for patients with COPD can improve health-related quality of life (HRQOL). However, it remains unclear what SMS strategies are most effective. Using peer support to advance self-management is promising, as peer supporters possess credibility and can serve as role models. METHODS: We conducted a single-blinded RCT comparing the effectiveness of two strategies to support patients with COPD. The strategies were 'Health Care Professional (HCP)' and 'HCP Plus Peer' support. Peer support was provided by patients with COPD who have stopped smoking, completed an acute pulmonary rehabilitation program, and met the requirements for becoming a peer supporter. We enrolled patients receiving treatment at inpatient and outpatient settings. Patients were encouraged to invite one family-caregiver to enroll with them. The primary outcome measure was the change in HRQOL at 6 months post enrollment. Secondary outcomes included COPD-related and all-cause hospitalizations and ED visits. Caregiver outcomes included preparedness for caregiving, caregiver stress, and coping. RESULTS: A total of 292 patients as well as 50 family-caregivers were enrolled. The average patient age was 67.3 yrs. (SD 9.4), 61% were female and 26% were African-Americans. The majority of caregivers were females (68%) and were a spouse/partner (58%). DISCUSSION: This study tested a dual strategy for providing support to patients with COPD that incorporates peer and health care professional support. The study had minimal exclusion criteria. If shown effective, the study offers a program of peer support that can be readily implemented in health care settings.

Accuracy of Milan, University of California San Francisco, and Up-To-7 Criteria in Predicting Tumor Recurrence Following Deceased-Donor Liver Transplant in Patients With Hepatocellular Carcinoma.

OBJECTIVES: We aimed to investigate the accuracy of the Milan, University of California San Francisco, and Up-to-7 criteria in predicting tumor recurrence after liver transplant for hepatocellular carcinoma. MATERIALS AND METHODS: For this study, 165 patients with deceased-donor liver transplant for hepatocellular carcinoma were evaluated. The Milan, University of California San Francisco, and Up-to-7 criteria were calculated based on explant pathology. RESULTS: Tumor recurrence rate after liver transplant was 14.6%. Of 165 patients, 115 (70%) were within Milan, 131 (79%) were within University of California San Francisco, and 135 (82%) were within Up-to-7 criteria. The odds ratio of tumor recurrence in patients outside versus within criteria for Milan, University of California San Francisco, and Up-to-7 was 3.6 (95% confidence interval, 1.5-9.1; P = .005), 7.5 (95% confidence interval, 2.5-19.3; P < .001), and 7.5 (95% confidence interval, 2.9-19.6; P < .001) times higher, respectively. The sensitivity of being outside of Milan in predicting tumor recurrence was comparable to University of California San Francisco and Up-to-7 criteria (56.5%, 56.5%, and 52.2%, respectively). Specificity was highest in Up-to-7 (87.3%) versus 85.2% for University of California San Francisco and 73.9% for Milan criteria. The area under the curve for Milan, University of California San Francisco, and Up-to-7 criteria was 0.63, 0.65, and 0.63. CONCLUSIONS: Application of standard criteria has significantly improved prediction of hepatocellular carcinoma recurrence. However, these criteria are inadequate, supporting the importance of other factors, including tumor biology. Research is ongoing in discovering novel biomarkers as predictors of tumor recurrence.

Higher odds of irritable bowel syndrome among hospitalized patients using cannabis: a propensity-matched analysis.

BACKGROUND: The endogenous cannabinoid system modulates many brain-gut and gut-brain physiologic pathways, which are postulated to be dysfunctional in irritable bowel syndrome (IBS). Herein, we examine the relationship between cannabis use disorder (CUD) and having IBS. PATIENTS AND METHODS: After selecting patients aged 18 years and above from the 2014 Nationwide Inpatient Survey, we used the International Classification of Diseases, 9th ed. codes to identify individuals with CUD, IBS, and the established risk factors for IBS. We then estimated the crude and adjusted odds ratios of having a diagnosis of IBS with CUD and assessed for the interactions of CUD with other risk factors (SAS 9.4). We confirmed our findings in two ways: conducting a similar analysis on a previous Nationwide Inpatient Survey data (2012); and using a greedy algorithm to design a propensity-scored case-control (1 : 10) study, approximating a pseudorandomized clinical trial. RESULTS: Out of 4 709 043 patients evaluated, 0.03% had a primary admission for IBS and 1.32% had CUD. CUD was associated with increased odds of IBS [adjusted odds ratio: 2.03; 95% confidence interval (CI): 1.53-2.71]. CUD was related to higher odds for IBS among males compared with females (3.48; 1.98-6.12 vs. 1.48; 0.88-2.50), and Hispanics and Caucasians compared with Blacks (5.28; 1.77-15.76, 1.80; 1.02-3.18 vs. 1.80; 0.65-5.03). On propensity-matching, CUD was associated with 80% increased odds for IBS (1.82; 1.27-2.60). CONCLUSION: Our findings suggest that CUD is significantly associated with IBS among the general population. Males, Caucasians, and Hispanics might be more impacted by CUD associated IBS. Additional biomedical studies are required to elucidate this relationship.

Endoscopic sleeve gastroplasty versus laparoscopic sleeve gastrectomy: a case-matched study.

BACKGROUND AND AIMS: Endoscopic sleeve gastroplasty (ESG) reduces the gastric lumen to a size comparable with that of laparoscopic sleeve gastrectomy (LSG). However, there is a paucity of research comparing outcomes between the 2 procedures. Our study compared the 6-month weight loss outcomes and adverse events of ESG with LSG in a case-matched cohort. METHODS: We retrospectively reviewed prospectively collected data for patients undergoing ESG or LSG at a single academic center. Weight was recorded at 1 and 6 months postprocedure, and percent total body weight loss (%TBWL) was calculated. Adverse events and new-onset Gastroesophageal Reflux Disease (GERD) were also recorded. RESULTS: A total of 54 ESG patients were matched with 83 LSG patients by age, sex, and body mass index. The proportion of patients with GERD at baseline was similar in the 2 groups (16.7% in ESG group vs 25.3% in LSG group, P = .27). At the 6-month follow-up, %TBWL (compared with baseline) was significantly lower in the ESG group compared with the LSG group (17.1% ± 6.5% vs 23.6% ± 7.6%, P < .01). ESG patients had significantly lower rates of adverse events compared with LSG patients (5.2% vs 16.9%, P < .05). New-onset GERD was also significantly lower in the ESG group compared with the LSG group (1.9% vs 14.5%, P < .05). CONCLUSIONS: ESG, a minimally invasive same-day procedure, achieved less weight loss at 6 months than LSG, with the caveat that LSG caused more adverse events and new-onset GERD than ESG.

Role of nucleoside/nucleotide analogues and low-dose hepatitis B immune globülin in prophylaxis of hepatitis B recurrence among cadaveric liver transplant recipients.

BACKGROUND/AIMS: Hepatitis B core antibody (HBcAb) positivity of the donor or the recipient may pose a risk of hepatitis B virus (HBV) reactivation following liver transplantation (LT). We retrospectively investigated patient survival and reactivation among recipients who were given low-dose Hepatitis B Immune Globulin (HBIG) plus antiviral agent (AV) versus AV only. MATERIALS AND METHODS: Records of cadaveric LT recipients, between 2013 and 2016, with positive Hepatitis B surface Antigen (HBsAg) and/or HBcAb and recipients who had received LT from HBcAb-positive donors were reviewed. Patient characteristics and clinical data were extracted. Donor variables were retrieved from the United Network of Organ Sharing (UNOS) database. HBIG (1560 IU/mL) Intravenous (IV) was intraoperatively administered with three daily doses. Entecavir 1 mg daily was also given. STATA was used for statistical analysis. RESULTS: There were 53 recipients; 39 (73.6%) were male with a median age of 59 y. HCV was the major indication in 30 (55.6%) patients. There were 28 recipients (52.8%) who received HBIG plus AV and 25 (47.2%) received AV only. The Model of End Stage Liver Disease (MELD) score between the groups were similar. Survival rates at 6, 12, and 24 months were 100% (n=53), 93.2% (n=44), and 100.0% (n=26), respectively. There was no reactivation; two recipients in the AV group and one in the HBIG plus AV group died within 12 months. CONCLUSION: This study supports the use of low-dose HBIG and AV for post-LT prophylaxis to be as effective as conventionally used high-dose HBIG (9600 IU) plus AV. Future prospective larger studies are warranted to examine the potential benefits of using AV alone without HBIG.

Cannabis use is associated with reduced prevalence of progressive stages of alcoholic liver disease.

BACKGROUND: Abusive alcohol use has well-established health risks including causing liver disease (ALD) characterized by alcoholic steatosis (AS), steatohepatitis (AH), fibrosis, cirrhosis (AC) and hepatocellular carcinoma (HCC). Strikingly, a significant number of individuals who abuse alcohol also use Cannabis, which has seen increased legalization globally. While cannabis has demonstrated anti-inflammatory properties, its combined use with alcohol and the development of liver disease remain unclear. AIM: The aim of this study was to determine the effects of cannabis use on the incidence of liver disease in individuals who abuse alcohol. METHODS: We analysed the 2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (NIS) discharge records of patients 18 years and older, who had a past or current history of abusive alcohol use (n = 319 514). Using the International Classification of Disease, Ninth Edition codes, we studied the four distinct phases of progressive ALD with respect to three cannabis exposure groups: non-cannabis users (90.39%), non-dependent cannabis users (8.26%) and dependent cannabis users (1.36%). We accounted for the complex survey sampling methodology and estimated the adjusted odds ratio (AOR) for developing AS, AH, AC and HCC with respect to cannabis use (SAS 9.4). RESULTS: Our study revealed that among alcohol users, individuals who additionally use cannabis (dependent and non-dependent cannabis use) showed significantly lower odds of developing AS, AH, AC and HCC (AOR: 0.55 [0.48-0.64], 0.57 [0.53-0.61], 0.45 [0.43-0.48] and 0.62 [0.51-0.76]). Furthermore, dependent users had significantly lower odds than non-dependent users for developing liver disease. CONCLUSIONS: Our findings suggest that cannabis use is associated with a reduced incidence of liver disease in alcoholics.

Direct-Acting Antiviral Therapy for Chronic HCV Infection Results in Liver Stiffness Regression Over 12 Months Post-treatment.

BACKGROUND: Liver fibrosis stage determines risk of morbidity and mortality from chronic hepatitis C virus (HCV) infection. Prior data have shown long-term reversal of liver fibrosis, measured by vibration-controlled transient elastography (VCTE), in patients successfully treated with interferon-based therapies. AIM: Our study sought to determine the effect of treatment with modern HCV direct-acting antiviral (DAA) therapy on noninvasive liver fibrosis measurements. METHODS: A total of 70 patients had VCTE-based liver stiffness measurement (LSM) taken before treatment, directly after treatment completion, and at least 12 months after completion of DAA therapy. Our primary outcome was a >30% improvement in VCTE score at the end of follow-up, relative to baseline. RESULTS: The sustained virologic response rate in our cohort was 95.7%. In our cohort, 34 (48.6%) met the primary outcome. Those who had baseline elevated alanine aminotransferase (OR 3.27; 95% CI 1.13-9.47) and genotype 1 (OR 14.63; 95% CI 1.70-125.83) had higher odds of meeting that outcome, and this remained significant after adjusting for age, baseline body mass index, gender, baseline elevated alkaline phosphatase levels, treatment experience, liver transplant status, smoking, and baseline liver stiffness. CONCLUSION: Treatment of chronic HCV with modern DAA therapy was associated with a significant improvement in LSM by VCTE measurement, suggesting possible early improvement in liver fibrosis along with resolution of inflammation over the first year after treatment completion.

Active 46-year-old man with right-sided visual loss and no family history of stroke · Dx?

A 46-year-old man presented to the emergency department with sudden-onset right-sided visual loss. He had a history of asthma, but no family history of hypercoagulability, deep vein thrombosis, or stroke. The patient had an active lifestyle that included scuba diving, mountain biking, and hockey (coaching and playing). The physical examination revealed a right homonymous upper quadrantanopia. The neurologic examination was within normal limits, except for the visual deficit and unequal pupil size. A computerized tomography scan of the patient's head did not reveal any lesions.

Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case-control study.

Background and study aims The variables associated with gastroesophageal reflux (GER) after peroral endoscopic myotomy (POEM) are largely unknown. This study aimed to: 1) identify the prevalence of reflux esophagitis and asymptomatic GER in patients who underwent POEM, and 2) evaluate patient and intraprocedural variables associated with post-POEM GER. Patients and methods All patients who underwent POEM and subsequent objective testing for GER (pH study with or without upper gastrointestinal [GI] endoscopy) at seven tertiary academic centers (one Asian, two US, four European) were included. Patients were divided into two groups: 1) DeMeester score ≥ 14.72 (cases) and 2) DeMeester score of < 14.72 (controls). Asymptomatic GER was defined as a patient with a DeMeester score ≥ 14.72 who was not consuming proton pump inhibitor (PPI). Results A total of 282 patients (female 48.2 %, Caucasian 84.8 %; mean body mass index 24.1 kg/m2) were included. Clinical success was achieved in 94.3 % of patients. GER evaluation was completed after a median follow-up of 12 months (interquartile range 10 - 24 months). A DeMeester score of ≥ 14.72 was seen in 57.8 % of patients. Multivariable analysis revealed female sex to be the only independent association (odds ratio 1.69, 95 % confidence interval 1.04 - 2.74) with post-POEM GER. No intraprocedural variables were associated with GER. Upper GI endoscopy was available in 233 patients, 54 (23.2 %) of whom were noted to have reflux esophagitis (majority Los Angeles Grade A or B). GER was asymptomatic in 60.1 %. Conclusion Post-POEM GER was seen in the majority of patients. No intraprocedural variables were identified to allow for potential alteration in procedural technique.

Cannabis use is associated with reduced prevalence of non-alcoholic fatty liver disease: A cross-sectional study.

Cannabis use is associated with reduced prevalence of obesity and diabetes mellitus (DM) in humans and mouse disease models. Obesity and DM are a well-established independent risk factor for non-alcoholic fatty liver disease (NAFLD), the most prevalent liver disease globally. The effects of cannabis use on NAFLD prevalence in humans remains ill-defined. Our objective is to determine the relationship between cannabis use and the prevalence of NAFLD in humans. We conducted a population-based case-control study of 5,950,391 patients using the 2014 Healthcare Cost and Utilization Project (HCUP), Nationwide Inpatient Survey (NIS) discharge records of patients 18 years and older. After identifying patients with NAFLD (1% of all patients), we next identified three exposure groups: non-cannabis users (98.04%), non-dependent cannabis users (1.74%), and dependent cannabis users (0.22%). We adjusted for potential demographics and patient related confounders and used multivariate logistic regression (SAS 9.4) to determine the odds of developing NAFLD with respects to cannabis use. Our findings revealed that cannabis users (dependent and non-dependent) showed significantly lower NAFLD prevalence compared to non-users (AOR: 0.82[0.76-0.88]; p<0.0001). The prevalence of NAFLD was 15% lower in non-dependent users (AOR: 0.85[0.79-0.92]; p<0.0001) and 52% lower in dependent users (AOR: 0.49[0.36-0.65]; p<0.0001). Among cannabis users, dependent patients had 43% significantly lower prevalence of NAFLD compared to non-dependent patients (AOR: 0.57[0.42-0.77]; p<0.0001). Our observations suggest that cannabis use is associated with lower prevalence of NAFLD in patients. These novel findings suggest additional molecular mechanistic studies to explore the potential role of cannabis use in NAFLD development.

Cardiac Arrest and Gastrointestinal Bleeding: A Case of Medical Heuristics.

Insufficient clinical data from patients is a major cause of errors in medical diagnostics. In an attempt to make a diagnosis, initial clinical information provided to the physician may be overly relied on as the only information required in making diagnosis leading to anchoring. Failure to rely on differential diagnoses in spite of new signs and symptoms or rethinking of initial hypothesis may lead to fixation on a certain diagnosis, which may lead to significant morbidity and mortality. In the event that there is an anchoring heuristic, like in our patient, it is important to consider differential diagnoses; however, it is not wrong to rely on some form of anchor. We report a case of a 62-year-old male with a history of multiple medical conditions and a history of acetaminophen overdose who presented to the hospital with large amounts of coffee ground emesis. He was subsequently transferred to the liver transplant center on discovery that he was in fulminant hepatic failure and died two days later in spite of aggressive medical treatment.

Allergic reaction to polysulphone membrane dialyser masquerading as infection.

Hypersensitivity reactions during haemodialysis are well documented in the literature. Most dialysis membrane reactions occur with ethylene oxide or non-biocompatible membranes and less frequently with biocompatible membranes. The symptoms are non-specific except for the temporal relationship typically occurring during the haemodialysis. Patients who present with the non-classic type of reaction pose a diagnostic challenge and clinicians must have a high index of suspicion. We present a non-classic presentation of a hypersensitivity reaction to a polysulfone membrane dialyser with recurrent fevers during and after haemodialysis, initially thought to be due to infection. After a series of negative work ups for infection, dialysis membrane reaction was considered and the patient improved after change of the membrane.

Host genetics predict clinical deterioration in HCV-related cirrhosis.

Single nucleotide polymorphisms (SNPs) in the epidermal growth factor (EGF, rs4444903), patatin-like phospholipase domain-containing protein 3 (PNPLA3, rs738409) genes, and near the interleukin-28B (IL28B, rs12979860) gene are linked to treatment response, fibrosis, and hepatocellular carcinoma (HCC) in chronic hepatitis C. Whether these SNPs independently or in combination predict clinical deterioration in hepatitis C virus (HCV)-related cirrhosis is unknown. We genotyped SNPs in EGF, PNPLA3, and IL28B from liver tissue from 169 patients with biopsy-proven HCV cirrhosis. We estimated risk of clinical deterioration, defined as development of ascites, encephalopathy, variceal hemorrhage, HCC, or liver-related death using Cox proportional hazards modeling. During a median follow-up of 6.6 years, 66 of 169 patients experienced clinical deterioration. EGF non-AA, PNPLA3 non-CC, and IL28B non-CC genotypes were each associated with increased risk of clinical deterioration in age, sex, and race-adjusted analysis. Only EGF non-AA genotype was independently associated with increased risk of clinical deterioration (hazard ratio [HR] 2.87; 95% confidence interval [CI] 1.31-6.25) after additionally adjusting for bilirubin, albumin, and platelets. Compared to subjects who had 0-1 unfavorable genotypes, the HR for clinical deterioration was 1.79 (95%CI 0.96-3.35) for 2 unfavorable genotypes and 4.03 (95%CI 2.13-7.62) for unfavorable genotypes for all three loci (Ptrend<0.0001). In conclusion, among HCV cirrhotics, EGF non-AA genotype is independently associated with increased risk for clinical deterioration. Specific PNPLA3 and IL28B genotypes also appear to be associated with clinical deterioration. These SNPs have potential to identify patients with HCV-related cirrhosis who require more intensive monitoring for decompensation or future therapies preventing disease progression.

Streptococcus viridians bacteraemia and colonic adenocarcinoma.

Even though Streptococcus bacteraemia is an infrequent presentation of colonic malignancies, there is a well-established link between Streptococcus bovis bacteraemia and colonic malignancies. Most of the physicians are well aware of this correlation and further workup is pursued in most of the cases. However, many physicians may not be aware that other species of Streptococcus viridians, other than S. bovis, can be associated with colonic malignancies. In this case report, we present a case of Streptococcus viridians (anginosus) bacteraemia as a complication of an undiagnosed sigmoid adenocarcinoma. While further evidence is needed to warrant a gastrointestinal (GI) workup in a patient with other species of Streptococcus viridians bacteraemia, we would like to increase the awareness in the physicians' community regarding Streptococcus viridians, other than S. bovis bacteraemia. This would be especially relevant for patients who have no GI screening, as Streptococcus viridians bacteraemia can be an early sign of colonic neoplasm.