Paracentesis is Associated with Reduced Mortality in Patients Hospitalized with Cirrhosis and Ascites

Diagnostic paracentesis is recommended for patients with cirrhosis admitted to the hospital for ascites or encephalopathy. However, it is not known if clinicians in the United States adhere to this recommendation; a relationship between paracentesis and clinical outcome has not been reported. We analyzed a US database to determine the frequency of paracentesis and its association with mortality. Methods The 2009 Nationwide Inpatient Sample (which contains data from approximately 8 million hospital discharges each year) was used to identify patients with cirrhosis and ascites admitted with a primary diagnosis of ascites or encephalopathy. In-hospital mortality, length of stay, and hospital charges were compared for those who did and did not undergo paracentesis. Outcomes were compared for those who received an early paracentesis (within 1 day of admission) and those who received one later. Results Of 17,711 eligible admissions, only 61% underwent paracentesis. In-hospital mortality was reduced by 24% among patients who underwent paracentesis (6.5% vs 8.5%, adjusted odds ratio [OR], 0.55; 95% confidence interval [CI], 0.41–0.74). Most paracenteses (66%) occurred ≤1 day after admission. In-hospital mortality was lower among patients who received early paracentesis than those who received it later (5.7% vs 8.1%; P=.049), although this difference was not significant after adjustment for confounders (OR, 1.26; 95% CI, 0.78–2.02). Among patients who underwent paracentesis, the mean hospital stay was 14% longer, and hospital charges were 29% greater than for patients that did not receive the procedure. Conclusions Paracentesis is underused for patients admitted to the hospital with ascites; the procedure is associated with increased short-term survival. These data support practice guidelines derived from expert opinion. Studies are needed to identify barriers to guideline adherence

The confusion assessment method for the intensive care unit in patients with cirrhosis

In the intensive care unit (ICU), delirium is routinely measured with the widely-used, validated Confusion Assessment Method for the ICU (CAM-ICU), but CAM-ICU has not been studied in patients with cirrhosis. We studied a group of patients with cirrhosis to determine the relationship between delirium measured by CAM-ICU and clinical outcomes. Consecutive patients with cirrhosis admitted to the ICU from 2009 to 2012 were included in a retrospective cohort study. Patients were screened twice daily for coma and delirium during their ICU stay using the Richmond Agitation Sedation Scale (RASS) and CAM-ICU. The association between delirium/coma and mortality was determined using multiple logistic regression. RASS and CAM-ICU were also compared to a retrospective assessment of hepatic encephalopathy (HE). Of 91 patients with cirrhosis, 26 (28.6 %) developed delirium/coma. RASS/CAM-ICU had fair agreement with the HE assessment (κ 0.38). Patients with delirium/coma had numerically greater mortality in-hospital (23.1 vs. 7.7 %, p = 0.07) and at 90 days (30.8 vs. 18.5 %, p = 0.26), and they also had longer hospital length of stay (median 19.5 vs. 6 days, p < 0.001). Delirium/coma was associated with increased inpatient mortality, independent of disease severity (unadjusted OR 3.6; 95 % CI, 0.99-13.1; MELD-adjusted OR 5.4; 95 % CI, 1.3-23.8; acute physiology score-adjusted OR 2.2; 95 % CI, 0.53-8.9). Delirium/coma was also associated with longer length of stay after adjusting for disease severity. In critically ill patients with cirrhosis, delirium/coma as measured by the RASS and CAM-ICU is associated with increased mortality and hospital length of stay. For these patients, these measures provide valuable information and may be useful tools for clinical care. RASS and CAM-ICU need to be compared to HE-specific measures in future studies

Predicting Liver Transplant Capacity Using Discrete Event Simulation

The number of liver transplants (LTs) performed in the US increased until 2006 but has since declined despite an ongoing increase in demand. This decline may be due in part to decreased donor liver quality and increasing discard of poor-quality livers. We constructed a discrete event simulation (DES) model informed by current donor characteristics to predict future LT trends through the year 2030. The data source for our model is the United Network for Organ Sharing database, which contains patient-level information on all organ transplants performed in the US. Previous analysis showed that liver discard is increasing and that discarded organs are more often from donors who are older, are obese, have diabetes, and donated after cardiac death. Given that the prevalence of these factors is increasing, the DES model quantifies the reduction in the number of LTs performed through 2030. In addition, the model estimatesthe total number of future donors needed to maintain the current volume of LTs and the effect of a hypothetical scenario of improved reperfusion technology.We also forecast the number of patients on the waiting list and compare this with the estimated number of LTs to illustrate the impact that decreased LTs will have on patients needing transplants. By altering assumptions about the future donor pool, this model can be used to develop policy interventions to prevent a further decline in this lifesaving therapy. To our knowledge, there are no similar predictive models of future LT use based on epidemiological trends

Harnessing Higher-Order (Meta-)Logic to Represent and Reason with Complex Ethical Theories

The computer-mechanization of an ambitious explicit ethical theory, Gewirth's Principle of Generic Consistency, is used to showcase an approach for representing and reasoning with ethical theories exhibiting complex logical features like alethic and deontic modalities, indexicals, higher-order quantification, among others. Harnessing the high expressive power of Church's type theory as a meta-logic to semantically embed a combination of quantified non-classical logics, our work pushes existing boundaries in knowledge representation and reasoning. We demonstrate that intuitive encodings of complex ethical theories and their automation on the computer are no longer antipodes.Comment: 14 page

Trends in Characteristics of Patients Listed for Liver Transplantation Will Lead to Higher Rates of Waitlist Removal Due to Clinical Deterioration

BACKGROUND: Changes in the epidemiology of end-stage liver disease may lead to increased risk of dropout from the liver transplant waitlist. Anticipating the future of liver transplant waitlist characteristics is vital when considering organ allocation policy. METHODS: We performed a discrete event simulation to forecast patient characteristics and rate of waitlist dropout. Estimates were simulated from 2015 to 2025. The model was informed by data from the Organ Procurement and Transplant Network, 2003 to 2014. National data are estimated along with forecasts for 2 regions. RESULTS: Nonalcoholic steatohepatitis will increase from 18% of waitlist additions to 22% by 2025. Hepatitis C will fall from 30% to 21%. Listings over age 60 years will increase from 36% to 48%. The hazard of dropout will increase from 41% to 46% nationally. Wait times for transplant for patients listed with a Model for End-Stage Liver Disease (MELD) between 22 and 27 will double. Region 5, which transplants at relatively higher MELD scores, will experience an increase from 53% to 64% waitlist dropout. Region 11, which transplants at lower MELD scores, will have an increase in waitlist dropout from 30% to 44%. CONCLUSIONS: The liver transplant waitlist size will remain static over the next decade due to patient dropout. Liver transplant candidates will be older, more likely to have nonalcoholic steatohepatitis and will wait for transplantation longer even when listed at a competitive MELD score. There will continue to be significant heterogeneity among transplant regions where some patients will be more likely to drop out of the waitlist than receive a transplant

Single Balloon Enteroscopy-Assisted ERCP for Treatment of Cholangitis in a Patient with a Kasai Portoenterostomy

Primary therapy for biliary atresia is a surgical hepatoportoenterostomy (Kasai procedure), which has been shown to reduce mortality, but is frequently complicated by ascending cholangitis and the development of biliary cirrhosis. Previously reported therapy for recurrent cholangitis caused by biliary obstruction has included surgical revision and percutaneous biliary drainage, but ERCP has not been previously described. Here we report a patient with recurrent cholangitis following a Kasai procedure and an anastomotic stricture successfully treated with single balloon enteroscopy-assisted ERCP. This novel technique could be considered in patients with this common complication of the Kasai procedure, and may impact long-term outcomes in this patient population

Impact of nighttime and weekend liver transplants on graft and patient outcomes

Safety concerns have been raised about nocturnal and weekend patient care, but it is unknown if these issues effect liver transplantation. We sought to identify the impact of nighttime and weekend liver transplants on graft and patient survival. We utilized the United Network of Organ Sharing database to review adult liver transplants from 1987 to 2010. Comparisons were made between nighttime and daytime operations, and weekday and weekend operations. Cox proportional hazard ratios were determined at 30, 90 and 365 days post-transplant after controlling for relevant factors. 94,768 transplants were included in the analysis. Patient survival at 30, 90 and 365 days for nighttime operations was 96%, 93% and 86%. Patient survival at 30, 90 and 365 days for weekend operations was 95%, 92% and 86%. This was no different from daytime or weekday operations, respectively. Graft failure was unchanged at 30 and 90 days for weekend transplants, but was modestly increased at 365 days (HR: 1.05 (1.01-1.11). Graft survival was unaffected by nighttime transplant. Nighttime and weekend operations for liver transplantation do not impact patient or graft survival, testifying to patient safety measures in place

Community Structure Characterization

This entry discusses the problem of describing some communities identified in a complex network of interest, in a way allowing to interpret them. We suppose the community structure has already been detected through one of the many methods proposed in the literature. The question is then to know how to extract valuable information from this first result, in order to allow human interpretation. This requires subsequent processing, which we describe in the rest of this entry

Declining liver graft quality threatens the future of liver transplantation in the United States

National liver transplantation (LT) volume has declined since 2006, in part because of worsening donor organ quality. Trends that degrade organ quality are expected to continue over the next 2 decades. We used the United Network for Organ Sharing (UNOS) database to inform a 20-year discrete event simulation estimating LT volume from 2010 to 2030. Data to inform the model were obtained from deceased organ donors between 2000 and 2009. If donor liver utilization practices remain constant, utilization will fall from 78% to 44% by 2030, resulting in 2230 fewer LTs. If transplant centers increase their risk tolerance for marginal grafts, utilization would decrease to 48%. The institution of "opt-out" organ donation policies to increase the donor pool would still result in 1380 to 1866 fewer transplants. Ex vivo perfusion techniques that increase the use of marginal donor livers may stabilize LT volume. Otherwise, the number of LTs in the United States will decrease substantially over the next 15 years. In conclusion, the transplant community will need to accept inferior grafts and potentially worse posttransplant outcomes and/or develop new strategies for increasing organ donation and utilization in order to maintain the number of LTs at the current level