AASLD Deepens Commitment to Diversity, Equity, and Inclusion
Outcomes of a quality improvement initiative to improve advance care planning among outpatients with decompensated cirrhosis [Meeting Abstract]
Introduction: Advance care planning (ACP) aims to provide care at the end of life (EOL) that is consistent with a patient's wishes, but it is infrequently performed in patients with decompensated cirrhosis. We implemented a quality improvement (QI) initiative in a hepatology fellows clinic at a major tertiary medical center with the goal of increasing advance directive (AD) completion among patients with decompensated cirrhosis. The goal of this analysis is to describe factors related to successful AD completion and preliminary effects of AD completion on EOL outcomes.
Method(s): The QI intervention, consisting of provider education, electronic health record templates, and standardized workflows, was conducted between November 2018 and March 2021. We performed a retrospective chart review of adult patients with decompensated cirrhosis seen during this period. We collected data on whether an AD was successfully completed and type of AD (first completed, if multiple). We also assessed location of death and receipt of hospice care among decedent patients. Descriptive statistics and univariate logistic regression were performed using STATA 14.2.
Result(s): A total of 120 patients with decompensated cirrhosis were seen during the QI intervention. Our cohort was mostly male (62%), Latino (55%), Medicaid-insured (70%) and non-transplant candidates (86%). AD completion improved from 8% (N=0) to 44% (N=53) by the end of the study period. Most ADs were completed in the outpatient setting (N=38, 72%) and were healthcare proxy designation forms (N=41, 77%). A diagnosis of NASH (OR: 4.25, 95% CI: 1.11-16.2) and divorced marital status (OR: 10.23, CI: 2.04-51.3) were the only factors associated with successful AD completion. Seventeen (14%) patients died during the study period, of which 12 (71%) had an AD. Decedents with an AD were more likely overall to receive hospice (67% vs. 20%) and die under hospice care (42% vs. 20%).
Conclusion(s): Following our QI intervention, 44% of patients with decompensated cirrhosis had an AD, which were largely health care proxy forms completed in the outpatient setting. No significant disparities in AD completion by age, gender, or race were observed from our intervention. AD completion was associated with higher rates of receiving hospice among decedents. These findings suggest benefits of AD completion on EOL care in this population
Advance care planning and early reports of end of life care among patients with decompensated cirrhosis: A single center experience [Meeting Abstract]
Background: Individuals with decompensated cirrhosis (DC) experience uncertain illness trajectories and significant healthcare burden towards the end of life (EOL) Advance care planning (ACP) has been associated with improved EOL outcomes in patients with serious illnesses We implemented a quality improvement (QI) intervention from November 2018 to March 2020 that aimed to increase advance directive (AD) completion among patients with DC seen in a once-weekly hepatology clinic staffed by transplant hepatology fellows, gastroenterology fellows, and attending hepatologists The goal of this study was to evaluate the effect of our QI intervention on EOL care, including the hospital length of stay (LOS) and concordance between documented preferences and care received Methods: We performed a retrospective chart review of adult patients with DC seen in our clinic during the QI intervention We followed patients from the time of their first appointment through June 2020, or until date of death We collected data on whether an AD was completed, along with contents of the most recent document Among decedents, we collected data on location of death, goals of care discussions (GCDs), LOS, and receipt of comfortfocused care Descriptive statistics were calculated and Wilcoxon rank sum tests were performed to compare LOS All analyses were conducted using STATA 14 2 Results: A total of 95 patients were seen during the follow-up period Our cohort consisted mostly of men (60%), of Latinx origin (60%), Medicaid-insured (69%) and with a mean age of 56 (standard deviation [SD]: 12) years The primary cause of cirrhosis was alcohol use (36%) Most patients had history of ascites (71%) or hepatic encephalopathy (57%). At first visit, the mean Model of End-Stage Liver Disease-Sodium (MELDNa) score was 13 9 (SD: 6 0), and most patients were never evaluated for transplant (77%) or declined for listing (11%) AD completion improved from 9 to 40% Nine (9%) patients died during follow-up, of which 8 were hospitalized Among decedents, 5 (56%) had a prior AD, of which all designated a healthcare proxy (HCP) and 4 designated care preferences at the EOL The care of 5 decedents (56%) involved GCDs, of which 4 (80%) included specialty palliative care (SPC) services All patients previously opting for limits to care received comfort care at the EOL and experienced shorter hospitalizations compared to patients with fully aggressive or unreported preferences (median LOS: 11 vs 14 days), though this difference was not statistically significant (p=0.30) (Table 1)
Conclusion(s): AD completion significantly improved over the follow-up period All patients who previously documented limits to care received goal-concordant care at the EOL and tended to have shorter hospitalizations Future iterations of this quality improvement project will involve more patients, longer follow up periods, and formal assessments of patient and family satisfaction at the EOL. (Table Presented)
Findings of Severe Hepatic SARS-CoV-2 Infection
BACKGROUND AND AIMS/OBJECTIVE:Liver injury due to COVID-19 is being increasingly recognized. Abnormal liver chemistry tests of varying severities occur in a majority of patients. However, there is a dearth of accompanying liver histologic studies in these patients. METHODS:The current report details the clinical courses of two patients having severe COVID-19 hepatitis. Liver biopsies were analyzed under light microscopy, portions of liver tissue were hybridized with a target probe to the SARS-CoV-2 S gene, and small sections from formalin-fixed paraffin embedded liver tissue were processed for electron microscopy. RESULTS:The liver histology of both cases showed a mixed inflammatory infiltrate with prominent bile duct damage, endotheliitis and many apoptotic bodies. In-situ hybridization and electron microscopy suggest the intrahepatic presence of the severe acute respiratory syndrome corona virus-2 (SARS-CoV-2), the findings of which may indicate the possibility of direct cell injury. CONCLUSIONS:Based on the abundant apoptosis and severe cholangiocyte injury, these histopathological changes suggest a direct cytopathic injury. Furthermore, some of the histopathological changes may resemble acute cellular rejection occurring after liver transplantation. These two cases demonstrate that severe COVID-19 hepatitis can occur even in the absence of significant involvement of other organs.
COVID-19 in Liver Transplant Recipients: An Initial Experience From the US Epicenter
DIFFERENCES IN PSC SEVERITY, COMORBIDITIES, AND LIVER TRANSPLANTATION BETWEEN RACIAL AND ETHNIC GROUPS IN A DIVERSE POPULATION [Meeting Abstract]
Prevalence of Functional GI Diseases and Pelvic Floor Symptoms in Marfan Syndrome and Ehlers-Danlos Syndrome: A National Cohort Study
BACKGROUND AND AIMS:Prior studies have shown a high prevalence of gastrointestinal (GI) symptoms, diagnoses of functional GI diseases (FGIDs), and pelvic floor symptoms associated with Ehlers-Danlos syndrome (EDS). It is unclear if Marfan syndrome (MFS), another common hereditary noninflammatory connective tissue disorder, is also associated these symptoms. This study evaluates the prevalence of and compares FGIDs and pelvic floor symptoms in a national cohort of EDS and MFS patients. METHODS:A questionnaire was sent to members of local and national MFS and EDS societies. The questionnaire evaluated the presence of GI and pelvic floor symptoms and diagnoses. The presence of FGIDs was confirmed using Rome III criteria. Quality of life was evaluated and scored with the CDC quality of life. KEY RESULTS:Overall, 3934 patients completed the questionnaire, from which 1804 reported that they had some form of EDS and 600 had MFS. In total, 93% of patients with EDS complained of GI symptoms and qualified for at least one FGID compared with 69.8% of patients with MFS. When comparing EDS prevalence of upper and lower GI symptoms as well as FGIDs, subjects with EDS reported significantly higher prevalence of Rome III FGIDs as compared with those with MFS. Irritable bowel syndrome (57.8% vs. 27.0%, P<0.001), functional dyspepsia (FD) (55.4% vs. 25.0%, P<0.001), postprandial distress (49.6% vs. 21.7%, P<0.001), heartburn (33.1% vs. 16.8%, P<0.001), dysphagia (28.5% vs. 18.3%, P<0.001), aerophagia (24.7% vs. 12.3%, P<0.001), and nausea (24.7% vs. 7.2%, P<0.001) were all significantly greater in the EDS population compared with MFS population. The prevalence of FGIDs was similar across subtypes of EDS. In general, participants with EDS were more likely to have nearly all pelvic floor symptoms as compared with participants with MFS. CONCLUSIONS:The prevalence of FGIDs and pelvic floor symptoms in EDS is higher than that found in MFS. The prevalence of FGIDs were similar across EDS subtypes. This study supports the mounting evidence for FGIDs in those with connective tissue diseases, but more specifically, in EDS.
Safety of Endoscopy in Heritable Connective Tissue Disorders
INTRODUCTION:Little is known about the gastrointestinal manifestations or safety of endoscopy among patients with heritable connective tissue disorders such as Marfan syndrome or Ehlers-Danlos syndrome (EDS). METHODS:We conducted an electronic cross-sectional survey nested within preexisting registries of patients with heritable connective tissue disorders and examined self-reported rates of endoscopic complications. RESULTS:The rate of endoscopy-related perforation was 9.4% (95% confidence interval 2.0%-25.0%) among individuals with vascular EDS, <1% in classical and hypermobility-type EDS, and zero in Marfan syndrome (P < 0.001). Spontaneous intestinal perforation was also significantly higher in the vascular EDS group. DISCUSSION:Clinicians should consider noninvasive screening methods for patients with vascular EDS.
Audit of Early Mortality among Patients Admitted to the General Medical Ward at a District Hospital in Botswana
BACKGROUND:Mortality among adult general medical admissions has been reported to be high across sub-Saharan Africa, yet there is a paucity of literature on causes of general medical inpatient mortality and quality-related factors that may contribute to the high incidence of deaths. Based on a prior study at our hospital as well as our clinical experience, death early in the hospitalization is common among patients admitted to the adult medical wards. OBJECTIVE:Quantify early inpatient mortality and identify factors contributing to early in-hospital mortalityÂ of medical patients in a resource-limited hospital setting in Botswana. METHODS:Twenty-seven cases of patients who died within 48 hours of admission to the general medical wards at Scottish Livingstone Hospital in Molepolole, Botswana from December 1, 2015-April 25, 2016 were retrospectively reviewed through a modified root cause analysis. FINDINGS:Early in-hospital mortality was most frequently attributed to septic shock, identified in 20 (74%) of 27 cases. The most common care management problems were delay in administration of antibiotics (15, 56%), inappropriate fluid management (15, 56%), and deficient coordination of care (15, 56%). The most common contributing factors were inadequate provider knowledge and skills in 25 cases (93%), high complexity of presenting condition in 20 (74%), and inadequate communication between team members in 18 (67%). CONCLUSIONS:Poor patient outcomes in low-and middle-income countries like Botswana are often attributedÂ to resource limitations. Our findings suggest that while early in-hospital mortality in such settings is associated with severe presenting conditions like septic shock, primary contributors to lack of better outcomes may be healthcare-provider and system-factors rather than lack of diagnostic and therapeutic resources. Low-cost interventions to improve knowledge, skills and communication through a focus on provider education and process improvement may provide the key to reducing early in-hospital mortality and improving hospitalization outcomes in this setting.
Sofosbuvir/velpatasvir/voxilaprevir in the treatment of chronic hepatitis C infection [Review]
The landscape of HCV treatment has been entirely transformed due to the development of direct-acting antivirals (DAAs), but there are limited data guiding salvage therapy in patients who previously failed an NS5A inhibitor-containing DAA regimen.We review the preclinical and clinical data for sofosbuvir/velpatasvir/voxilaprevir (SOF/VEL/VOX), an interferon-free, oral, once daily, pan-genotypic treatment for chronic HCV infection. This combination is a highly effective, well-tolerated and safe 12-week treatment regimen for patients with any genotype, including genotype-3 patients with baseline resistance-associated substitutions (RAS). Its most distinctive role is in patients who have previously failed treatment with advanced DAA regimens. Its efficacy is not significantly affected by RASs, and treatment-emergent RASs are uncommon.