Publications by authors named "Arpan Patel"

78 Publications

Predictors of Mortality and Outcomes of Liver Transplant in Spur Cell Hemolytic Anemia.

Am J Hematol 2021 Sep 22. Epub 2021 Sep 22.

Harvard Medical School, Boston, MA.

Spur cell hemolytic anemia (SCHA) is a rare, acquired, non-immune hemolytic anemia of decompensated cirrhosis. Data describing prognostic impact, outcomes of liver transplant, and clinical hematologic characteristics of SCHA are absent or limited. We performed a multicenter, 24-year observational cohort study of patients with SCHA, retrospectively analyzing hepatic and hematologic parameters, independent predictors of mortality, and long-term outcomes of liver transplant. Sixty-nine patients with SCHA met eligibility for inclusion. The median (IQR) age was 53 (42-59) years; 46.4% were female, and 11 (15.9%) received liver transplant. Thirty-nine patients (56.5%) were RBC transfusion-dependent. All 11 patients undergoing transplant had rapid and complete resolution of SCHA, with improvement in median hematocrit from 22.1% to 34.6% post-transplant (P=0.001) and excellent post-transplant outcomes. In multivariable logistic models adjusting for age, sex, etiology of cirrhosis, active/recent variceal bleeding, and Child-Turcotte-Pugh score, transfusion dependence had an OR for 90-day mortality of 9.14 (95% CI, 2.46-34.00) and reduced pre-transfusion hematocrit had an OR of 4.73 (95% CI, 1.42-15.82) per 6% decrease; increased red cell transfusion requirement, reduced hemoglobin, increased lactate dehydrogenase, and increased indirect bilirubin were also independently predictive of higher 90-day mortality. MELD-Na and Child-Turcotte-Pugh scores consistently significantly underestimated 90-day mortality, with standardized mortality ratios (SMRs) >1 across all scores/classes [MELD-Na 20-29, SMR 2.42 (1.18-4.44); Child-Turcotte-Pugh class B, SMR 4.46 (1.64-9.90)]. In conclusion, SCHA is associated with substantial excess mortality than predicted by MELD-Na or Child-Turcotte-Pugh scores and uniformly resolves with liver transplant, without recurrence. Multiple parameters of hemolytic anemia severity independently predict higher 90-day mortality. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1002/ajh.26359DOI Listing
September 2021

Developing Priorities for Palliative Care Research in Advanced Liver Disease: A Multidisciplinary Approach.

Hepatol Commun 2021 Sep 16;5(9):1469-1480. Epub 2021 Jun 16.

Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, CA, USA.

Individuals with advanced liver disease (AdvLD), such as decompensated cirrhosis (DC) and hepatocellular carcinoma (HCC), have significant palliative needs. However, little research is available to guide health care providers on how to improve key domains related to palliative care (PC). We sought to identify priority areas for future research in PC by performing a comprehensive literature review and conducting iterative expert panel discussions. We conducted a literature review using search terms related to AdvLD and key PC domains. Individual reviews of these domains were performed, followed by iterative discussions by a panel consisting of experts from multiple disciplines, including hepatology, specialty PC, and nursing. Based on these discussions, priority areas for research were identified. We identified critical gaps in the available research related to PC and AdvLD. We developed and shared five key priority questions incorporating domains related to PC. Conclusion: Future research endeavors focused on improving PC in AdvLD should consider addressing the five key priorities areas identified from literature reviews and expert panel discussions.
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http://dx.doi.org/10.1002/hep4.1743DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8435283PMC
September 2021

Multimodal Mapping of the Tumor and Peripheral Blood Immune Landscape in Human Pancreatic Cancer.

Nat Cancer 2020 Nov 26;1(11):1097-1112. Epub 2020 Oct 26.

Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor MI 48109, USA.

Pancreatic ductal adenocarcinoma (PDA) is characterized by an immune-suppressive tumor microenvironment that renders it largely refractory to immunotherapy. We implemented a multimodal analysis approach to elucidate the immune landscape in PDA. Using a combination of CyTOF, single-cell RNA sequencing, and multiplex immunohistochemistry on patient tumors, matched blood, and non-malignant samples, we uncovered a complex network of immune-suppressive cellular interactions. These experiments revealed heterogeneous expression of immune checkpoint receptors in individual patient's T cells and increased markers of CD8 T cell dysfunction in advanced disease stage. Tumor-infiltrating CD8 T cells had an increased proportion of cells expressing an exhausted expression profile that included upregulation of the immune checkpoint , a finding that we validated at the protein level. Our findings point to a profound alteration of the immune landscape of tumors, and to patient-specific immune changes that should be taken into account as combination immunotherapy becomes available for pancreatic cancer.
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http://dx.doi.org/10.1038/s43018-020-00121-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8294470PMC
November 2020

A patient with concurrent multiple sclerosis and moyamoya disease.

Mult Scler Relat Disord 2021 Jul 16;54:103151. Epub 2021 Jul 16.

Division of Neuro-Immunology, Department of Neurology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY. Electronic address:

Background: Moyamoya disease (MMD) is a rare vasculopathy and Multiple Sclerosis (MS) is an autoimmune disease which causes CNS demyelination. While most literature has focused on misdiagnosis of MMD as an "MS-mimic", we present a patient in which both co-existed.

Methods: Case Report RESULTS: A 57-year-old woman presented with gait dysfunction and paresthesias in both feet. MRI revealed brain and spinal cord lesions consistent with MS. Vessel imaging revealed multivessel stenosis consistent with MMD. Lumbar puncture demonstrated oligoclonal bands, leading to two diagnoses, MS and MMD.

Conclusions: MS can exist concurrently with MMD, potentially due to underlying propensity for autoimmunity.
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http://dx.doi.org/10.1016/j.msard.2021.103151DOI Listing
July 2021

Validation and performance of a machine-learning derived prediction guide for total knee arthroplasty component sizing.

Arch Orthop Trauma Surg 2021 Jul 13. Epub 2021 Jul 13.

University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.

Introduction: Anticipation of patient-specific component sizes prior to total knee arthroplasty (TKA) is essential to avoid excessive cost associated with additional surgical trays and morbidity associated with imperfect sizing. Current methods of size prediction, including templating, are inconsistent and time-consuming. Machine learning (ML) algorithms may allow for accurate TKA component size prediction with the ability to make predictions in real-time.

Methods: Consecutive patients receiving primary TKA between 2012 and 2020 from two large tertiary academic and six community hospitals were identified. The primary outcomes were the final femoral and tibial component sizes extracted from automated inventory systems. Five ML algorithms were trained with routinely corrected demographic variables (age, height, weight, body mass index, and sex) using 80% of the study population and internally validated on an independent set of the remaining 20% of patients. Algorithm performance was evaluated through accuracy, mean absolute error (MAE), and root mean-squared error (RMSE).

Results: A total of 17,283 patients that received one of 9 TKA implants from independent manufacturers were included. The SGB model accuracy for predicting ± 4-mm of the true femoral anteroposterior diameter was 83.6% and for ± 1 size of the true femoral component size was 95.0%. The SGB model accuracy for predicting ± 4-mm of the true tibial medial/lateral diameter was 83.0% and for ± 1 size of the true tibial component size was 97.8%. Patient sex was the most influential feature in terms of informing the SGB model predictions for both femoral and tibial component sizing. A TKA implant sizing application was subsequently created.

Conclusion: Novel machine learning algorithms demonstrated good to excellent performance for predicting TKA component size. Patient sex appears to contribute an important role in predicting TKA size. A web-based real-time prediction application was created capable of integrating patient specific data to predict TKA size, which will require external validation prior to clinical use.
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http://dx.doi.org/10.1007/s00402-021-04041-5DOI Listing
July 2021

Obstructive Sleep Apnea: Cognitive Outcomes.

Clin Geriatr Med 2021 08;37(3):457-467

Department of Neurology, Zucker School of Medicine at Hofstra/Northwell Health, Lenox Hill Hospital, 130 East 77th Street, 8 Black Hall, New York, NY 10075, USA. Electronic address:

There is a strong association between obstructive sleep apnea (OSA) and cognitive dysfunction. Executive function, attention, verbal/visual long-term memory, visuospatial/constructional ability, and information processing are more likely to be affected, whereas language, psychomotor function, and short-term memory are less likely to be affected. Increased accumulation of Aß-amyloid in the brain, episodic hypoxemia, oxidative stress, vascular inflammation, and systemic comorbidities may contribute to the pathogenesis. Patients with OSA should have cognitive screening or formal testing, and patients with cognitive decline should have testing for OSA. Treatment with continuous positive airway pressure may improve cognitive symptoms in the patient with OSA.
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http://dx.doi.org/10.1016/j.cger.2021.04.007DOI Listing
August 2021

Plasma D-dimer Does Not Anticipate the Fate of Reimplantation in Two-stage Exchange Arthroplasty for Periprosthetic Joint Infection: A Preliminary Investigation.

Clin Orthop Relat Res 2021 07;479(7):1458-1468

Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA.

Background: Inflammatory markers such as the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels have always been a part of the diagnostic criteria for periprosthetic joint infection (PJI), but they perform poorly anticipating the outcome of reimplantation. D-dimer has been reported in a small series as a potential marker to measure infection control after single-stage revisions to treat PJI. Nonetheless, its use to confirm infection control and decide the proper timing of reimplantation remains uncertain.

Questions/purposes: (1) What is the best diagnostic threshold and accuracy values for plasma D-dimer levels compared with other inflammatory markers (ESR and CRP) or what varying combinations of these tests are associated with persistent infection after reimplantation? (2) Do D-dimer values above this threshold, ESR, CRP, and varying test combinations at the time of reimplantation indicate an increased risk of subsequent persistent infection after reimplantation?

Methods: We retrospectively studied the electronic medical records of all 53 patients who had two-stage revisions for PJI and who underwent plasma D-dimer testing before reimplantation at one of two academic institutions from November 22, 2017 to December 5, 2020. During that period, all patients undergoing two-stage revisions also had a D-dimer test drawn. The minimum follow-up duration was 1 year. We are reporting at this early interval (rather than the more typical 2-year time point) because of the poorer-than-expected performance of this diagnostic test. Of these 53 patients, 17% (9) were lost to follow-up before 1 year and could not be analyzed; the remaining 44 patients (17 hips and 27 knees) were studied here. The mean follow-up was 503 ± 135 days. Absence or persistence of infection after reimplantation were defined according to the Delphi criteria. The conditions included in these criteria were: (1) control of infection, as characterized by a healed wound without fistula, drainage, or pain; (2) no subsequent surgical intervention owing to infection after reimplantation; and (3) no occurrence of PJI-related mortality. The absence of any of the aforementioned conditions until the final follow-up examination was deemed a persistent infection after reimplantation. Baseline patient characteristics were not different between patients with persistent infection (n = 10) and those with absence of it after reimplantation (n = 34) as per the Delphi criteria. Baseline patient characteristics evaluated were age, gender, self-reported race (white/Black/other) or ethnicity (nonHispanic/Hispanic), BMI, American Society of Anesthesiologists (ASA) status, smoking status(smoker/nonsmoker), and joint type (hip/knee). The optimal D-dimer threshold to differentiate between persistence of infection or not after reimplantation was calculated using the Youden index. A receiver operating characteristic curve analysis was performed to test the accuracy of D-dimer, ESR, CRP, and their combinations to establish associations, if any, with persistent infection after reimplantation. A Kaplan-Meier survival analysis (free of infection after reimplantation) with a log-rank test was performed to investigate if D-dimer, ESR, and CRP were associated with absence of infection after reimplantation. Survival or being free of infection after reimplantation was determined as per Delphi criteria. Alpha was set at p < 0.05.

Results: In the receiver operating characteristic curve analysis, with an area under the curve of 0.62, D-dimer showed low accuracy and did not anticipate persistent infection after reimplantation. The optimal D-dimer threshold differentiating between persistence of infection or not after reimplantation was 3070 ng/mL. When using this threshold, D-dimer demonstrated a sensitivity of 90% (95% CI 55.5% to 99.7%) and negative predictive value of 94% (95% CI 70.7% to 99.1%), but low specificity (47% [95% CI 29.8% to 64.9%]) and positive predictive value (33% [95% CI 25.5% to 42.2%]). Although D-dimer showed the highest sensitivity, the combination of D-dimer with ESR and CRP showed the highest specificity (91% [95% CI 75.6% to 98%]) defining the persistence of infection after reimplantation. Based on plasma D-dimer levels, with the numbers available, there was no difference in survival free from infection after reimplantation (Kaplan-Meier survivorship free from infection at minimum 1 year in patients with D-dimer below 3070 ng/mL versus survivorship free from infection with D-dimer above 3070 ng/mL: 749 days [95% CI 665 to 833 days] versus 615 days [95% CI 471 to 759 days]; p = 0.052). Likewise, there were no associations between high ESR and CRP levels and persistent infection after reimplantation, but the number of events was very small, and insufficient power is a concern with this analysis.

Conclusion: In this preliminary series, with the numbers available, D-dimer alone had poor accuracy and was not associated with survival free from infection after reimplantation in patients who underwent two-stage exchange arthroplasty. D-dimer alone might be used to establish that PJI is unlikely, and the combination of D-dimer, ESR, and CRP should be considered to confirm PJI diagnosis in the setting of reimplantation.Level of Evidence Level IV, diagnostic study.
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http://dx.doi.org/10.1097/CORR.0000000000001738DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8208420PMC
July 2021

Wallerian degeneration as a mimic of recurrence of myelitis.

Pract Neurol 2021 Jun 18;21(3):235-236. Epub 2021 Mar 18.

Neurology, North Shore University Hospital, Manhasset, New York, USA

A middle-aged woman with idiopathic longitudinally extensive myelitis underwent repeat MR scan of cervical spine at 5-month follow-up, which showed new non-enhancing T2 hyperintensities, initially reported as myelitis recurrence. However, the hyperintensities involved both lateral corticospinal tracts caudal to the initial lesion and both dorsal columns rostral to the initial lesion and were therefore compatible with Wallerian degeneration. This radiological mimic should be considered in the differential of recurrence of myelitis.
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http://dx.doi.org/10.1136/practneurol-2020-002911DOI Listing
June 2021

Top Ten Tips Palliative Care Clinicians Should Know About End-Stage Liver Disease.

J Palliat Med 2021 06 16;24(6):924-931. Epub 2021 Mar 16.

Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.

End-stage liver disease (ESLD) is an increasingly prevalent condition with high morbidity and mortality, especially for those ineligible for liver transplantation. Patients with ESLD, along with their family caregivers, have significant needs related to their quality of life, and there is increasing attention being paid to integration of palliative care (PC) principles into routine care throughout the disease spectrum. To provide upstream care for these patients and their family caregivers, it is essential for PC providers to understand their complex psychosocial and physical needs and to be aware of the unique challenges around medical decision making and end-of-life care for this patient population. This article, written by a team of liver and PC experts, shares 10 high-yield tips to help PC clinicians provide better care for patients with advanced liver disease.
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http://dx.doi.org/10.1089/jpm.2021.0097DOI Listing
June 2021

Progressive Multifocal Leukoencephalopathy in a Patient With Progressive Multiple Sclerosis Treated With Ocrelizumab Monotherapy.

JAMA Neurol 2021 Jun;78(6):736-740

Division of Neuro-Immunology, Department of Neurology, Lenox Hill Hospital, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, New York, New York.

Importance: Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection caused by the JC virus that has no proven effective treatment. Although rare cases of PML have occurred with other anti-CD20 therapies, there had been no prior cases associated with ocrelizumab.

Objective: To report the first ever case of PML occurring with ocrelizumab monotherapy in a patient with progressive multiple sclerosis without prior immunomodulation.

Design, Setting, And Participant: This case was reported from an academic medical center. The patient had multiple sclerosis while receiving ocrelizumab monotherapy.

Exposures: Ocrelizumab monotherapy.

Results: A 78-year-old man with progressive multiple sclerosis treated with ocrelizumab monotherapy for 2 years presented with 2 weeks of progressive visual disturbance and confusion. Examination demonstrated a right homonymous hemianopia, and magnetic resonance imaging revealed an enlarging nonenhancing left parietal lesion without mass effect. Cerebrospinal fluid revealed 1000 copies/mL of JC virus, confirming the diagnosis of PML. Blood work on diagnosis revealed grade 2 lymphopenia, with absolute lymphocyte count of 710/μL, CD4 of 294/μL (reference range, 325-1251/μL), CD8 of 85/μL (reference range, 90-775/μL), CD19 of 1/μL, preserved CD4/CD8 ratio (3.45), and negative HIV serology. Retrospective absolute lymphocyte count revealed intermittent grade 1 lymphopenia that preceded ocrelizumab (absolute lymphocyte count range, 800-1200/μL). The patient's symptoms progressed over weeks to involve bilateral visual loss, right-sided facial droop, and dysphasia. Ocrelizumab was discontinued and off-label pembrolizumab treatment was initiated. The patient nevertheless declined rapidly and ultimately died. PML was confirmed at autopsy.

Conclusions And Relevance: In this case report, PML occurrence was likely a result of the immunomodulatory function of ocrelizumab as well as age-related immunosenescence. This case report emphasizes the importance of a thorough discussion of the risks and benefits of ocrelizumab, especially in patients at higher risk for infections such as elderly patients.
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http://dx.doi.org/10.1001/jamaneurol.2021.0627DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7967248PMC
June 2021

Deficits in Advance Care Planning for Patients With Decompensated Cirrhosis at Liver Transplant Centers.

JAMA Intern Med 2021 May;181(5):652-660

Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA.

Importance: The burden of end-of-life care for patients with cirrhosis is increasing in the US, and most of these patients, many of whom are not candidates for liver transplant, die in institutions receiving aggressive care. Advance care planning (ACP) has been associated with improved end-of-life outcomes for patients with other chronic illnesses, but it has not been well-characterized in patients with decompensated cirrhosis.

Objective: To describe the experience of ACP in patients with decompensated cirrhosis at liver transplant centers.

Design, Setting, And Participants: For this multicenter qualitative study, face-to-face semistructured interviews were conducted between July 1, 2017, and May 30, 2018, with clinicians and patients with decompensated cirrhosis at 3 high-volume transplant centers in California. Patient participants were adults and had a diagnosis of cirrhosis, at least 1 portal hypertension-related complication, and current or previous Model for End-Stage Liver Disease with sodium score of 15 or higher. Clinician participants were health care professionals who provided care during the illness trajectory.

Main Outcomes And Measures: Experiences with ACP reported by patients and clinicians. Participants were asked about the context, behaviors, thoughts, and decisions concerning elements of ACP, such as prognosis, health care preferences, values and goals, surrogate decision-making, and documentation.

Results: The study included 42 patients (mean [SD] age, 58.2 [11.2] years; 28 men [67%]) and 46 clinicians (13 hepatologists [28%], 11 transplant coordinators [24%], 9 hepatobiliary surgeons [20%], 6 social workers [13%], 5 hepatology nurse practitioners [11%], and 2 critical care physicians [4%]). Five themes that represent the experiences of ACP were identified: (1) most patient consideration of values, goals, and preferences occurred outside outpatient visits; (2) optimistic attitudes from transplant teams hindered the discussions about dying; (3) clinicians primarily discussed death as a strategy for encouraging behavioral change; (4) transplant teams avoided discussing nonaggressive treatment options with patients; and (5) surrogate decision makers were unprepared for end-of-life decision-making.

Conclusions And Relevance: This study found that, despite a guarded prognosis, patients with decompensated cirrhosis had inadequate ACP throughout the trajectory of illness until the end of life. This finding may explain excessively aggressive life-sustaining treatment that patients receive at the end of life.
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http://dx.doi.org/10.1001/jamainternmed.2021.0152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7961470PMC
May 2021

Innovations in Hepatitis C Screening and Treatment.

Hepatol Commun 2021 03 7;5(3):371-386. Epub 2020 Dec 7.

Division of Liver Diseases Icahn School of Medicine at Mount Sinai New York NY USA.

New therapies offer hope for a cure to millions of persons living with hepatitis C virus (HCV) infection. HCV elimination is a global goal that will be difficult to achieve using the traditional paradigms of diagnosis and care. The current standard has evolved toward universal HCV screening and treatment, to achieve elimination goals. There are several steps between HCV diagnosis and cure with major barriers along the way. Innovative models of care can address barriers to better serve hardly reached populations and scale national efforts in the United States and abroad. Herein, we highlight innovative models of HCV care that aid in our progress toward HCV elimination.
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http://dx.doi.org/10.1002/hep4.1646DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7917266PMC
March 2021

Identifying Quality Gaps in Preventive Care for Outpatients With Cirrhosis Within a Large, Academic Health Care System.

Hepatol Commun 2020 Dec 9;4(12):1802-1811. Epub 2020 Sep 9.

Vatche and Tamar Manoukian Division of Digestive Diseases Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA.

We sought to identify specific gaps in preventive care provided to outpatients with cirrhosis and to determine factors associated with high quality of care (QOC), to guide quality improvement efforts. Outpatients with cirrhosis who received care at a large, academic tertiary health care system in the United States were included. Twelve quality indicators (QIs), including preventive care processes for ascites, esophageal varices, hepatic encephalopathy, hepatocellular carcinoma (HCC), and general cirrhosis care, were measured. QI pass rates were calculated as the proportion of patients eligible for a QI who received that QI during the study period. We performed logistic regression to determine predictors of high QOC (≥ 75% of eligible QIs) and receipt of HCC surveillance. Of the 439 patients, the median age was 63 years, 59% were male, and 19% were Hispanic. The median Model for End-Stage Liver Disease-Sodium score was 11, 64% were compensated, and 32% had hepatitis C virus. QI pass rates varied by individual QIs, but were overall low. For example, 24% received appropriate HCC surveillance, 32% received an index endoscopy for varices screening, and 21% received secondary prophylaxis for spontaneous bacterial peritonitis. In multivariable analyses, Asian race (odds ratio [OR]: 3.7, 95% confidence interval [CI]: 1.3-10.2) was associated with higher QOC, and both Asian race (OR: 3.3, 95% CI: 1.2-9.0) and decompensated status (OR: 2.1, 95% CI: 1.1-4.2) were associated with receipt of HCC surveillance. A greater number of specialty care visits was not associated with higher QOC. Receipt of outpatient preventive cirrhosis QIs was variable and overall low in a diverse cohort of patients with cirrhosis. Variation in care by race/ethnicity and illness trajectory should prompt further inquiry into identifying modifiable factors to standardize care delivery and to improve QOC.
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http://dx.doi.org/10.1002/hep4.1594DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7706302PMC
December 2020

Assessment of Financial Toxicity Among Older Adults With Advanced Cancer.

JAMA Netw Open 2020 12 1;3(12):e2025810. Epub 2020 Dec 1.

Division of Hematology/Oncology, James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York.

Importance: Financial toxicity (FT), unintended and unanticipated financial burden experienced by cancer patients undergoing cancer care, is associated with negative consequences and increased risk of mortality. Older patients (≥70 years) with cancer are at risk for FT, yet data are limited on FT and whether oncologists discuss FT with their patients.

Objective: To examine the prevalence of FT in older adults with advanced cancer, its association with health-related quality of life (HRQoL), and cost conversations between oncologists and patients.

Design, Setting, And Participants: This cross-sectional secondary analysis was performed on baseline data from the Improving Communication in Older Cancer Patients and Their Caregivers study, a cluster randomized trial from 31 community oncology practices across the US that was conducted from October 29, 2014, to April 28, 2017. Participants included 536 patients with advanced cancer who answered 3 questions regarding financial toxicity. Data were analyzed from September 1, 2019, to May 1, 2020.

Exposure: Older patients undergoing cancer care treatments.

Main Outcomes And Measures: The main outcome looked at FT and its association with HRQoL. Three questions were used to identify patients 70 years or older experiencing FT. Multivariable linear regression models were used to assess the independent associations of FT with HRQoL. A single audio-recorded clinic transcript was analyzed within 4 weeks of enrollment for patients with FT. The framework method was used to identify frequency and themes related to cost conversations.

Results: This study evaluated 536 patients 70 years or older with advanced cancer. Ninety-eight patients (18.3%) reported FT; mean (SD) age was 76.4 (5.4) years; 59 (60.2%) were female, 14 (14.3%) were Black/African American, 91 (92.9%) were not employed, and 29 (29.6%) had Medicare as their sole insurance coverage. On multivariate regression analyses, FT was associated with higher levels of depression (β = 0.81; 95% CI, 0.15-1.48), anxiety (β = 1.67; 95% CI, 0.74-2.61), and distress (β = 0.73; 95% CI, 0.08-1.39) and lower HRQoL (β = -5.30; 95% CI, -8.92 to -1.69). Among those who reported FT, 49% had a conversation with their health care professional about costs. Most conversations (79%) were initiated by oncologists or patients. Four themes were generated from cost conversations: statements regarding cost of care, ability to afford medical prescriptions, indirect consequences associated with inability to work and provide for family, and cost burden in nontreatment domains.

Conclusions And Relevance: In this study, among older adults with advanced cancer, FT is associated with worse HRQoL. Almost half of conversations among patients reporting FT demonstrated costs are being actively discussed. Resources and interventions are needed to manage FT.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.25810DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8184122PMC
December 2020

Ketamine for empiric treatment of cortical spreading depolarization after subdural hematoma evacuation.

Clin Neurol Neurosurg 2021 01 17;200:106318. Epub 2020 Oct 17.

Department of Neurosurgery, Northwell Health, Manhasset, NY 11030, USA. Electronic address:

Background: It is widely known that some patients surgically treated for subdural hematoma (SDH) experience neurologic deficits not clearly explained by the acute brain injury or known sequelae like seizures. There is increasing evidence that cortical spreading depolarization (CSD) may be the cause. A recent article demonstrated that CSD occurred at a rate of 15 % and was associated with neurological deterioration in a subset of patients following chronic subdural hematoma evacuation. Furthermore, CSD can lead to ischemia leading to worsening neurologic deficits. CSD is usually detected on electrocorticography (ECoG) and needs cortical strip electrode placement with equipment and expertise that may not be readily available.

Case Description: We report three cases of patients with subdural hematoma (SDH) not undergoing ECoG in whom CSD was suspected to be the cause of their neurologic deficits post evacuation. Extensive workup including neuroimaging and electroencephalography (EEG) were inconclusive. Patients were subsequently treated with ketamine infusion and had resultant neurological recovery.

Conclusions: Ketamine infusion can help reverse neurologic deficits in patients with SDH in whom the deficits are not explained by neuroimaging or electrographic seizure. CSD is a known phenomenon that can result in neurological injury and must remain in the differential diagnosis of such patients. Though only limited cases are discussed (n = 3), this small case series provides the basis for conducting clinical trials evaluating the efficacy of ketamine in improving functional outcome in brain-injured patients demonstrating evidence of CSD.
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http://dx.doi.org/10.1016/j.clineuro.2020.106318DOI Listing
January 2021

Impact of exposure to patients with COVID-19 on residents and fellows: an international survey of 1420 trainees.

Postgrad Med J 2020 Oct 21. Epub 2020 Oct 21.

Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington, USA

Objectives: To determine how self-reported level of exposure to patients with novel coronavirus 2019 (COVID-19) affected the perceived safety, training and well-being of residents and fellows.

Methods: We administered an anonymous, voluntary, web-based survey to a convenience sample of trainees worldwide. The survey was distributed by email and social media posts from April 20th to May 11th, 2020. Respondents were asked to estimate the number of patients with COVID-19 they cared for in March and April 2020 (0, 1-30, 31-60, >60). Survey questions addressed (1) safety and access to personal protective equipment (PPE), (2) training and professional development and (3) well-being and burnout.

Results: Surveys were completed by 1420 trainees (73% residents, 27% fellows), most commonly from the USA (n=670), China (n=150), Saudi Arabia (n=76) and Taiwan (n=75). Trainees who cared for a greater number of patients with COVID-19 were more likely to report limited access to PPE and COVID-19 testing and more likely to test positive for COVID-19. Compared with trainees who did not take care of patients with COVID-19 , those who took care of 1-30 patients (adjusted OR [AOR] 1.80, 95% CI 1.29 to 2.51), 31-60 patients (AOR 3.30, 95% CI 1.86 to 5.88) and >60 patients (AOR 4.03, 95% CI 2.12 to 7.63) were increasingly more likely to report burnout. Trainees were very concerned about the negative effects on training opportunities and professional development irrespective of the number of patients with COVID-19 they cared for.

Conclusion: Exposure to patients with COVID-19 is significantly associated with higher burnout rates in physician trainees.
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http://dx.doi.org/10.1136/postgradmedj-2020-138789DOI Listing
October 2020

A Multicentered Academic Medical Center Experience of a Simulated Root Cause Analysis (RCA) for Hematology/Oncology Fellows.

J Cancer Educ 2020 Oct 14. Epub 2020 Oct 14.

James P Wilmot Cancer Institute, Division of Hematology/Oncology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14620, USA.

Quality improvement and patient safety education is an Accreditation Council for Graduate Medical Education (ACGME) common program requirement for hematology/oncology fellowships. Interprofessional clinical patient safety activities, such as root cause analyses (RCA), can be challenging to incorporate into busy schedules. We report on a multicentered experience utilizing a simulated RCA educational module in an attempt to provide fellows with the tools needed to participate in a live RCA and to increase awareness of the need to analyze patient safety events. The 2-h module included a didactic session explaining the basics of an RCA including common terminology, effective chart review, and personal interviews. The fellows assessed a patient safety event of a missed coagulopathy and created an event flow map and fishbone analysis. They then formed root cause/contributing factor statements and proposed a solution. Twenty-three fellows from two institutions completed the experience. There was a significant difference in fellow reported comfort with participating in a live RCA (p = 0.03), and in utilizing the tools of an RCA following the mock RCA experience (p = 0.005). About 70% of respondents felt that as a result of the mock RCA, they were more likely to report a near miss or adverse event and were more likely to be thorough in their documentation. Mock RCAs are a feasible method of incorporating ACGME-required patient safety activities into hematology/oncology fellow education and are effective in increasing their comfort and understanding of important quality improvement skills.
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http://dx.doi.org/10.1007/s13187-020-01899-8DOI Listing
October 2020

Acute on Chronic Liver Failure From Nonalcoholic Fatty Liver Disease: A Growing and Aging Cohort With Rising Mortality.

Hepatology 2021 May 25;73(5):1932-1944. Epub 2021 Mar 25.

Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA.

Background And Aims: We assessed the burden of nonalcoholic fatty liver disease (NAFLD)-related acute on chronic liver failure (ACLF) among transplant candidates in the United States, along with waitlist outcomes for this population.

Approach And Results: We analyzed the United Network for Organ Sharing registry from 2005 to 2017. Patients with ACLF were identified using the European Association for the Study of the Liver/Chronic Liver Failure criteria and categorized into NAFLD, alcohol-associated liver disease (ALD), and hepatitis C virus (HCV) infection. We used linear regression and Chow's test to determine significance in trends and evaluated waitlist outcomes using Fine and Gray's competing risks regression and Cox proportional hazards regression. Between 2005 and 2017, waitlist registrants for NAFLD-ACLF rose by 331.6% from 134 to 574 candidates (P < 0.001), representing the largest percentage increase in the study population. ALD-ACLF also increased by 206.3% (348-1,066 registrants; P < 0.001), whereas HCV-ACLF declined by 45.2% (P < 0.001). As of 2017, the NAFLD-ACLF population consisted primarily of persons aged ≥60 years (54.1%), and linear regression demonstrated a significant rise in the proportion of patients aged ≥65 in this group (β = 0.90; P = 0.011). Since 2014, NAFLD-ACLF grade 1 was associated with a greater risk of waitlist mortality relative to ALD-ACLF (subhazard ratio [SHR] = 1.24; 95% confidence interval [CI], 1.05-1.44) and HCV-ACLF (SHR = 1.35; 95% CI, 1.08-1.71), among patients aged ≥60 years. Mortality was similar among the three groups for patients with ACLF grade 2 or 3.

Conclusions: NAFLD is the fastest rising etiology of cirrhosis associated with ACLF among patients listed in the United States. As the NAFLD population continues to grow and age, patients with NAFLD-ACLF will likely have the highest risk of waitlist mortality.
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http://dx.doi.org/10.1002/hep.31566DOI Listing
May 2021

Telemedicine During COVID-19 and Beyond: A Practical Guide and Best Practices Multidisciplinary Approach for the Orthopedic and Neurologic Pain Physical Examination.

Pain Physician 2020 08;23(4S):S205-S238

LSU Health Science Center, New Orleans.

Background: The COVID pandemic has impacted almost every aspect of human interaction, causing global changes in financial, health care, and social environments for the foreseeable future. More than 1.3 million of the 4 million cases of COVID-19 confirmed globally as of May 2020 have been identified in the United States, testing the capacity and resilience of our hospitals and health care workers. The impacts of the ongoing pandemic, caused by a novel strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have far-reaching implications for the future of our health care system and how we deliver routine care to patients. The adoption of social distancing during this pandemic has demonstrated efficacy in controlling the spread of this virus and has been the only proven means of infection control thus far. Social distancing has prompted hospital closures and the reduction of all non-COVID clinical visits, causing widespread financial despair to many outpatient centers. However, the need to treat patients for non-COVID problems remains important despite this pandemic, as care must continue to be delivered to patients despite their ability or desire to report to outpatient centers for their general care. Our national health care system has realized this need and has incentivized providers to adopt distance-based care in the form of telemedicine and video medicine visits. Many institutions have since incorporated these into their practices without financial penalty because of Medicare's 1135 waiver, which currently reimburses telemedicine at the same rate as evaluation and management codes (E/M Codes). Although the financial burden has been alleviated by this policy, the practitioner remains accountable for providing proper assessment with this new modality of health care delivery. This is a challenge for most physicians, so our team of national experts has created a reference guide for musculoskeletal and neurologic examination selection to retrofit into the telemedicine experience.

Objectives: To describe and illustrate musculoskeletal and neurologic examination techniques that can be used effectively in telemedicine.

Study Design: Consensus-based multispecialty guidelines.

Setting: Tertiary care center.

Methods: Literature review of the neck, shoulder, elbow, wrist, hand, lumbar, hip, and knee physical examinations were performed. A multidisciplinary team comprised of physical medicine and rehabilitation, orthopedics, rheumatology, neurology, and anesthesia experts evaluated each examination and provided consensus opinion to select the examinations most appropriate for telemedicine evaluation. The team also provided consensus opinion on how to modify some examinations to incorporate into a nonhealth care office setting.

Results: Sixty-nine examinations were selected by the consensus team. Household objects were identified that modified standard and validated examinations, which could facilitate the examinations.The consensus review team did not believe that the modified tests altered the validity of the standardized tests.

Limitations: Examinations selected are not validated for telemedicine. Qualitative and quantitative analyses were not performed.

Conclusions: The physical examination is an essential component for sound clinical judgment and patient care planning. The physical examinations described in this manuscript provide a comprehensive framework for the musculoskeletal and neurologic examination, which has been vetted by a committee of national experts for incorporation into the telemedicine evaluation.
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August 2020

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

Dig Dis Sci 2021 08 14;66(8):2595-2602. Epub 2020 Sep 14.

Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

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.
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http://dx.doi.org/10.1007/s10620-020-06582-yDOI Listing
August 2021

Endoscopic ultrasound-directed transgastric ERCP (EDGE): a retrospective multicenter study.

Endoscopy 2021 06 3;53(6):611-618. Epub 2020 Sep 3.

Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.

Background: Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) is an alternative to enteroscopy- and laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Although short-term results are promising, the long-term outcomes are not known. The aims of this study were: (1) to determine the rates of long-term adverse events after EDGE, with a focus on rates of persistent gastrogastric or jejunogastric fistula; (2) to identify predictors of persistent fistula; (3) to assess the outcomes of endoscopic closure when persistent fistula is encountered.

Methods: This was a multicenter retrospective study involving 13 centers between February 2015 and March 2019. Adverse events were defined according to the ASGE lexicon. Persistent fistula was defined as an upper gastrointestinal series or esophagogastroduodenoscopy showing evidence of fistula.

Results: 178 patients (mean age 58 years, 79 % women) underwent EDGE. Technical success was achieved in 98 % of cases (175/178), with a mean procedure time of 92 minutes. Periprocedural adverse events occurred in 28 patients (15.7 %; mild 10.1 %, moderate 3.4 %, severe 2.2 %). The four severe adverse events were managed laparoscopically. Persistent fistula was diagnosed in 10 % of those sent for objective testing (9/90). Following identification of a fistula, 5 /9 patients underwent endoscopic closure procedures, which were successful in all cases.

Conclusions: The EDGE procedure is associated with high clinical success rates and an acceptable risk profile. Persistent fistulas after lumen-apposing stent removal are uncommon, but objective testing is recommended to identify their presence. When persistent fistulas are identified, endoscopic treatment is warranted, and should be successful in closing the fistula.
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http://dx.doi.org/10.1055/a-1254-3942DOI Listing
June 2021

Novel suture placement to affix overlapping metal stents in the treatment of an acute leak after sleeve gastrectomy.

VideoGIE 2020 Aug 29;5(8):344-346. Epub 2020 May 29.

Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan.

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http://dx.doi.org/10.1016/j.vgie.2020.04.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7426623PMC
August 2020

A Telephone and Mail Outreach Program Successfully Increases Uptake of Hepatocellular Carcinoma Surveillance.

Hepatol Commun 2020 Jun 24;4(6):825-833. Epub 2020 Apr 24.

Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine University of California Los Angeles Los Angeles CA.

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death worldwide. Society guidelines recommend surveillance with abdominal ultrasound with or without serum alpha-fetoprotein every 6 months for adults at increased risk of developing HCC. However, adherence is often suboptimal. We assessed the feasibility of a coordinated telephone outreach program for unscreened patients with cirrhosis within the Veteran's Affairs (VA) health care system. Using a patient care dashboard of advanced chronic liver disease in the VA Greater Los Angeles Healthcare System, we identified veterans with a diagnosis of cirrhosis, a platelet count ≤ 150,000/uL, and no documented HCC surveillance in the previous 8 months. Eligible veterans received a telephone call from a patient navigator to describe the risks and benefits of HCC surveillance. Orders for an abdominal ultrasound and alpha-fetoprotein were placed for veterans who agreed to surveillance. Veterans who were not reached by telephone received an informational letter by mail to encourage participation. Of the 129 veterans who met the eligibility criteria, most were male (96.9%). The most common etiology for cirrhosis was hepatitis C (64.3%), and most of the patients had compensated cirrhosis (68.2%). The patient navigators reached 32.5% of patients by phone. Patients in each group were similar across clinical and demographic characteristics. Patients who were called were more likely to undergo surveillance (adjusted odds ratio = 2.56, 95% confidence interval: 1.03-6.33). Most of the patients (72.1%) completed abdominal imaging when reached by phone. Targeted outreach increased uptake of HCC surveillance among patients with cirrhosis in a large, integrated, VA health care system.
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http://dx.doi.org/10.1002/hep4.1511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7262281PMC
June 2020

Integrating Palliative Care in the Management of Patients With Advanced Liver Disease.

Clin Liver Dis (Hoboken) 2020 Apr 7;15(4):136-140. Epub 2020 May 7.

Gastroenterology Massachusetts General Hospital Boston MA.

http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-4-reading-patel a video presentation of this article.
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http://dx.doi.org/10.1002/cld.936DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7206323PMC
April 2020

Patient-Controlled Analgesia Following Lumbar Spinal Fusion Surgery Is Associated With Increased Opioid Consumption and Opioid-Related Adverse Events.

Neurosurgery 2020 09;87(3):592-601

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.

Background: Optimal postoperative pain control is critical after spinal fusion surgery. There remains significant variability in the use of postoperative intravenous opioid patient-controlled analgesia (PCA) and few data evaluating its utility compared with nurse-controlled analgesia (NCA) among patients with lumbar fusion.

Objective: To investigate the efficacy of postoperative PCA compared with NCA to improve opiate prescription practices.

Methods: A retrospective review from a single institution was conducted in consecutive patients treated with posterior lumbar spinal fusion for degenerative pathology. Patients were divided into cohorts on the basis of postoperative treatment with PCA or NCA. Postoperative pain scores, length of stay, and total opioid consumption data were collected. Patients were stratified according to preoperative opioid consumption as opioid naive (0 morphine milligram equivalents [MME] daily), low consumption (1-60 MME), high consumption (61-90 MME), or very high consumption (>90 MME).

Results: A total of 240 patients were identified, including 62 in the PCA group and 178 in the NCA group. PCA patients had higher mean preoperative opioid consumption than NCA patients (49.2 vs 24.3 MME, P = .009). PCA patients had higher mean opioid consumption in the first 72 h in all 4 of the preoperative opioid consumption subcategories. Pain control and adverse event rates were similar between PCA and NCA in the low to high preoperative opioid consumption groups.

Conclusion: Postoperative PCA is associated with significantly more opioid consumption in the first 72 h after surgery and equal or worse postoperative pain scores compared with NCA after lumbar spinal fusion surgery.
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http://dx.doi.org/10.1093/neuros/nyaa111DOI Listing
September 2020

EUS-guided cholecystogastrostomy for acute cholecystitis in a patient with an omphalocele.

VideoGIE 2020 Mar 9;5(3):102-103. Epub 2020 Jan 9.

Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA.

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http://dx.doi.org/10.1016/j.vgie.2019.11.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7058710PMC
March 2020

How to focus our efforts in improving prognostic disclosure in oncology.

Cancer 2020 06 19;126(11):2716-2717. Epub 2020 Feb 19.

Division of Digestive Diseases, University of California Los Angeles, Los Angeles, California.

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http://dx.doi.org/10.1002/cncr.32767DOI Listing
June 2020

Measuring the Quality of Palliative Care for Patients with End-Stage Liver Disease.

Dig Dis Sci 2020 09 11;65(9):2562-2570. Epub 2020 Jan 11.

West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA.

Background/aims: We examined the quality of palliative care received by patients with decompensated cirrhosis using an explicit set of palliative care quality indicators (QIs) for patients with end-stage liver disease (PC-ESLD).

Methods: We identified patients newly diagnosed with decompensated cirrhosis at a single veterans health center and followed up them for 2 years or until death. We piloted measurement of PC-ESLD QIs in all patients confirmed to have ESLD using a chart abstraction tool.

Results: Out of 167 patients identified using at least one sampling strategy, 62 were confirmed to meet ESLD criteria with chart abstraction. Ninety-eight percent of veterans in the cohort were male, mean age at diagnosis was 61 years, and 74% were White. The overall QI pass rate was 68% (64% for information care planning QIs and 76% for supportive care QIs). Patients receiving specialty palliative care consultation were more likely to receive information care planning QIs (67% vs. 37%, p = 0.02). The best performing sampling strategy had a sensitivity of 62% and specificity of 60%.

Conclusion: Measuring the quality of palliative care for patients with ESLD is feasible in the veteran population. Our single-center data suggest that the quality of palliative care is inadequate in the veteran population with ESLD, though patients offered specialty palliative care consultation and those affected by homelessness, drug, and alcohol abuse may receive better care. Our combination of ICD-9 codes can be used to identify a cohort of patients with ESLD, though better sensitivity and specificity may be needed.
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http://dx.doi.org/10.1007/s10620-019-05983-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223418PMC
September 2020

Improving Advance Care Planning in Outpatients With Decompensated Cirrhosis: A Pilot Study.

J Pain Symptom Manage 2020 04 25;59(4):864-870. Epub 2019 Dec 25.

Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA.

Background: Despite significant morbidity and mortality among patients with decompensated cirrhosis, reported rates of advance directive (AD) completion and goals of care discussions (GCDs) between patients and providers are very low. We aimed to improve these rates by implementing a hepatologist-led advance care planning (ACP) intervention.

Measures: Rates of AD and GCD completion, as well as self-reported barriers to ACP.

Intervention: Provider-led ACP in patients with decompensated cirrhosis without a prior documented AD.

Outcomes: Sixty-two patients were seen over 115 clinic visits. After the intervention, AD completion rates increased from 8% to 31% and GCD completion rates rose from 0% to 51%. Women (P = 0.048) and nonmarried adults (P = 0.01) had greater changes in AD completion compared to men and married adults, respectively. Needing more time during visits was seen as the major barrier to ACP among providers.

Conclusions/lessons Learned: Addressing provider and system-specific barriers dramatically improved documentation rates of ACP.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.12.355DOI Listing
April 2020
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