History Of Liver Cirrhosis Research Articles

Relationship between STAP1 methylation in peripheral blood T cells and the clinicopathological characteristics and prognosis of patients within 5-cm diameter HCC.

The aim of this study is to explore the methylation of signal transduction adaptor protein 1 (STAP1) in peripheral blood T cells as a prognostic marker for hepatocellular carcinoma (HCC) ≤5 cm. A total of 66 HCC patients who visited our hospital from November 2012 to June 2016 were retrospectively analyzed, and 55 patients who met the inclusion and exclusion criteria were studied. Clinical and pathological data were collected from all patients to detect STAP1 methylation. STAP1 methylation expression was analyzed in HCC patients ≤5 cm with different clinicopathological features; univariate and independent prognostic factors were analyzed in HCC patients; and the relationship between STAP1 methylation expression and prognosis was analyzed in HCC patients. There was no significant difference in STAP1 methylation expression between patients with different gender, age, history of alcoholism, history of liver cirrhosis, recurrence, 3-year OS, 5-year OS, treatment, number of tumors, tumor diameter, HBV-DNA, HBSAg, Hbe-Ag expression, and AFP level (P>0.05); however, there was significant difference in STAP1 methylation expression between patients with different survival, 3-year DFS, and 5-year DFS (P<0.05). Multivariate Cox regression analysis showed that recurrence and STAP1 methylation were independent factors for OS and DFS (P<0.05). Kaplan-Meier survival curve results showed that the median survival time, OS, and DFS of STAP1 hypermethylation expression were shorter than those of hypomethylation (P<0.05). STAP1 methylation in peripheral blood T cells serves as a potential prognostic marker for HCC ≤5 cm.

Acute hearing and visual loss caused by thiamine deficiency

BackgroundWernicke encephalopathy (WE) is a devastating acute or subacute neurological disorder caused by thiamine deficiency. Wernicke encephalopathy is characterized by the triad of ocular signs, cerebellar dysfunction, and confusion. Visual loss and hearing loss are less common findings in WE. Here, we report a case of Wernicke encephalopathy in a nonalcoholic liver cirrhosis patient who presented with acute bilateral deafness and bilateral blindness.Case presentationA 60-year-old Chinese man presented with a history of bilateral blindness and bilateral hypoacousia for 3 days. He had a history of liver cirrhosis and chronic hepatitis C virus infection and did not have a habit of alcohol consumption. Ophthalmologic and otologic examinations showed no obvious abnormalities. MRI findings revealed symmetric fluid-attenuated inversion recovery (FLAIR) hyperintensities in the bilateral medial dorsal thalamus, periventricular region around the third ventricle and tectum, and dorsal medulla oblongata. One day after hospitalization, the patient developed a mild coma. Based on the laboratory and neuroimaging findings, we diagnosed the patient with Wernicke encephalopathy. He soon regained consciousness after administration of thiamine. Both his visual acuity and his hearing function improved gradually.ConclusionsWe suggest that Wernicke encephalopathy can present with bilateral blindness and bilateral deafness.

Previous antithrombotic therapy does not have an impact on the in-hospital mortality of patients with upper gastrointestinal bleeding.

The association between antithrombotics (ATs) and the risk of gastrointestinal bleeding is well known; however, data regarding the influence of ATs on outcomes are scarce. The goals of this study are: (i) to assess the impact of prior AT therapy on in-hospital and 6-month outcomes and (ii) to determine the re-initiation rate of the ATs after a bleeding event. All patients with upper gastrointestinal bleeding (UGB) who underwent urgent gastroscopy in three centres from 1 January 2019 to 31 December 2019 were retrospectively analysed. Propensity score matching (PSM) was used. Among 333 patients [60% males, mean age 69.2 (±17.3) years], 44% were receiving ATs. In multivariate logistic regression, no association between AT treatment and worse in-hospital outcomes was observed. Development of haemorrhagic shock led to worse survival [odds ratio (OR) 4.4, 95% confidence interval (CI) 1.9-10.2, P < 0.001; after PSM: OR 5.3, 95% CI 1.8-15.7, P = 0.003]. During 6-months follow-up, higher age (OR 1.0, 95% CI 1.0-1.1, P = 0.002), higher comorbidity (OR 1.4, 95% CI 1.2-1.7, P < 0.001), a history of cancer (OR 3.6, 95% CI 1.6-8.1, P < 0.001) and a history of liver cirrhosis (OR 2.2, 95% CI 1.0-4.4, P = 0.029) were associated with higher mortality. After a bleeding episode, ATs were adequately re-initiated in 73.8%. Previous AT therapy does not worsen in-hospital outcomes in after UGB. Development of haemorrhagic shock predicted poor prognosis. Higher 6-month mortality was observed in older patients, patients with more comorbidities, with liver cirrhosis and cancer.

Injection Sclerotherapy vs Rubber Band Ligation in the Management of Patients with 2nd Degree Haemorrhoids

Objective: To compare the efficacy of injection sclerotherapy and rubber band ligation in patients with 2nd degree haemorrhoids. Study design &amp; Setting: Prospective Observational study was conducted in PNS Shifa Karachi from 1st July 2018 to 31st March 2019. Methodology: A total of 240 patients of both genders, known cases of 2nd degree haemorrhoids were included in the study. Patients with a known history of liver cirrhosis, previous history of haemorrhoidectomy, severe anaemia uncontrolled hypertension and patient requiring additional intervention post-procedure were excluded. Patients were randomized to either the injection sclerotherapy Group A or rubber band ligation Group B by lottery method. Final assessment was done at 6-months post-procedure regarding the effect of treatment on rectal bleeding. Results: The age range in this study was from 18 to 65 years with a m e a n of 36.641±7.00 years in Group A while 35.700± 5.65 years in Group B. Mean BMI was 26.525±1.54 Kg/m2 in Group A and 26.316±1.48 Kg/m2 in Group B and duration of disease was 7.466±2. 15 months in Group A and 7.883±1.78 months in Group B. Efficacy was seen in 87.5% patients in Group A as compared to 98.3% in Group B (p=0.001). Conclusion: Rubber band ligation is more efficacious in the management of 2nd-degree haemorrhoids in terms of perrectal bleeding from 3rd-week to 6 months post-application.

Sonographische Differenzialdiagnostik fokaler Leberläsionen

Rapid diagnostic assessment is crucial for the clinical management of focal liver lesions. In addition to standard B‑mode sonography, color-coded Doppler sonography and contrast-enhanced ultrasound are widely used for the classification of liver tumors. In gastroenterology, clinical sonography plays an important role in the detection of tumors, in the follow-up of oncological patients and for the screening for hepatocellular carcinoma. Thereby, correctly classifying focal liver lesions essentially requires the interpretation of ultrasound findings in the clinical context (e.g., incidental finding, known risk factors, history of liver cirrhosis or malignant disease). In this review, we summarize the available ultrasound techniques for the characterization of focal liver lesions and discuss their importance and relevance for the differential diagnosis and further diagnostic and therapeutic management.

EUS-guided biliary drainage in a patient after postcholecystectomy complete biliary transection (with video).

Biliary injury occurs after cholecystectomy in 0.3%–2.7% of patients.[1] Minor injuries can be managed endoscopically, whereas major injuries generally require surgical reconstruction.[2] However, due to the development of EUS-guided biliary drainage (EUS-BD) techniques, endoscopic minimally invasive treatment may be applied even for major injuries. Here, we describe a case of postcholecystectomy complete biliary transection managed endoscopically using the EUS-BD technique. An 85-year-old man was referred to our hospital for the treatment of severe cholecystitis. He was a bedridden patient with a history of liver cirrhosis and normal-pressure hydrocephalus. We performed subtotal cholecystectomy instead of total cholecystectomy due to severe adhesions and intraoperative bleeding. After the surgery, continuous biliary leakage occurred. Computed tomography showed a small amount of perihepatic ascites. The hilar bile duct was obscured, but the intrahepatic bile ducts were not dilated [Figure 1a and b]. We attempted endoscopic biliary stenting via ERCP to relieve the biliary pressure. However, we abandoned this approach because cholangiography revealed common bile duct disruption [Figure 2]. Magnetic resonance cholangiopancreatography also revealed complete transection of the common bile duct [Figure 3]. We decided to try endoscopic biliary stenting via EUS-BD because we considered that reoperation for this patient might lead to a poor result [Video 1]. The transected hilar duct was punctured from the duodenum because the B2 and B3 branches were not dilated. Cholangiography showed biliary leakage from the B6 branch. A plastic stent (TYPE-IT stent; Gadelius Medical Co., Ltd., Tokyo, Japan) was placed from the hilar bile duct to the duodenum. No procedure-related complications occurred, and biliary leakage was resolved.Figure 1: Computed tomography showing a small amount of perihepatic ascites. The hilar bile duct is obscured (arrow). The intrahepatic bile ducts are not dilated. (a) Axial view. (b) Coronal viewFigure 2: Cholangiography showing common bile duct disruptionFigure 3: Magnetic resonance cholangiopancreatography showings complete transection of the common bile duct (arrows)Surgical reconstruction for biliary injury was associated with a high morbidity rate of 20%–31%.[2] Endoscopic biliary stenting via EUS-BD can serve as a minimally invasive treatment option for patients with poor general conditions. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Comorbidities Associated with Early Mortality after CD19 CAR-T Cell Therapy

Objective: CD19 chimeric antigen receptor (CAR) T-cell therapy has changed the standard for treatment of relapsed and/or refractory (r/r) large b-cell lymphoma (LBCL). Currently, pre-treatment evaluation of patients and disease factors do not accurately predict outcomes. This study aims to identify risk factors associated with early mortality prior to day 100 after CAR-T infusion. Methods: We performed a single-centered retrospective adult patients (pts) with r/r LBCL who received CAR-T cell therapy between 2018-2021. CAR-T cell toxicities graded according to either CAR T-Cell Therapy-Associated Toxicity (CARTOX) grading system prior to May, 2019 or American Society of Transplantation and Cellular Therapy (ASTCT) consensus grading thereafter for cytokine release syndrome (CRS) and immune cell associated neurotoxicity syndrome (ICANS). Comorbidities defined as per Hematopoietic Cell Transplantation-specific Comorbidity Index (HCT-CI). (Sorror et al., 2009). Hepatic dysfunction defined as infection with hepatitis B or C or history of liver cirrhosis or elevated total bilirubin, AST, or ALT on at least two values on two different days from day -24 till day -10 prior to CAR-T. Cardiovascular (CV) comorbidity determined by presence of coronary heart disease, congestive heart failure or reduced ejection fraction detected by echocardiogram. Psychiatric disturbance defined as presence of depression and/or anxiety requiring treatment or consultation. Patient demographics, disease characteristics and clinical outcomes summarized through descriptive statistics. Wilcoxon rank sum test used to evaluate difference in a continuous variable between patient groups. Kaplan-Meier method used to estimate time-to-event endpoints including progression free survival (PFS), and overall survival (OS). Results: Two hundred and fifty patients included in analysis. Median age of 61years (range: 18-89) and 30.8% of patients were female (n=77). Histology was categorized as LBCL (65.9%) and included diffuse LBCL or high grade LBCL, transformed follicular lymphoma (26.9%), primary mediastinal b-cell lymphoma (6.4%) or follicular lymphoma (0.8%). Majority of pts received axicabtagene ciloleucel 95.6% (n=239) while 4.4% (n=11) received tisagenlecleucel and 52% (n=130) of pts received bridging therapy. CRS of any grade was 90.4% ; ICANS any grade was 57.2% while grade 3 CRS/ICANS occurred 6.4% and 38.4% respectively. Median follow-up 24.7 months (mo) (95% CI: 20.7 ~ 26.4 mo). One-hundred twenty-eight pts died during follow-up, 48 pts died within 100 days, and most common cause of death was progression of lymphoma (29.2%; n=73). Early 30-day mortality occurred in 4.8% pts and causes of death due to CAR-T related toxicity in 6 pts, disease progression in 3 pts, and infection in 1 pts. 100-day mortality rate was 24.6% (n=32) for pts >60 years old vs 13.3% (n=16) for <60 (p-value=0.02). 100-day mortality rate was 36.5% for ECOG 2-4 vs 14.9% for ECOG 0-1 (p-value=0.0005). In terms of non-relapsed mortality (NRM), risk stratification according to cumulative HCT-CI score was not associated with higher 100-day NRM (p=0.24). Pts with cardiac score of 1 had a higher NRM (26.9% vs. 8.1%; p-value=0.005). The 100-day NRM rates for hepatic score of 0, 1, and 3 were 8.9%, 14.3%, and 50% (p-value=0.04). Pts with psychiatric disturbance score of 1 had higher 100-day NRM (19.6% vs. 7.8%; p-value=0.03). Conclusion: This single center retrospective study observed an increase in 100-day mortality in correlation with pre-treatment performance status, and older age. Pts with cardiac comorbidity, hepatic dysfunction or psychiatric disturbance had a higher 100-day NRM. Similar to other studies, the combined HCT-CI score was not predictive of NRM, but individual variables were associated with higher non-CART related toxicity. These findings require validation with further studies. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

ODP302 Cushing's Disease: A Challenging Diagnosis in Patients with Underlying Co-Morbidities

Abstract Introduction Cushing's disease (CD) is a rare endocrine disorder with significant morbidity and mortality. This case is a complicated ACTH (adrenocorticotropic hormone)-dependent hypercortisolism with a negative pituitary MRI inthe setting of underlying liver cirrhosis and chronic kidney disease. Hypercortisolism work up was challenging due to liver and kidney disease. Case Presentation A 42-year-old woman with a history of liver cirrhosis(MELDscore: 19) and stage 3b chronic kidney disease (CKD) presented with nausea, vomiting and abdominal pain. She reported proximal muscle weakness. On examination, she had central adiposity with large purple abdominal striae and proximal muscle wasting. Medical history was pertinent for uncontrolled hypertension and type 2 diabetes mellitus. Due to concern for Cushing's syndrome, an overnight 1 mg dexamethasone suppression test (DST) was performed. She had an inappropriately elevated morning cortisol of 10.1 mcg/dL (n &amp;lt; 1.8 mcg/dL), but suboptimal dexamethasone level of 104 ng/dL (140-295 ng/dL), suggesting incomplete absorption secondary to emesis. A repeat DST was not performed given concerns for reduced dexamethasone clearance with her underlying renal and liver disease. Her 24-hour urine free cortisol (UFC) was elevated at 55 ug/24 hr (6-42 ug/24 hr). A repeat 24-hour UFC was again elevated at 265 ug/24 hr (6-42 ug/24 hr). Three late night salivary cortisol levels were also elevated at 0.231 ug/dL, 0.429 ug/dL and 0.19 ug/dL (n &amp;lt;0. 01-0. 09 ug/dL). Diagnosis of Cushing's syndrome was confirmed. ACTH level obtained was detectable at 70.1 pg/mL (7.2-63.3 pg/mL), suggestive of ACTH-dependent Cushing's syndrome. Pituitary MRI without contrast was obtained due to CKD. MRI reported no pituitary abnormalities. High dose DST was not performed due to concerns for aforementioned reduced dexamethasone clearance and due to lack of availability of CRH (corticotropin-releasing hormone), CRH stimulation testing was not done. She underwent inferior petrosal sinus sampling (IPSS) which showed central to peripheral ACTH ratio of 2.11 at baseline and ratios of 3.53, 3.45 and 3.32 at 5 minutes, 10 minutes and 15 minutes respectively after vasopressin stimulation, solidifying the diagnosis of Cushing's disease. Patient is now scheduled for an exploration of the sella via endoscopic endonasal approach. Conclusion This case highlights the limitations of biochemical tests and imaging modalities in the workup of hypercortisolism, notably in patients with underlying liver and kidney disease. The ordering physician should be mindful of the caveats associated with each biochemical testing. ACTH-dependent Cushing's syndrome can be difficult to diagnose properly in the setting of a negative pituitary MRI. IPSS, although an expensive and invasive test, has the best diagnostic accuracy. This case further demonstrates the importance of performing an IPSS to diagnose CD and distinguish from an ectopic source when imaging is non-diagnostic. Presentation: No date and time listed

Previous antithrombotic therapy does not have an impact on the in-hospital mortality of patients with upper gastrointestinal bleeding

Abstract Background The association between antithrombotic therapy due to concomitant cardiovascular disorders and the risk of gastrointestinal bleeding is well known; however, data regarding the influence of antithrombotics on outcomes and further management after a bleeding episode are scarce. Purpose This study was conducted to assess the impact of concomitant antithrombotic therapy and other variables on in-hospital and 6-month outcomes and to determine the re-initiation rate of the antithrombotic treatment after a bleeding event. Methods We retrospectively analysed all patients with upper gastrointestinal bleeding (UGB) who underwent urgent gastroscopy in 3 centres from 1 January 2019 to 31 December 2019. Demographic and medical data were collected from the electronic hospital database system. Results Among 333 patients (60% males, mean age 69±16 years), 44% were receiving antithrombotics. The in-hospital mortality rate was 12%, and the 6-months was 32%. In logistic regression we observed no association between antithrombotics and worse in-hospital outcomes. Haemorrhagic shock (OR 5.7, 95% CI 2.7 to 12.2; p&amp;lt;0.001), as well as a history of cancer (OR 2.7, 95% CI 1.1 to 6.9; p=0.03) and higher comorbidity (mean Charlson comorbidity index 5.6 vs. 6.9, OR 1.3, 95% CI 1.1 to 1.6; p=0.005) led to higher in-hospital mortality (tab. 1). In terms of 6-months outcomes, higher age (OR 1.03, 95% CI 1.00 to 1.05; p=0.02), higher comorbidity (OR 1.4, 95% CI 1.2 to 1.6; p&amp;lt;0.001), a history of cancer (OR 4.5, 95% CI 2.0 to 10.1; p&amp;lt;0.001) and a history of liver cirrhosis (OR 2.3, 95% CI 1.2 to 4.6; p=0.02) were associated with higher mortality. Other tested variables such as ischemic heart disease, heart failure or diabetes did not influence 6-month outcomes at statistically significant level (tab. 2). After a bleeding episode, antithrombotic treatment in patients with lasting indication from cardiovascular reasons was re-initiated in 81% of cases. One patient with atrial fibrillation was referred for a left atrial appendage closure. Conclusions Based on our observations, previous antithrombotic therapy does not worsen in-hospital outcomes in patients with UGB. Development of haemorrhagic shock during hospitalization predicted poor prognosis. Higher 6-month mortality was observed in older patients and patients with a history of liver cirrhosis. A history of cancer and higher comorbidity negatively affected the short- as well as long-term prognosis. Funding Acknowledgement Type of funding sources: None.

ACQUIRED BRONCHOBILIARY FISTULA PRESENTING AS COUGH

ACQUIRED BRONCHOBILIARY FISTULA PRESENTING AS COUGH

S2633 Omental Varices Causing Umbilical Bleeding: A Rare Presentation in Cirrhotic Patients With Portal Hypertension

Introduction: Ectopic varices account for less than 5% of all varix-related bleeding episodes. Umbilical bleeding is a well-recognized but unusual complication of portal hypertension, and most of the time is caused by bleeding from umbilical varices (UV). On the other hand, rupture of omental varices (OV) leading to spontaneous umbilical bleeding is rare and has been reported once in the previous literature. Case Description/Methods: A 54-year-old male with a history of liver cirrhosis, MELD score of 21, Child-Pugh Class B, who was found lying in a pool of blood in his bedroom, was transported to the hospital with profuse spontaneous bleeding from his umbilical hernia site. He gave a history of similar, but mild bleeding episodes occurring intermittently over the last week, with no trauma associated. Initially, the patient was hypotensive, tachycardic, and had a protuberant abdomen with a large ventral hernia, covered by a dressing. Removal of the dressing revealed active venous hemorrhage. Laboratories showed hemoglobin 6.9 g/dL, mean corpuscular volume 95.3 fL, platelets 88 × 103/mcL, INR 1.36, total bilirubin 0.7 mg/dL, ammonia level 160 µg/dL, and mild transaminitis. The patient’s hemorrhagic shock was treated with blood transfusions, IV fluids, and vasopressors. Abdomen CT scan showed anterior abdominal wall hernias containing herniated fat with fat stranding. The surgery service evaluated the patient and suspected OV bleeding. Intraoperatively, he was treated with periumbilical excision and ligation of the OV contained within the hernia. The omentum became adhered to the skin of the umbilicus, allowing venous communications to develop between the varices and cutaneous veins of the umbilicus. The section was dissected and a Seprafilm was placed to prevent future adherence, and the bleeding was controlled (Figure 1). Discussion: The most reported cause of spontaneous umbilical bleeding is UV. In our case, the presence of bilateral anterior abdominal hernias containing herniated fat with some fat stranding on the abdominal CT was suspicious for OV, which was confirmed to be the source of bleeding intraoperatively. In such cases, OV as the source of umbilical bleeding should be ruled out. Previous reports have suggested a portosystemic abdominopelvic CT scan preoperatively to define the portal vascular anatomy, identify associated varices, and sites of bleeding before the procedure.Figure 1.: CT Abdomen and pelvis without contrast showing umbilical hernia containing omental fat.

Pathological Significance and Prognostic Roles of Indirect Bilirubin/Albumin Ratio in Hepatic Encephalopathy

Background and Aim: Hepatic encephalopathy (HE) is a neurological disease caused by severe liver disease. Early identification of the risk factor is beneficial to the prevention and treatment of HE. Free bilirubin has always been considered to be the culprit of neonatal kernicterus, but there is no research to explore its role in HE. In this study, we aim to study the clinical significance of the indirect bilirubin-albumin ratio in HE.Methods: A retrospective case-control study of 204 patients with liver failure was conducted. Human serum albumin (HSA) or heme oxygenase-1 (HO-1) inhibitor SnPP (Tin protoporphyrin IX dichloride) was injected intraperitoneally into Ugt1−/− mice to establish a treatment model for endogenous hyperbilirubinemia.Results: IBil/albumin ratio (OR = 1.626, 95% CI1.323–2.000, P < 0.001), white blood cell (WBC) (OR = 1.128, 95% CI 1.009–1.262, P = 0.035), ammonia (OR = 1.010, 95% CI 1.001–1.019, P = 0.027), platelet (OR=1.008, 95% CI 1.001–1.016, P = 0.022), Hb (OR = 0.977, 95% CI 0.961–0.994, P = 0.007), and PTA (OR = 0.960, 95% CI 0.933–0.987, P = 0.005) were independent factors of HE. Patients with a history of liver cirrhosis and severe HE (OR = 12.323, 95% CI 3.278–47.076, P < 0.001) were more likely to die during hospitalization. HSA or SnPP treatment improved cerebellum development and reduced apoptosis of cerebellum cells.Conclusion: The IBil/albumin ratio constitutes the most powerful risk factor in the occurrence of HE, and reducing free bilirubin may be a new strategy for HE treatment.

Screening, clinical features and prognostic analysis of liver cirrhosis-related hepatocellular carcinoma

Objective To explore the impact of the screening interval and methods on cirrhosis-related hepatocellular carcinoma (HCC) detection and to analyse the clinical features and prognosis of HCC. Materials and methods We recruited 3000 patients diagnosed with liver cirrhosis, who had been treated at the First Affiliated Hospital of Anhui Medical University from January 2016 to January 2020. The time of admission was divided into 3- (group A, 539 cases), 6- (group B, 1012 cases), and 12-month screening groups (group C, 1449 cases). We compared the detection rate of small HCCs in each group and analysed the clinical characteristics and prognosis of the patients with HCC. Results We detected a total of 124 HCC cases, including 41 cases of small HCC: 21, 14, and 6 cases in groups A, B, and C, respectively. The detection rate was 3.9% (21/539) in group A, which was significantly higher than that in groups B and C (χ 2 = 31.186, p < .001). Single small, right liver lobe, and alpha-fetoprotein-negative HCCs accounted for 90.2%, 73.2%, and 68.3%, respectively. We detected vascular invasion and lymph node metastasis in one and three cases, respectively. The average survival time of patients in the small HCC group was significantly higher than that in the non-small-HCC group (35.68 ± 12.95 vs. 22.87 ± 11.42 months) (t = 5.623, p < .001). Conclusions Screening patients with a history of liver cirrhosis at intervals of 3 months can increase the detection rate of small HCCs. Early detection can provide more patients with an opportunity for radical treatment and prolong their survival.

COVID-19 in hospitalized liver transplant recipients: An early systematic review and meta-analysis.

Adverse clinical outcomes related to SARS‐CoV‐2 infection among liver transplant (LTx) recipients remain undefined. We performed a meta‐analysis to determine the pooled prevalence of outcomes among hospitalized LTx recipients with COVID‐19. A database search of literature published between December 1, 2019, and November 20, 2020, was performed per PRISMA guidelines. Twelve studies comprising 517 hospitalized LTx recipients with COVID‐19 were analyzed. Common presenting symptoms were fever (71%), cough (62%), dyspnea (48%), and diarrhea (28%). Approximately 77% (95% CI, 61%‐93%) of LTx recipients had a history of liver cirrhosis. The most prevalent comorbidities were hypertension (55%), diabetes (45%), and cardiac disease (21%). In‐hospital mortality was 20% (95% CI, 13%‐28%) and rose to 41% (95% CI, 19%‐63%) (P < 0.00) with ICU admission. Additional subgroup analysis demonstrated a higher mortality risk in the elderly (>60‐65 years) (OR 4.26; 95% CI, 2.14‐8.49). There was no correlation in respect to sex or time since transplant. In summary, LTx recipients with COVID‐19 had a high prevalence of dyspnea and gastrointestinal symptoms. In‐hospital mortality was comparable to non‐transplant populations with similar comorbidities but appeared to be less than what is reported elsewhere for cirrhotic patients (26%‐40%). Importantly, the observed high case fatality in the elderly could be due to age‐associated comorbidities.

Surgical outcomes of pulmonary metastasectomy in hepatocellular carcinoma patients according to approach method: thoracoscopic versus open approach

BackgroundThe role of surgical intervention as a treatment for pulmonary metastasis (PM) from hepatocellular carcinoma (HCC) has not been established. In this study, we investigated the clinical outcomes of pulmonary metastasectomy. Using propensity score matching (PSM) analysis, we compared the results according to the surgical approach: video-assisted thoracic surgery (VATS) versus the open method.MethodsA total of 134 patients (115 men) underwent pulmonary metastasectomy for isolated PM of HCC between January 1998 and December 2010 at Seoul Asan Medical Center. Of these, 84 underwent VATS (VATS group) and 50 underwent thoracotomy or sternotomy (open group). PSM analysis between the groups was used to match them based on the baseline characteristics of the patients.ResultsDuring the median follow-up period of 33.4 months (range, 1.8–112.0), 113 patients (84.3%) experienced recurrence, and 100 patients (74.6%) died of disease progression. There were no overall survival rate, disease-free survival rate, and pulmonary-specific disease-free survival rate differences between the VATS and the open groups (p = 0.521, 0.702, and 0.668, respectively). Multivariate analysis revealed local recurrence of HCC, history of liver cirrhosis, and preoperative alpha-fetoprotein level as independent prognostic factors for overall survival (hazard ratio, 1.729/2.495/2.632, 95% confidence interval 1.142–2.619/1.571–3.963/1.554–4.456; p = 0.010/< 0.001/< 0.001, respectively).ConclusionsMetastasectomy can be considered a potential alternative for selected patients. VATS metastasectomy had outcomes comparable to those of open metastasectomy.

Epidemiology, clinical characteristics, and outcome of candidemia in critically ill patients in Germany: a single-center retrospective 10-year analysis

BackgroundDespite advances in the management of bloodstream infections (BSI) caused by Candida spp., the mortality still remains high in critically ill patients. The worldwide epidemiology of yeast-related BSI is subject to changing species distribution and resistance patterns, challenging antifungal treatment strategies. The aim of this single-center study was to identify predictors of mortality after 28 and 180 days in a cohort of mixed surgical and medical critically ill patients with candidemia.MethodsPatients, who had been treated for laboratory-confirmed BSI caused by Candida spp. in one of 12 intensive care units (ICU) at a University hospital between 2008 and 2017, were retrospectively identified. We retrieved data including clinical characteristics, Candida species distribution, and antifungal management from electronic health records to identify risk factors for mortality at 28 and 180 days using a Cox regression model.ResultsA total of 391 patients had blood cultures positive for Candida spp. (incidence 4.8/1000 ICU admissions). The mortality rate after 28 days was 47% (n = 185) and increased to 60% (n = 234) after 180 days. Age (HR 1.02 [95% CI 1.01–1.03]), a history of liver cirrhosis (HR 1.54 [95% CI 1.07–2.20]), septic shock (HR 2.41 [95% CI 1.73–3.37]), the Sepsis-related Organ Failure Assessment score (HR 1.12 [95% CI 1.07–1.17]), Candida score (HR 1.25 [95% CI 1.11–1.40]), and the length of ICU stay at culture positivity (HR 1.01 [95% CI 1.00–1.01]) were significant risk factors for death at 180 days. Patients, who had abdominal surgery (HR 0.66 [95% CI 0.48–0.91]) and patients, who received adequate (HR 0.36 [95% CI 0.24–0.52]) or non-adequate (HR 0.31 [95% CI 0.16–0.62]) antifungal treatment, had a reduced mortality risk compared to medical admission and no antifungal treatment, respectively.ConclusionsThe mortality of critically ill patients with Candida BSI is high and is mainly determined by disease severity, multiorgan dysfunction, and antifungal management rather than species distribution and susceptibility. Our results underline the importance of timely treatment of candidemia. However, controversies remain on the optimal definition of adequate antifungal management.

Predictors of hospital expenses and hospital stay among patients undergoing total laryngectomy: Cost effectiveness analysis.

To determine the predictive factors of postoperative hospital stay and total hospital medical cost among patients who underwent total laryngectomy. A total of 213 patients who underwent total laryngectomy in a tertiary referral center for tumor ablation were enrolled retrospectively between January 2009 and May 2018. Statistical analyses including Pearson's chi-squared test were used to determine whether there was a significant difference between each selected clinical factors and outcomes. The outcomes of interest including postoperative length of hospital stay and inpatient total medical cost. Logistic regression analyses were performed to reveal the relationship between clinical factors and postoperative length of hospital stay or total inpatient medical cost. Preoperative radiotherapy (p = 0.007), method of wound closure (p < 0.001), postoperative serum albumin level (p = 0.025), and postoperative serum hemoglobin level (p = 0.04) were significantly associated with postoperative hospital stay in univariate analysis. Postoperative hypoalbuminemia (odds ratio [OR]: 2.477; 95% confidence interval [CI]: 1.189-5.163; p = 0.015) and previous radiotherapy history (OR 2.194; 95% CI: 1.228-3.917; p = 0.008) are independent predictors of a longer postoperative hospital stay in multiple regression analysis. With respect to total inpatient medical cost, method of wound closure (p < 0.001), preoperative serum albumin level (p = 0.04), postoperative serum albumin level (p < 0.001), and history of liver cirrhosis (p = 0.037) were significantly associated with total inpatient medical cost in univariate analysis. Postoperative hypoalbuminemia (OR: 6.671; 95% CI: 1.927-23.093; p = 0.003) and microvascular free flap reconstruction (OR: 5.011; 95% CI: 1.657-15.156; p = 0.004) were independent predictors of a higher total inpatient medical cost in multiple regression analysis. Postoperative albumin status is a significant factor in predicting prolonged postoperative hospital stay and higher inpatient medical cost among patients who undergo total laryngectomy. In this cohort, the inpatient medical cost was 48% higher and length of stay after surgery was 35% longer among hypoalbuminemia patients.

Circular RNA 0016788 displays as a biomarker for tumor progression and poor prognosis in surgical hepatocellular carcinoma patients.

ObjectiveThis study aimed to investigate the clinical significance of circular RNA 0016788 (circ_0016788) regarding its correlation with tumor progression and survival in hepatocellular carcinoma (HCC).MethodsTwo hundred and seventy‐eight HCC patients who received tumor resection were retrospectively analyzed. Circ_0016788 expression in 278 tumor tissues and 116 adjacent tissues was detected by reverse transcription‐quantitative polymerase chain reaction.ResultsCirc_0016788 was elevated in tumor tissue compared with adjacent tissue, and it had an excellent value in distinguishing tumor tissue from adjacent tissue (area under the curve: 0.913; 95% confidence interval: 0.885‐0.941). Furthermore, circ_0016788 correlated to higher performance status score, larger tumor size, increased Barcelona clinic liver cancer (BCLC) stage, abnormal aspartate aminotransferase, abnormal alpha‐fetoprotein, and abnormal carbohydrate antigen 199 levels. Moreover, by Kaplan‐Meier curve and log‐rank test, circ_0016788 high expression correlated with shorter overall survival (OS). Importantly, multivariate Cox's regression analysis displayed that circ_0016788 high expression, older age (≥60 years), history of hepatitis B, history of liver cirrhosis, raised Child‐Pugh stage (B vs A), multifocal disease, largest tumor size (≥5 cm), and increased BCLC stage (B vs A) were independent predictors for poorer OS.ConclusionCirc_0016788 displays the potential as a biomarker for assisting personalized treatment, tumor management, and prognosis surveillance in surgical HCC patients.

The efficacy and safety of elbasvir/grazoprevir treatment in HCV genotype 1 patients in Taiwan.

BackgroundElbasvir/grazoprevir (EBR/GZR) is a new generation, fixed‐dose, combination antiviral drug used in chronic hepatitis C virus (HCV) genotype (GT) 1 or 4 infection. Our study evaluates the clinical efficacy and safety of EBR/GZR after its launch in Taiwan.MethodsThis is a retrospective observational study. Patients who had received EBR/GZR for chronic HCV GT 1 between June 2017 and April 2018 were recruited. Patients’ age, sex, HCV GT, changes in HCV RNA level before and after treatment, sustained virologic response 12 weeks (SVR12) after the cessation of drug administration, side effects, and interaction effects were used to evaluate the clinical efficacy and safety.ResultsA total of 149 patients were recruited. Of them, 145 (97.3%) had HCV GT 1b, and the rest had HCV GT 1a; most of the EBR/GZR‐related side effects in this study were mild. Three participants were discontinued because their alanine transaminase levels were elevated to over 10 times the upper limit of normal. The therapeutic effect analyses revealed a rapid virologic response rate of 95.3% and an SVR12 rate of 98%. Subgroup analyses performed using SVR12 as the outcome variable revealed three demographic factors HCV GT 1, hepatocellular carcinoma medical history, and noncirrhosis plus HCV RNA level.ConclusionsThis study confirmed that EBR/GZR is safe and effective for treating patients with HCV GT 1 and exhibited excellent overall clinical efficacy in Taiwan. The therapeutic effects are unrelated to factors such as sex, HCV RNA level before treatment, and history of liver cirrhosis.

2414 One Time Hepatitis a Virus Vaccination Might Not Be Enough in Cirrhotic Patients

INTRODUCTION: Acute HAV infection was a highly prevalent infection in the US prior to the development of the vaccine in 1995, after which a drastic decline was observed. Unfortunately, increasing outbreaks have been reported around the world in the last 5 years. In 2016 there was a 44% increase in cases compared to 2015 in the US. Immunogenicity to the HAV vaccine occurs in more than 95% of recipients. However, the increasing number of cases reported is thought to be associated with the immunocompromised population which does not experience a similar rate of seroconversion after vaccination. CASE DESCRIPTION/METHODS: We present a 58-year-old male with a history of liver cirrhosis who presented to the ED with generalized weakness and jaundice for one week. The patient denied recent travel or drug use, however, admitted to daily alcohol use. His vital signs were normal. Physical exam was unremarkable aside from generalized jaundice. Laboratory results were relevant for markedly elevated transaminases, INR and total bilirubin (Table 1). Ethanol and acetaminophen levels were negative, but viral hepatitis serologies were reactive for HAV IgM and IgG (Table 2), despite prior immunity to HAV two years ago. Supportive treatment was started. His hospital stay was complicated by fulminant liver failure and hepatorenal syndrome. The patient was not a candidate for liver transplant due to continued alcohol use. He pursued hospice care and later expired. DISCUSSION: Immunity to HAV occurs after exposure to its antigen (Ag) confirmed by a positive IgG. Vaccination should offer lifelong immunity. T-cells play a main role in Ag presentation, cytokine induction and B cell differentiation. However, patients with a compromised immune system often experience T-cell dysfunction, hindering a proper immune response. Immunocompromised states, such as HIV infection, affect seroconversion rates after vaccination. One study showed 4% of patients with HAV infection were HIV positive and 55% were previously vaccinated. Our patient was negative for HIV but had a history of liver cirrhosis. The liver is the first organ in contact with the HAV Ag, delivered from the gut via the portal vein. Liver macrophages prevent systemic spread of Ag and hepatocytes synthesize complement. Both are essential for a robust immune response. This case highlights the risk of reinfection with HAV in cirrhotic patients, even with prior immunization. We suggest consideration for booster immunization in this population similar to that suggested for HIV patients.