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The Association of Black Gastroenterologists and Hepatologists (ABGH) was established to improve health equity in Black communities and to provide academic and social support for Black gastroenterologists and hepatologists. In this Viewpoint, four members of ABGH (early career, mid-career and late career) discuss their route into gastroenterology and hepatology, how academia and medicine can promote inclusivity and equity, and their advice to Black students interested in a career in medicine or science.

Background Web-based portals can enhance communication between patients and providers to support IBD self-management and improve care. We aimed to identify portal use patterns of patients with inflammatory bowel disease (IBD) to inform future web portal-based interventions and portal design. Methods Patients with IBD receiving care at the University of Michigan between 2012 and 2021 were identified. Meta-data from electronic logs of each patient’s most recent year of portal use were abstracted. Portal engagement was characterized in terms of intensity (ie, frequency of use); comprehensiveness (ie, number of portal functions used); and duration (ie, quarters per year of portal use). We used k-means clustering, a machine-learning technique, to identify groupings of portal users defined in terms of engagement features. Results We found 5605 patients with IBD who had accessed their portal account at least once. The average age was 41.2 years (SD 16.7), 3035 (54.2%) were female, and 2214 (39.5%) received immune-targeted therapies. We identified 3 patterns of portal engagement: (1) low intensity users (29.5%); (2) moderate intensity, comprehensive, and sustained users (63.3%); and (3) high intensity, comprehensive, sustained users (7.2%). Patients with more intense, comprehensive, and sustained use of the portal were older, female, with more comorbidities, and were more likely to receive immune-targeted therapies. Conclusion Understanding distinct patterns of portal use can inform portal-based interventions and portal design. Patient portals may be particularly helpful in delivering assistance to those with comorbidities and those receiving immune-targeted therapies—many of whom demonstrate more intense, comprehensive, and sustained portal use.

The aim of this study was to determine the utility of combining three K72 codes (hepatic failure) with 15 individual T-Codes (drug toxicity/poisoning) to identify potential DILI cases. The EMR was searched for encounters that had a K72 code combined with a T-code that also met minimal liver injury laboratory criteria between 10/1/15 and 9/30/18. After manual chart review, a DILIN expert opinion causality score (1–5) was assigned to each case. Among the 345 patient encounters identified, mean age was 57 years, 53% were male, and 89% Caucasian. Thirty-seven cases (10.7%) were adjudicated as probable DILI with antibiotics being the most frequently identified suspect drugs. Of the 308 non-DILI cases, liver injury was most commonly due to congestive hepatopathy (38%) and hepatic metastases (15%). The probable-DILI cases were significantly more likely to have hepatocellular liver injury (57% vs 32.5%, p = 0.01), higher total bilirubin levels (7.7 vs 4.6 mg/dl, p = 0.03), and more severe liver injury scores (p

Frailty is a powerful prognostic tool in cirrhosis. Claims- based frailty scores estimate the presence of frailty without the need for in- person evaluation. These algorithms have not been validated in cirrhosis. Whether they measure true frailty or perform as well as frailty in outcome prediction is unknown. We evaluated 2 claims- based frailty scores— Hospital Frailty Risk Score (HFRS) and Claims- Based Frailty Index (CFI)— in 3 prospective cohorts comprising 1100 patients with cirrhosis. We assessed differences in neuromuscular/neurocognitive capabilities in those classified as frail or nonfrail based on each score. We assessed the ability of the indexes to discriminate frailty based on the Fried Frailty Index (FFI), chair stands, activities of daily living (ADL), and falls. Finally, we compared the performance of claims- based frailty measures and physical frailty measures to predict transplant- free survival using competing risk regression and patient- reported outcomes. The CFI identified neuromuscular deficits (balance, chair stands, hip strength), whereas the HFRS only identified poor chair- stand performance. The CFI had areas under the receiver operating characteristic curve (AUROCs) for identifying frailty as measured by the FFI, ADL, and falls of 0.57, 0.60, and 0.68, respectively; similarly, the AUROCs were 0.66, 0.63, and 0.67, respectively, for the HFRS. Claims- based frailty scores were associated with poor quality of life and sleep but were outperformed by the FFI and chair stands. The HFRS, per 10- point increase (but not the CFI) predicted survival of patients in the liver transplantation (subdistribution hazard ratio [SHR], 1.08; 95% confidence interval [CI], 1.03– 1.12) and non– liver transplantation cohorts (SHR, 1.13; 95% CI, 1.05– 1.22). Claims- based frailty scores do not adequately associate with physical frailty but are associated with important cirrhosis- related outcomes.

Background and Aims Multiple medications are associated with an increased risk of incident hepatic encephalopathy. Despite this known risk, medications such as opioids, benzodiazepines, gabapentin/pregabalin, and/or proton pump inhibitors are increasingly prescribed to persons with cirrhosis. Deprescribing is a promising intervention to reduce the burden of hepatic encephalopathy. Given that deprescribing has not been trialed in cirrhosis, we evaluated the barriers and facilitators to safe and successful deprescribing in cirrhosis. Methods We conducted, transcribed, and analyzed semi‐structured interviews using qualitative methodology with 22 subjects. This included eight patients with cirrhosis and recent use of opiates, benzodiazepines, gabapentin/Lyrica, and/or proton pump inhibitors as well as 14 providers (primary care, transplant surgery, transplant hepatology). Interviews explored opinions, behaviors, and understanding surrounding the risks and benefits of deprescribing. Results Major provider‐specific barriers included deferred responsibility of the deprescribing process, knowledge gaps regarding the risk of hepatic encephalopathy associated with medications (e.g., proton pump inhibitors) as well as the safe method of deprescription (i.e., benzodiazepines), and time constraints. Patient‐specific barriers included knowledge gaps regarding the cirrhosis‐specific risks of their medications and anxiety about the recurrence of symptoms after medication discontinuation. Patients uniformly reported trust in their provider's opinions on risks and wished for more comprehensive education during or after visits. Providers uniformly reported support for deprescription resources including pharmacist or nurse outreach. Conclusion Given knowledge of medication risks related to hepatic encephalopathy in patients with cirrhosis, deprescribing is universally seen as important. Knowledge gaps, inaction, and uncertainty regarding feasible alternatives prevent meaningful implementation of deprescription. Trials of protocolized pharmacy‐based deprescribing outreach and patient‐facing education on risks are warranted., Key Summary Summarize the established knowledge on this subject Hepatic encephalopathy (HE) is a morbid complication of cirrhosis.The risk of HE may be increased by psychoactive medications and proton pump inhibitors.Deprescribing is felt to be a promising approach to HE prevention. What are the significant and/or new findings of this study? Patients are unaware of how their medications influence the risk of HE.Patients are willing to follow physician recommendations regarding deprescribing but are afraid of worsening symptoms.Physicians do not feel comfortable deprescribing opioids or benzodiazepines.Physicians do not feel responsible or equipped with the resources for deprescribing.

BACKGROUND AND AIMS: The development of cirrhosis-related smartphone applications for remote monitoring is increasing. Whether patients with cirrhosis will welcome such new technology, however, is uncertain. METHODS: We prospectively enrolled patients with cirrhosis (N = 102) to determine predictors of acceptance and utilization of a smartphone application for cirrhosis management using a 12-item Technology Acceptance Model (TAM) survey. Patients were then shown the EncephalApp(©) and evaluated for their willingness to download and use the application. RESULTS: Patients had a median age of 61.3 years and 63.7% had a history of hepatic decompensation. Intention to use the hypothetical application was associated with perceived usefulness (β: 0.4, 95% CI: 0.3–0.5) and the presence of a caregiver (β: 1.1, 95% CI: 0.2–2.0). Of the eligible participants, 71% agreed to download the EncephalApp(©) and the decision was influenced by computer anxiety, behavioural intent, caregiver presence and disease state factors. Actual usage was 32% and not associated with baseline characteristics or the technology acceptance model. CONCLUSIONS: Patient acceptance of smartphone applications for the management of cirrhosis is high and related to their attitudes towards technology and the presence of a caregiver. However, usage was low. Future research must employ behavioural interventions to optimize uptake and utilization of remote monitoring technology.

INTRODUCTION: Idiosyncratic drug-induced liver injury (DILI) is an important cause of liver injury that is difficult to diagnose and identify in the electronic medical record (EMR). OBJECTIVE: Our objective was to develop a computerized algorithm that can reliably identify DILI cases from the EMR. METHODS: The EMR was searched for all encounters with an International Classification of Diseases, Tenth Revision (ICD-10) T code for drug toxicity and a K-71 code for toxic liver injury between 1 October 2015 and 30 September 2018. Clinically significant liver injury was defined using predetermined laboratory values. An expert opinion causality score (1–3 = probable DILI, 4/5 = non-DILI), Roussel Uclaf Causality Assessment Method (RUCAM) score, and severity score was assigned to each case. RESULTS: Among the 1,211,787 encounters searched, 517 had both an ICD-10 T code and a K-71 code, with 257 patients meeting the laboratory criteria. After excluding 75 cases of acetaminophen hepatotoxicity, the final study sample included 182 cases of potential DILI, with antineoplastics and antibiotics being the most frequently implicated agents. Causality assessment identified probable DILI in 121 patients (66.5%), whereas 61 (33.5%) had an alternative cause of liver injury. Although age, sex, race, and suspect drugs were similar, the probable DILI cases were more likely to present with a hepatocellular injury profile and have more severe liver injury than the non-DILI cases (p < 0.05). CONCLUSION: A computerized algorithm based on a combination of ICD-10 codes identified 182 potential DILI cases with 121 true positives, 61 false positives, and a positive predictive value of 66.5%. Future studies incorporating natural language processing may further improve the utility of this algorithm in identifying high-causality idiosyncratic DILI cases.

We examined trends in rural-urban cirrhosis mortality disparities in the United States from decedents aged 25 years and older from 1999 to 2019.We calculated cirrhosis age-adjusted mortality rates across 3 population categories: large metropolitan (≥1 million), medium/small metropolitan (50,000-999,999), and rural (50,000) areas using the US Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research database.We found an almost 20-fold increase in the absolute difference in cirrhosis age-adjusted mortality rates between rural and large metropolitan areas between 1999 and 2019.Future research is needed to investigate reasons for this widening rural-urban disparity to improve rural cirrhosis care.

BACKGROUND: Frailty is an important contributor to morbidity and mortality in chronic liver disease. Understanding the contributors to frailty has the potential to identify individuals at risk for frailty and may potentially provide targets for frailty-modifying interventions. We evaluated the relationship among cognitive function, inflammation, and sarcopenia and frailty. METHODS: Using cohorts from the Framingham Heart Study (2011-2014), we evaluated for factors associated with frailty. Exposures included cognitive tests (combined Trails A/B test, Animal Naming Test, and combined Digit Span Forward/Backward test), inflammation (interleukin-6 and tumor necrosis factor receptor II), and sarcopenia (creatinine-to-cystatin C ratio). We performed linear and logistic regression to identify the relationship between these exposures and the Liver Frailty Index (LFI). RESULTS: The study population (N = 1208) had a median age of 70 years, was 56% female, and 48.5% had evidence of liver disease. The combined Trails A/B test (β 0.05, P < .001), creatinine-to-cystatin C (β −0.17, P = .006), and both inflammatory markers, interleukin-6 levels (β 0.16, P = .002) and tumor necrosis factor receptor II (β 0.21, P = .04), were independently associated with the LFI. Using an LFI cutoff of ≥4.5 to define frailty, Trails A/B (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.07-1.37), Animal Naming Test (OR 0.64, 95% CI 0.42-0.97), sarcopenia (OR 0.10, 95% CI 0.01-0.73), and interleukin-6 (OR 4.99, 95% CI 1.03-15.53) were all associated with frailty. Although liver disease did not modify the relationship between the LFI and the Trails A/B test, interleukin-6 was significantly associated with the LFI only in the presence of liver disease. CONCLUSIONS: Cognitive performance, inflammation, and sarcopenia, each highly prevalent in cirrhosis, are associated with the LFI in this population-based study of persons without cirrhosis. Further research is warranted for interventions aiming to prevent frailty by tailoring their approach to the patient’s underlying risk factors.

BACKGROUND: Advances in imaging technology have the potential to transform the early diagnosis and treatment of hepatocellular carcinoma (HCC) through quantitative image analysis. Computational ‘radiomic’ techniques extract biomarker information from images which can be used to improve diagnosis and predict tumor biology. AIMS: We performed a systematic review of literature on radiomic features in HCC diagnosis and prognosis, with a focus on reporting metrics and methodologic standardization. METHODS: A systematic review was performed of all full-text articles published from inception through December 1, 2019. Standardized data extraction and quality assessment metrics were applied to all studies. RESULTS: A total of 54 unique studies were included for analysis. Radiomic features demonstrated good discriminatory performance to differentiate HCC from other solid lesions (c-statistics 0.66–0.95), predict microvascular invasion (c-statistic 0.76–0.92), predict early recurrence after hepatectomy (c-statistics 0.71–0.86), and predict prognosis after locoregional or systemic therapies (c-statistics 0.74–0.81). Common stratifying features for diagnostic and prognostic radiomic tools included analyses of imaging skewness, analysis of the peritumoral region, and feature extraction from the arterial imaging phase. The overall quality of the included studies was low, with common deficiencies in both internal and external validation, standardized imaging segmentation, and lack of comparison to a gold standard. CONCLUSIONS: Quantitative image analysis demonstrates promise as a non-invasive biomarker to improve HCC diagnosis and management. However, standardization of protocols and outcome measurement, sharing of algorithms and analytic methods, and external validation are necessary prior to widespread application of radiomics to HCC diagnosis and prognosis in clinical practice.

Prior drug allergies are common and may increase susceptibility to adverse medication effects. The aim of this study was to compare the frequency, clinical features, and outcomes of DILI among patients with and without a history of prior drug allergy.The EMR at a large liver referral center was searched for all DILI encounters using ICD-10 T-codes for drug poisoning/toxicity and K-71 codes for toxic liver injury between 10/1/2015 and 9/30/2019. Clinically significant liver injury was identified using predefined laboratory criteria, and cases were adjudicated using a 5-point expert opinion scale: 1/2/3 = probable DILI and 4/5 = non-DILI. Drug allergy was defined as a history of anaphylaxis, hives, rash, or pruritus after drug exposure.Among 766,930 patient encounters, 127 unique patients met inclusion criteria with 72 (56.7%) cases adjudicated as probable DILI and 55 (43.3%) as non-DILI. In the probable DILI group, the most frequent suspect drug classes were: antimicrobials (41.9%), herbal and dietary supplements (9.5%), and antineoplastics (8.1%). Twenty-three of the 72 DILI patients (31.9%) had a history of drug allergy before the DILI episode compared to 16 (29.1%) of the 55 non-DILI cases (p = 0.89). However, none of the allergy drugs and suspect DILI drugs were the same although many were in the same drug class. DILI patients with a prior drug allergy were more likely to be female (73.9% vs. 44.9%, p = 0.04) and have lower serum bilirubin (4.0 vs. 7.8, p = 0.08) and INR (1.1 vs. 1.6, p = 0.043) levels at presentation. The likelihood of death or liver transplantation among probable DILI cases with prior drug allergy was lower than those without prior drug allergy (0% vs. 8.2%, p = 0.35). The suspect drug was subsequently documented in the "Drug Allergy" section of the EMR in only 23 (31.9%) of the 72 probable DILI patients, and these patients were more likely to present with a rash (7% vs. 2%, p = 0.006) and higher serum bilirubin levels (10.5 vs. 4.7, p = 0.008) compared to those in whom the suspect drug was not listed as "drug allergy."A prior drug allergy history was not associated with a greater likelihood of developing DILI compared to other causes of acute liver injury. However, the probable DILI patients with a history of prior drug allergy tended to have less severe liver injury and clinical outcomes. The low rate of suspect drug documentation in the "Drug Allergy" section of EMR after a DILI episode is of concern and could lead to avoidable harm from inadvertent suspect drug re-challenge.

The prognosis of critically ill patients with cirrhosis who require mechanical ventilation is guarded. Data are lacking for the optimal therapeutic approach to hepatic encephalopathy (HE) in the ventilated patient.Retrospective cohort analysis of 314 encounters (298 patients) with cirrhosis who underwent mechanical ventilation in a medical ICU and were ordered at least 1 dose of lactulose. Hazard of extubation alive was determined using a competing risk model. Primary exposures were HE therapy (lactulose and rifaximin) which were adjusted for the indication for ventilation (HE, procedures, respiratory failure), age, MELD-Na, and compensation status.Indications for ventilation were 22.3% for grade 4 HE, 29.9% for procedures, and 47.8% for respiratory or cardiovascular failure. Median length of intubation was 2.63 days; death rate on ventilator was 31.2%. Relative to intubation for procedure, hazard of extubation for intubation for HE was 0.34 (95% confidence interval (CI): 0.22-0.52) and 0.33 (CI: 0.23-0.47) for respiratory failure. Hazard of extubation for rifaximin administration within 24-h after intubation was significant at 1.74 (1.21-2.50). Lactulose dosing was not significant for hazard of extubation.Mortality is high for all patients with cirrhosis requiring mechanical ventilation, including those intubated for grade 4 HE. Efforts to optimize the odds of successful extubation are urgently needed. Our findings suggest improved incidence of extubation associated with rifaximin administration in the first 24-h after intubation. Prospective, multi-center data to confirm these findings in this vulnerable population are warranted.

Thromboelastography (TEG) and Rotational Thromboelastometry (ROTEM) analyze hemostatic function in patients with coagulopathy. We sought to quantify the impact of TEG and ROTEM-guided transfusion algorithms on blood product utilization in patients with cirrhosis undergoing non-surgical procedures.We performed a systematic review and meta-analysis on the utility of viscoelastic testing prior to non-surgical procedures to determine their impact on pre-procedural blood product use and post-procedural bleeding events. Studies comparing TEG or ROTEM-guided transfusions with standard-of-care (SOC) prior to non-surgical procedures in adult patients with cirrhosis were included. Primary outcomes were fresh frozen plasma (FFP) and platelet transfusion and secondary outcomes of post-procedure bleeding, transfusion-related complications, and mortality; and were reported as standardized mean differences (SMD) and risk ratios (RR).Six studies (five randomized controlled trials and one cohort study) involving 367 patients met inclusion criteria. Compared with SOC, TEG/ROTEM-guided transfusions led to an overall decreased number of patients who received FFP transfusions (SMD = -0.93, 95% CI [-1.54, -0.33], p 0.001) and platelets transfusions (SMD = -1.50, CI [-1.85, -1.15], p 0.001). Total amount of FFP (SMD-0.86, p 0.001) and platelet (SMD = -0.99, p 0.001) transfused in the TEG/ROTEM group were also lower. Decreased pre-procedure transfusion in the TEG/ROTEM group did not result in increased post-procedure bleeding (RR = 0.61, p = 0.09) or in mortality (RR = 0.91, p = 0.93).In patients with cirrhosis, TEG or ROTEM significantly reduces blood product utilization prior to non-surgical procedures, with no increase in post-procedure bleeding or mortality. TEG and ROTEM utilization can promote high-value care and improve transfusion stewardship in this population.

Background: Cirrhosis is associated with increased perioperative risks related to hepatic decompensation. However, data are lacking regarding the incidence and outcomes of postoperative hepatic encephalopathy (HE). Objective: To determine the incidence of HE postoperatively, factors associated with its development, and its association with in-hospital mortality. Methods: Retrospective cohort study of 583 patients with cirrhosis undergoing non-hepatic surgery over a 10-year period. Outcomes included postoperative HE and in-hospital mortality and were, respectively, evaluated using multi-state modeling and Fine-Gray competing risk regression (with postoperative HE as a time-varying covariate). Results: Overall, the median Model for End-Stage Liver Disease Sodium was 10, 61.7% had a history of ascites, 49.9% esophageal varices, and 34.6% HE. The most common surgeries including abdominal/non-bowel (33.3%), orthopedic (18.0%), and bowel (12.2%). A total of 42 (7.2%) patients developed HE postoperatively during admission. The cumulative risk of HE was 7.2%, which was most associated with a history of HE, ASA class, postoperative AKI, and postoperative infection. In-hospital mortality occurred in 34 (5.8%) individuals. Only ASA class was independently associated (HR 2.46, 95%CI 1.21–5.02), but there was a trend for postoperative HE (HR 1.71, 95%CI 0.73–3.98). Discussion: HE is an uncommon but not rare postoperative complication that increases the risk of patient harm. This study implies its development is predictable. Consequently, at-risk patients should have consultation with a hepatologist before undergoing elective surgery.

Background and Aims Intestinal strictures are a common complication of Crohn’s disease (CD). Biomarkers of intestinal strictures would assist in their prediction, diagnosis, and monitoring. Herein we provide a comprehensive systematic review of studies assessing biomarkers that may predict or diagnose CD-associated strictures. Methods We performed a systematic review of PubMed, EMBASE, ISI Web of Science, Cochrane Library, and Scopus to identify citations pertaining to biomarkers of intestinal fibrosis through July 6, 2020, that used a reference standard of full-thickness histopathology or cross-sectional imaging or endoscopy. Studies were categorized based on the type of biomarker they evaluated (serum, genetic, histopathologic, or fecal). Results Thirty-five distinct biomarkers from 3 major groups were identified: serum (20 markers), genetic (9 markers), and histopathology (6 markers). Promising markers include cartilage oligomeric matrix protein, hepatocyte growth factor activator, and lower levels of microRNA-19-3p (area under the curves were 0.805, 0.738, and 0.67, respectively), and multiple anti-flagellin antibodies (A4-Fla2 [odds ratio, 3.41], anti Fla-X [odds ratio, 2.95], and anti-CBir1 [multiple]). Substantial heterogeneity was observed and none of the markers had undergone formal validation. Specific limitations to acceptance of these markers included failure to use a standardized definition of stricturing disease, lack of specificity, and insufficient relevance to the pathogenesis of intestinal strictures or incomplete knowledge regarding their operating properties. Conclusions There is a lack of well-defined studies on biomarkers of intestinal stricture. Development of reliable and accurate biomarkers of stricture is a research priority. Biomarkers can support the clinical management of CD patients and aid in the stratification and monitoring of patients during clinical trials of future antifibrotic drug candidates.

Ammonia is key in the development of hepatic encephalopathy. A clear relationship between the degree of hyperammonemia and worsening encephalopathy is well-established in acute liver failure. The utility of ammonia testing in the diagnosis of overt hepatic encephalopathy (OHE), however, has been repeatedly questioned. First, the route (venous or arterial), laboratory and prandial state all contribute to wide variations in ammonia levels.1 Second, the correlation between ammonia levels and stage of OHE is only modest with many patients with ‘normal’ levels presenting with clinically high-grade encephalopathy.2 Lastly, hepatic encephalopathy is a clinical diagnosis dependent on a history and physical examination; as such, ammonia is notably absent from diagnostic and grading algorithms. Therefore, since ammonia levels are often not clinically relevant, its frequent misuse can result in excess healthcare costs. To answer the question of the impact of excessive ammonia ordering, Aby et al explore the prevalence and resulting financial consequences of inappropriate ammonia testing.3 In a large multicentre retrospective analysis, the authors longitudinally reviewed the frequency of inappropriate ammonia testing; defined as indications for testing other than for acute liver failure, urea cycle disorder …

Background Coronavirus disease-2019 (COVID-19) is a global pandemic. Obesity has been associated with increased disease severity in COVID-19, and obesity is strongly associated with hepatic steatosis (HS). However, how HS alters the natural history of COVID-19 is not well characterized, especially in Western populations. Aims To characterize the impact of HS on disease severity and liver injury in COVID-19. Methods We examined the association between HS and disease severity in a single-center cohort study of hospitalized COVID-19 patients at Michigan Medicine. HS was defined by either hepatic steatosis index > 36 (for Asians) or > 39 (for non-Asians) or liver imaging demonstrating steatosis > 30 days before onset of COVID-19. The primary predictor was HS. The primary outcomes were severity of cardiopulmonary disease, transaminitis, jaundice, and portal hypertensive complications. Results In a cohort of 342 patients, metabolic disease was highly prevalent including nearly 90% overweight. HS was associated with increased transaminitis and need for intubation, dialysis, and vasopressors. There was no association between HS and jaundice or portal hypertensive complications. In a sensitivity analysis including only patients with liver imaging > 30 days before onset of COVID-19, imaging evidence of hepatic steatosis remained associated with disease severity and risk of transaminitis. Conclusions HS was associated with increased disease severity and transaminitis in COVID-19. HS may be relevant in predicting risk of complications related to COVID-19.

BACKGROUND: Patients with decompensated cirrhosis are at high risk of frequent hospitalizations. Whether the level of perceived social support impacts this risk is unknown. We sought to determine the relationship between social support and burden of hospitalization in patients with decompensated cirrhosis. METHODS: A total of 73 patients, all with decompensated cirrhosis and an index cirrhosis-related admission between 7/1/2017 and 7/1/2019, completed the modified medical outcomes study social support (mMOS-SS) survey. We retrospectively assessed the relationship between mMOS-SS scores and probability of readmission 90-days after the index admission. Additionally, we prospectively analyzed the association between mMOS-SS scores at enrollment and risk of 90-day hospitalization. RESULTS: At enrollment, 50.7% were female, median age 61 years, and median mMOS-SS score was 87.5. Median model for end-stage liver disease sodium (MELD-Na) at the time of the index admission was 15 and was 13 at the time of enrollment. The mMOS-SS score did not modify the rate of readmission 90-days after the index admission date (adjusted HR 1.01, 95%CI 0.98-1.03) nor was it associated with the rate of admission 90-days after enrollment prospectively (adjusted HR 0.99, 95%CI 0.96-1.02). The MELD-Na score at enrollment was the only significant predictor of hospitalization during prospective follow-up (adjusted HR 1.18, 95%CI 1.09-1.27). CONCLUSIONS: Social support, as measured by the mMOS-SS survey, in patients with decompensated cirrhosis was high. However, this did not modify the risk of cirrhosis-related hospitalizations. Future investigation to define the specific components of social support that could modify readmission risk is needed.

INTRODUCTION: COVID-19 is a global pandemic However, the effects of underlying liver disease on COVID-19 in the United States is not well described We investigated whether COVID-19 was associated with elevations in liver enzymes or hepatic decompensation in patients with underlying hepatic steatosis METHODS: We retrospectively reviewed the charts of consecutive adults with RT-PCR positive for COVID-19 treated at Michigan Medicine between March 1 and April 30, 2020, who had ultrasound, computed tomography, or magnetic resonance imaging >30 days before COVID-19 diagnosis Hepatic steatosis was defined based on imaging Outcomes were: (1) peak ALT or bilirubin following COVID-19 diagnosis, (2) ALT >2 or = times upper limit of normal (ULN), defined as the higher of baseline ALT or 19 U/L in women and 30 U/L in men, (3) jaundice defined as bilirubin >2 or 4mg/ dl, and (4) new/worsening ascites or encephalopathy We conducted regressions with the above outcomes as dependent variables and hepatic steatosis as the primary predictor, adjusting for age, sex, race, recent healthcare exposure, body mass index, hypertension, dyslipidemia, and diabetes These regression models were logistic for outcomes of abnormal ALT or bilirubin, and linear for maximal ALT or bilirubin RESULTS: Of patients with prior imaging, 80/159 (50 3%) had steatosis Overall, 89% of patients were hospitalized, 51% were admitted to intensive care, and 16% died 14% had chronic liver disease other than NAFLD, 5% had cirrhosis, and 2 7% had prior liver decompensation with ascites, variceal bleeding, or hepatic encephalopathy Patients with steatosis were older, had higher body mass index, and were more often Black than those without steatosis (Table 1) Baseline ALT and total bilirubin were higher in the steatosis group (Table 1) Hepatic steatosis was associated with increased incidence of ALT >2x ULN (OR 2 93 [1 23-6 97]) or >5x ULN (OR 6 21 [1 45-26 62]), and with peak ALT (beta 39 7 [7 85-71 49]) (Table 2) Hepatic steatosis was not associated with increased bilirubin (Table 2) Rates of new/worsening ascites and encephalopathy were very low: 1 3% and 2 5%, respectively, with no difference based on NAFLD status (P >0 4 for both) CONCLUSION: Hepatic steatosis is associated with acute hepatocellular injury with COVID-19 infection Steatosis was not associated with jaundice Rates of new/worsening ascites or hepatic encephalopathy were very low and unrelated to steatosis status

INTRODUCTION: Coronavirus disease (COVID)-19 is a global pandemic that carries significant morbidity and mortality However, the effect of COVID-19 on liver disease, and vice versa, is not well-characterized in the United States Non-alcoholic fatty liver disease (NAFLD) is a highly prevalent condition associated with metabolic disease including diabetes and obesity We examined the association between NAFLD and COVID19 disease severity in a large cohort of patients METHODS: We retrospectively reviewed a cohort of 396 consecutive adult patients with RT-PCR positive for COVID-19 between March 1 and April 30, 2020 at Michigan Medicine NAFLD was defined as either prior imaging evidence of steatosis or hepatic steatosis index >36 for Asians or >39 for non-Asians, with no history of alcohol abuse The primary outcome was disease severity based on admission to intensive care, intubation, death, or the World Health Organization (WHO) ordinal scale We used multivariable logistic regression to assess the predictors of intensive care, intubation, or death and linear regression for disease severity on WHO ordinal scale NAFLD was the primary predictor and models were adjusted for age, sex, race, recent healthcare exposure, hypertension, and dyslipidemia RESULTS: The median age was 60 5 years, 52% were male, 46% were Black, 41% were White and 54% had NAFLD Of 396 patients, 86% were hospitalized, 45% required intensive care, 30% required intubation, and 14% died 213 (54%) patients had NAFLD Patients with NAFLD were older (65 vs 57 years;P < 0 001), had higher body mass index (34 5 vs 26 4;P < 0 001), and higher prevalence of diabetes (45% vs 34%;P = 0 039) than those without NAFLD (Table 1) NAFLD was independently associated with increased odds of requiring admission to the intensive care unit (odds ratio [OR] 1 66 [1 06-2 62], P = 0 027) and intubation (OR 2 46 [1 50-4 04], P < 0 001), as well as higher WHO ordinal scale (beta 0 43 [0 03-0 84], P = 0 036) There was no significant association between NAFLD and death (OR 0 84 [0 46-1 67], P = 0 62) (Table 2 ) CONCLUSION: Our study shows that patients with NAFLD were more likely to develop severe disease with COVID-19 (Table Presented)

OBJECTIVES: Hepatic encephalopathy (HE) is common in advanced cirrhosis and is characterized by marked neuropsychiatric abnormalities. However, despite its severity and effects on brain function, the impact of HE on psychological status of patients has not been adequately assessed. The aim of this study was to evaluate the effect of HE on psychological status of patients and their informal caregivers. METHODS: Fifteen patients with cirrhosis and episodic or persistent HE and their corresponding informal caregivers were included. Semistructured interviews were performed in patients and caregivers. Quality of life (QoL) was assessed by the short-form 36 in both patients and caregivers, and the Zarit burden score was measured in caregivers. The analysis of interviews was performed using qualitative methodology. RESULTS: HE causes a major psychological impact on patients with HE. The first episode of HE caused a very significant impact that was reported with deep feelings, mainly of fear, anger, misery, anxiety, and sorrow, which persisted with time. Symptoms causing more psychological impact on patients were impaired ability to walk and speak. All effects were associated with a marked impairment in QoL. The psychological impact was also marked in caregivers who had a major burden, as assessed by the Zarit score. Moreover, QoL, particularly the mental component score, was markedly impaired in caregivers in intensity similar to that of patients. DISCUSSION: HE has a profound psychological impact on patients and their informal caregivers, associated with a marked negative influence on QoL. The psychological effects of HE on patients and caregivers should be evaluated and treated.