MELD-Na Is More Strongly Associated with Risk of Infection and Outcomes Than Other Characteristics of Patients with Cirrhosis.

BACKGROUND AND AIMS: The nature and outcomes of infection among patients with cirrhosis in safety-net hospitals are not well described. We aimed to characterize the rate of and risk factors for infection, both present on admission and nosocomial, in this unique population. We hypothesized that infections would be associated with adverse outcomes such as short-term mortality. METHODS: We used descriptive statistics to characterize infections within a retrospective cohort characterized previously. We used multivariable logistic regression models to assess potential risk factors for infection and associations with key outcomes such as short-term mortality and length of stay. RESULTS: The study cohort of 1112 patients included 33% women with a mean age of 56 ± 10 years. Infections were common (20%), with respiratory and urinary tract infections the most frequent. We did not observe a difference in the incidence of infection on admission based on patient demographic factors such as race/ethnicity or estimated household income. Infections on admission were associated with greater short-term mortality (12% vs 4% in-hospital and 14% vs 7% 30-day), longer length of stay (6 vs 3 days), intensive care unit admission (28% vs 18%), and acute-on-chronic liver failure (10% vs 2%) (p < 0.01 for all). Nosocomial infections were relatively uncommon (4%), but more frequent among patients admitted to the intensive care unit. Antibiotic resistance was common (38%), but not associated with negative outcomes. CONCLUSION: We did not identify demographic risk factors for infection, but did confirm its morbid effect among patients with cirrhosis in safety-net hospitals.

Knowledge, Attitudes, and Practices Pertaining to Lung Cancer Screening Among Primary Care Physicians in a Public Urban Health Network.

INTRODUCTION: Lung cancer screening (LCS) with annual low-dose computed tomography in high-risk groups decreases the mortality related to lung cancer. Its implementation rate has been low, and knowledge relating to LCS has not been assessed in providers treating underserved populations. MATERIALS AND METHODS: An institutional review board-approved anonymous survey was sent to primary care physicians of the Cook County Health system, a safety-net healthcare system. The survey assessed the knowledge pertaining to LCS guidelines, providers' experience with LCS, and their recommendations for quality improvement using 24 questions. The predictors of LCS within the previous 6 months were identified using logistic regression analysis. RESULTS: Of the 152 survey responses, 43% were from nontrainees with diverse training backgrounds. Adequate knowledge of LCS was demonstrated by 72% of the respondents, and pretest counseling was the domain most often answered incorrectly in the questionnaire. LCS had been ordered in the previous 6 months by 57% of the respondents. However, 88% estimated that they had screened < 50% of eligible patients. Higher patient volume, more experience, and family medicine training predicted for ordering LCS in the previous 6 months. In addition, 82.2% indicated that prompts in the electronic medical records would increase LCS, and 78.3% reported that receiving statistics about their LCS practice would increase LCS performance. CONCLUSIONS: Primary care physicians in the hospital healthcare system had reasonable knowledge of LCS, but the implementation rate was low. We have identified areas for improvement relating to LCS implementation.

Thin Patient, Fatty Liver.

A 49-year-old lady with no past medical history presented with dysphagia and 40-pound weight loss, which occurred over eight months. On physical examination, she had proximal muscle weakness and crackles in basilar regions of the lungs. Labs were significant for low albumin, elevated transaminases, and high aldolase. Imaging suggested aspiration pneumonitis in both lungs and hepatic steatosis. A swallow evaluation revealed oropharyngeal dysphagia and muscle biopsy confirmed a rare form of myositis. A liver biopsy showed steatohepatitis and a diagnosis of starvation-induced steatohepatitis was made. The patient succumbed to hypoxic respiratory failure from aspiration pneumonitis before the treatment for myositis could be initiated. We report the first case of starvation-induced steatohepatitis in a patient with dysphagia from myositis affecting the oropharyngeal musculature.

Early predictors of outcomes of hospitalization for cirrhosis and assessment of the impact of race and ethnicity at safety-net hospitals.

BACKGROUND: Safety-net hospitals provide care for racially/ethnically diverse and disadvantaged urban populations. Their hospitalized patients with cirrhosis are relatively understudied and may be vulnerable to poor outcomes and racial/ethnic disparities. AIMS: To examine the outcomes of patients with cirrhosis hospitalized at regionally diverse safety-net hospitals and the impact of race/ethnicity. METHODS: A study of patients with cirrhosis hospitalized at 4 safety-net hospitals in 2012 was conducted. Demographic, clinical factors, and outcomes were compared between centers and racial/ethnic groups. Study endpoints included mortality and 30-day readmission. RESULTS: In 2012, 733 of 1,212 patients with cirrhosis were hospitalized for liver-related indications (median age 55 years, 65% male). The cohort was racially diverse (43% White, 25% black, 22% Hispanic, 3% Asian) with cirrhosis related to alcohol and viral hepatitis in 635 (87%) patients. Patients were hospitalized mainly for ascites (35%), hepatic encephalopathy (20%) and gastrointestinal bleeding (GIB) (17%). Fifty-four (7%) patients died during hospitalization and 145 (21%) survivors were readmitted within 30 days. Mortality rates ranged from 4 to 15% by center (p = .007) and from 3 to 10% by race/ethnicity (p = .03), but 30-day readmission rates were similar. Mortality was associated with Model for End-stage Liver Disease (MELD), acute-on-chronic liver failure, hepatocellular carcinoma, sodium and white blood cell count. Thirty-day readmission was associated with MELD and Charlson Comorbidity Index >4, with lower risk for GIB. We did not observe geographic or racial/ethnic differences in hospital outcomes in the risk-adjusted analysis. CONCLUSIONS: Hospital mortality and 30-day readmission in patients with cirrhosis at safety-net hospitals are associated with disease severity and comorbidities, with lower readmissions in patients admitted for GIB. Despite geographic and racial/ethnic differences in hospital mortality, these factors were not independently associated with mortality.

Single institution experience of sorafenib for advanced HCC in a US tertiary care hospital.

BACKGROUND: Sorafenib is first line chemotherapy for advanced hepatocellular carcinoma (HCC). There are little real-world experiences with sorafenib done on US population except for the US arm of the GIDEON study, a phase IV multi-national study. In this context, we present a single institution experience with sorafenib for HCC in a tertiary inner-city safety-net hospital of Chicago. METHODS: We retrospectively analyzed electronic medical records of patients with HCC (confirmed with radiographic criteria and/or biopsy) who received sorafenib from 2009 to 2016. We collected data regarding the demographics, characteristics of tumor, liver cirrhosis, duration of treatment with sorafenib, reported adverse effects with sorafenib and laboratory investigations done at the time of sorafenib initiation. Overall survival was calculated from the time of sorafenib initiation and cases were censored at the date of last follow up, if date of death was not known. Kaplan-Meier curves were estimated to evaluate the prognostic significance of various clinical variables. RESULTS: Fifty-nine patients received sorafenib in the study period and the median overall survival was 7 months (25-75 percentile =3-15 months). Alcohol was the leading cause of cirrhosis, 64% of them had Child-Turcotte-Pugh (CTP) class A cirrhosis or did not have cirrhosis and 73% had Barcelona stage C HCC at the time of sorafenib initiation. Close to half of them suffered from adverse effects of sorafenib, most common being those involving skin and gut. Patients with CTP class A cirrhosis or no cirrhosis (median OS 39 vs. 16 months, log rank test 3.913, P=0.048), absence of extrahepatic spread (EHS) (median OS 39 vs. 9 months, log rank test 5.632, P=0.018) and hepatitis C virus (HCV) infection (median OS 39 vs. 9 months, log rank test 5.015, P=0.025) had better survival. CONCLUSIONS: Overall survival of patients with HCC treated with sorafenib in US is lower than those observed in cohorts from Europe or Japan. HCV infection could be a marker of benefit in those treated with sorafenib for HCC. Further studies to confirm this association and understand it's pathophysiologic basis could be useful in development of other therapeutic options for advanced HCC.

Duodenorenal Fistula after Microwave Ablation Presenting as Melena.

A 53-year-old man presented with melena 3 months after microwave ablation of a renal mass. Esophago-gastroduodenoscopy and radiological imaging revealed that a fistulous tract extended from the duodenum to the right kidney. The patient had a hemorrhage that originated from a branch of the renal artery and bled through the fistulous tract into the duodenal lumen. Angiography was used in the successful coiling of the bleeding vessel to control the bleeding. Consideration of a fistulous tract as a source of gastrointestinal bleeding should be included in a clinician's differential diagnosis when dealing with patients who had a recent ablative procedure.