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Using data from Time History of Events and Macroscale Interactions during Substorms (THEMIS), a statistical study was performed to determine whether a dawn-dusk asymmetry exists in the occurrence rates of the Kelvin-Helmholtz instability during Parker-Spiral (PS) and Ortho-Parker-Spiral (OPS) orientations of the interplanetary magnetic field (IMF). It is determined from the data that there is a strong preference toward the dawnside during PS orientation, and although a preference to the duskside during OPS is suggested, this requires further study for an unambiguous confirmation. The uncertainty in the OPS result is due to a low number of events, which satisfied our selection criteria. Because IMF is statistically in PS orientation, the Kelvin-Helmholtz instability (KHI) preference for the dawn flank during this orientation may help explain the origin of the plasma sheet asymmetry of cold component ions because it has been shown that KHI can drive kinetic-scale wave activity capable of ion heating.

AIM To investigate the incidence of spontaneous bacterial peritonitis (SBP) in pre-transplant patients and its effect on post transplant mortality and graft failure. METHODS We conducted a retrospective cohort study of patient records from the organ procurement and transplant network data set. Patients were identified by the presence of SBP pre-transplant. Univariate post-transplant survival models were constructed using the Kaplan-Meier technique and multivariate models were constructed using the Cox proportional hazards model. Variables that affected post-transplant graft survival were identified in the SBP population. RESULTS Forty-seven thousand eight hundred and eighty patient records were included in the analysis for both groups, and 1966 (4.11%) patients were identified in the data set as having pre-transplant SBP. Patients that had pre-transplant SBP had higher rates of graft loss from recurrent hepatitis C virus (HCV) (3.6% vs 2.0%, P < 0.0001), infections leading to graft loss (1.9% vs 1.3%, P = 0.02), primary non-function (4.3% vs 3.0%, P < 0.0001) and chronic rejection (1.1% vs 0.7%, P = 0.04). Kaplan-Meier survival analysis showed a statistically significant difference in all-cause survival in patients with a history of SBP vs those without (P < 0.0001). Pre-transplant history of SBP was independently predictive of mortality due to recurrent HCV (HR = 1.11, 95%CI: 1.02-1.21, P < 0.017) after liver transplantation. CONCLUSION HCV patients prior to the advent of directing acting anti-viral agents had a higher incidence of pre-transplant SBP than other patients on the liver transplant wait list. SBP history pre-transplant resulted in a higher rate of graft loss due to recurrent HCV infection and chronic rejection.

Background Hepatitis C virus (HCV) infection is now curable for most individuals and national goals for elimination have been established. Transmission remains ongoing, particularly in non-urban regions affected by the opioid epidemic. To reach elimination goals, barriers to treatment must be identified with a priority placed on those with substance abuse. Methods In this retrospective cohort study of all individuals with chronic HCV from 2010 to 2016 at a large medical center serving a predominately non-urban population, we identified patient and clinic characteristics associated with our primary outcome, sustained virologic response (SVR). We performed a subgroup analysis for those with documented substance abuse. Results SVR was achieved in 1,544 (41%) of 3,790 people with chronic HCV (Figure 1). In a multivariate Poisson regression model adjusted for patient demographics and year of diagnosis, SVR was less likely in those with substance abuse (IRR 0.8, 95% CI 0.7–0.9). In the subgroup analysis of those with substance abuse (N = 682), SVR rates were higher in those linked to the infectious diseases clinic, which has embedded support services, than in those linked to gastroenterology, which does not (IRR 1.4, 95% CI 1.1–1.9) (table). Higher SVR rates were driven by an increased rate of medication prescribing in those linked to infectious diseases (IRR 1.3, 95% CI 1.1–1.6) (Figure 2). Conclusion Those with substance abuse, a high priority population for treatment of HCV, had better outcomes when receiving care in a clinic with embedded support services. Figure 1. Hepatitis C cascade of care. Table. Factors Associated with SVR in a Multivariable Poisson Regression Model Among Those with Substance Abuse Linked to Care (N = 458) Incidence Rate Ratio* (95% CI) P Hepatitis C clinic Gastroenterology 1 (ref) - Infectious diseases 1.4 (1.1–1.9) 0.01 Diagnosis characteristics Outpatient diagnosis 1.5 (1.1–2.1) 0.01 * Incidence rate ratios are adjusted for patient demographics (age, sex, race, proximity to medical center, financial status, insurance type), diagnosis year and comorbidities (cirrhosis, hepatocellular carcinoma, HIV, hepatitis B) in addition to variables shown in table above. Figure 2. HCV cascade of care for those with substance abuse linked to care. Disclosures All authors: No reported disclosures.

Portal vein thrombosis is an unusual thrombotic condition not frequently seen in the general population; however, it has a higher prevalence in special circumstances such as in liver cirrhosis and hepatic or pancreatic malignancy. It also can be associated with significant morbidity and mortality. In this review, we discuss the current data available to guide therapy in the setting of different associated co-morbidities, hypercoagulable states, and associated thrombosis of the remaining splanchnic circulation. We discuss indications for anticoagulation, including the choice of anticoagulants, as well as the role of conservative ‘wait and watch’ and invasive therapies, such as thrombolysis, thrombectomy, and transjugular intrahepatic portosystemic shunt.

Direct oral anticoagulants (DOAC) are important new anticoagulant therapies that are not well studied in patients with chronic liver disease. The aim of this study was to compare rates of bleeding in cirrhosis patients treated with DOAC (factor Xa inhibitors: rivaroxaban and apixaban) to those in cirrhosis patients treated with traditional anticoagulation (warfarin and low molecular weight heparin). We identified a total of 39 patients with cirrhosis who received anticoagulation therapy over a 3-year period (20 DOAC and 19 traditional anticoagulation) from a research database. Medical records were reviewed to obtain clinical data to compare between the groups. Clinical characteristics between the two groups were similar. There were three documented bleeding events in the traditional anticoagulation group and four bleeding events in the DOAC group (p = 0.9). There were two major bleeding events in the traditional anticoagulation group and one major bleeding event in the DOAC group. There were no documented reports of drug-induced liver injury during this study period. Among all patients, no significant predictors of bleeding were identified using univariate regression and Cox proportional hazard modeling. This is the first clinical study evaluating the use of DOAC in patients with cirrhosis. DOAC display similar safety characteristics when compared to traditional anticoagulation in patients with cirrhosis and are potentially attractive agents for anticoagulation therapy. Larger studies are now needed to better understand the safety and efficacy of these agents in cirrhosis.

Non-selective beta-blockers have been a cornerstone of therapy for prevention of esophageal variceal bleeding in cirrhosis patients for more than two decades. When lowering the hepatic vein portal pressure gradient (HVPG) below 12 mm Hg or decreasing the pressure by 20% from baseline, these drugs are of proven benefit in reducing variceal bleeding and improving survival in this patient population. The recent work by Hendández-Gea et al., suggests that initiation of the beta-blocker nadolol in cirrhosis patients with high-risk varices can delay or prevent the first occurrence of clinically evident ascites. This finding comes with some caveats, however. The beneficial effect was only seen in patients who had an improvement by 10% or more from baseline HVPG pressure (only 51% of the treated patients in this study). This class of medications has some risk and tolerance issues, and many patients do not respond, even when the heart rate is optimally decreased. Despite this, the use of beta-blockers may be beneficial in the primary prevention of the formation of ascites and further decompensation of cirrhosis.

Aging is defined as a time-sequential deterioration of living things that is prompted by increased susceptibility to disease and adverse events, leading to loss of viability and physiologic functions. In simpler terms, aging is characterized by the individual’s inability to respond in a useful way to stress. Perhaps the most vital physiological component a person has for surviving aging is their body’s immune system. Along with the ability to clear antigens from the body, the immune system is equally important in keeping the body’s own physiology in check by monitoring for reactions that may go awry and unchecked, leading to malignancies, or helping the body rebuild and reshape itself in the face of any stress. Decreased ability to cope with stressors expected to be handled by the immune system could support the notion that aging may itself be considered a disease state. Although aging is accompanied by a decline in normal immune function of the B and T cells, aging is not reflected in profound changes in one of the many variables used to assess immune status with respect to a specific disease such as in HIV’s viral load or T cell count. Without the benefit of specific laboratory-derived values to measure in discrete steps a shrinking of immune function, the concept of immunodeficiency being a disease state of the elderly might itself be arbitrary.

Heavy snowfall, cold temperatures, and low atmospheric pressure during the winter months have been associated with increased adverse cardiovascular events. However, only a few cases of the "snow shoveler's infarction" have been reported. The investigators describe their experience with 6 patients presenting with ST elevation myocardial infarctions, all within a 24-hour period during an unprecedented snowfall (4 of whom were shoveling snow), and provide a detailed review of previously reported cases of snow shoveler's infarction. Consistent with other reports, most patients reported here had the traditional cardiac risk factors of hypertension, hyperlipidemia, diabetes mellitus, tobacco use, and sedentary lifestyle. Unique to this case series, however, was that the 4 patients who had histories of coronary artery disease and previous coronary artery stenting all presented with subacute stent thromboses documented on coronary angiography performed emergently. Moreover, these patients constituted 25% of all subacute stent thromboses diagnosed in the cardiac catheterization laboratory in the preceding 12 months. In conclusion, these findings suggest that in typically sedentary individuals with cardiac risk factors or histories of coronary artery disease, snow shoveling may trigger ST elevation myocardial infarction and therefore should be avoided. This may be most critical in patients with histories of coronary stent placement, considering that these findings suggest that snow shoveling may precipitate subacute stent thrombosis.

Background The presence of meshed capillary (MC) vessels is highly sensitive (96%) and specific (92%) for diagnosing colorectal neoplasia on colonoscopy by using narrow-band imaging (NBI) with optical magnification, which is not available in North America. However, the efficacy of NBI to identify an MC pattern without optical magnification has not been determined. Objective To determine the diagnostic capabilities of NBI colonoscopy without optical magnification in differentiating neoplastic from non-neoplastic colorectal polyps by using the MC pattern. Design Retrospective comparison of prospectively collected colorectal polyp data. Setting Large, academic medical center. Patients This study involved 126 consecutive colorectal polyps (median size 3 mm) that were found in 52 patients (33 men) with a median age of 59.5 years. Intervention All lesions identified by white-light colonoscopy were prospectively diagnosed in real-time by using the MC pattern as determined on high-definition NBI, with 1.5× zoom but without true optical magnification, and then endoscopically excised. Surgical pathology was used as the criterion standard. Main outcome measurements Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of identifying neoplastic polyps were calculated. Results NBI without optical magnification was found to have a sensitivity of 93%, specificity of 88%, positive predictive value of 90%, negative predictive value of 91%, and diagnostic accuracy of 91% when all polyp sizes were considered. For lesions ≤5 mm, sensitivity was 87%, specificity was 93%, positive predictive value was 89%, negative predictive value was 91%, and diagnostic accuracy was 90%. Limitations Single-center, single-endoscopist experience. Conclusion Use of the MC pattern on NBI colonoscopy without optical magnification effectively distinguishes neoplastic from non-neoplastic colorectal polyps. NBI colonoscopy without optical magnification for neoplastic polyp diagnosis appears to be comparable with NBI with optical magnification when the MC pattern is used. A large, prospective trial is needed for further validation.

Background: The increased prevalence of non-alcoholic steatohepatitis (NASH) in cirrhotic patients will likely lead to higher rates of cardiac disease. Mortality in cirrhotic patients is often focused on complications of portal hypertension. In this study, we hoped to demonstrate the prevalence and clinical outcomes of cirrhotic patients with acute myocardial infarction (MI). Methods: Using the Clinical data repository we identified patients age ≥ 18 years from 1/1/2011 to 12/31/12 who were admitted with an International Classification of Disease-9 (ICD-9) code for cirrhosis and an ICD-9 code for acute MI. Inclusion required a diagnosis of cirrhosis based on biopsy or clinical, laboratory, and radiological findings. Acute MI was defined by the American Heart Association's 3rd Universal Definition of MI. Data regarding the type of MI, results of invasive or non-invasive testing, and in-hospital mortality were collected. Results: A total of 118 patients were identified, and of these 31 met the inclusion criteria. The overall prevalence of MI in hospitalized cirrhotic patients during the study period was 2.7%. Non-ST elevation MI (NSTEMI) Type 1 and Type 2 accounted for 84%. Only 5 patients sustained an ST-elevation MI (STEMI) and of these 4 underwent coronary angiography (2 were treated with stenting and 2 with balloon angioplasty alone). There were no in-hospital deaths in the STEMI group. Of the patients with NSTEMI, 75% with Type 1 NSTEMI underwent coronary angiography and 5 patients received a stent. One patient in this group required coronary artery bypass graft surgery. In-hospital mortality in the Type 2 NSTEMI group was 50%. In this group only 57% received aspirin and 29% received beta-blocker or statin therapy as part of their medical management. Average MELD score was higher in Type 2 compared to Type 1 NSTEMI (24 vs. 14, p