LT performed for NASH and HCC are increasing. Potent treatment options resulted in a decrease in number of transplants for HBV, HCV, and PBC. Better treatment modalities for HCV are expected to further reduce the number of LT for HCV. Excellent posttransplantation outcomes for NASH and AC are encouraging, resulting in wider acceptance of transplants for these etiologies.

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SUMMARY BackgroundFive oral nucleos(t)ide analogues are available to treat chronic hepatitis B (CHB). With the availability of newer agents, their efficacy on incidence of hepatocellular carcinoma (HCC) is not well described.

Summary Background Data on bacterial infections in hospitalised patients in the US with cirrhosis are derived largely from single centre data. Countrywide data in this population are lacking. Aim To assess prevalence of infections among hospitalised patients in the US and examine their impact on in‐hospital mortality and health care resources utilisation. Methods Nationwide Inpatient Sample (1998–2007) was queried for hospitalisations with cirrhosis and examined for infections including spontaneous bacterial peritonitis (SBP), urinary tract infection (UTI), skin and soft tissue infections, pneumonia and Clostridium difficile infections (CDI). In‐hospital mortality, length of stay (LOS) and total charges were analysed. Results Of 742 391 admissions with cirrhosis, 168 654 (23%) had discharge diagnosis of any infection. Between 1998 and 2007, there was a trend towards increasing prevalence of infections (21–25%). Higher rates of infection were associated with ascites (22–25%) and renal insufficiency (RI) (38–43%). Infection with RI increased from 13% in 1998 to 27% in 2007. UTI was the most common infection (9–12%) followed by subcutaneous tissue infections (5–6%) and SBP (2–3%, around 12% in patients with ascites). Infection rate was similar among teaching and nonteaching hospitals with CDI and SBP being more common in teaching hospitals. In‐hospital mortality was about 5%, over fivefold higher in infected cirrhotics, and associated with higher LOS and charges. Sepsis (38–42%), pneumonia (23–30%), SBP (16–23%) and CDI (11–16%) contributed most to in‐hospital mortality. Conclusions The prevalence of infections among hospitalised patients with cirrhosis in the US is increasing and is associated with in‐hospital mortality, renal insufficiency and costs.

BackgroundMore effective treatments are needed for patients with postinfectious, diarrhoea-predominant, irritable bowel syndrome (IBS-D). Accordingly, we conducted a randomised, double-blind, placebo-controlled, 8-week-long trial to assess the efficacy and safety of oral glutamine therapy in patients who developed IBS-D with increased intestinal permeability following an enteric infection.MethodsEligible adults were randomised to glutamine (5 g/t.i.d.) or placebo for 8 weeks. The primary end point was a reduction of ≥50 points on the Irritable Bowel Syndrome Severity Scoring System (IBS-SS). Secondary endpoints included: raw IBS-SS scores, changes in daily bowel movement frequency, stool form (Bristol Stool Scale) and intestinal permeability.ResultsFifty-four glutamine and 52 placebo subjects completed the 8-week study. The primary endpoint occurred in 43 (79.6%) in the glutamine group and 3 (5.8%) in the placebo group (a 14-fold difference). Glutamine also reduced all secondary endpoint means: IBS-SS score at 8 weeks (301 vs 181, p<0.0001), daily bowel movement frequency (5.4 vs 2.9±1.0, p<0.0001), Bristol Stool Scale (6.5 vs 3.9, p<0.0001) and intestinal permeability (0.11 vs 0.05; p<0.0001). ‘Intestinal hyperpermeability’ (elevated urinary lactulose/mannitol ratios) was normalised in the glutamine but not the control group. Adverse events and rates of study-drug discontinuation were low and similar in the two groups. No serious adverse events were observed.ConclusionsIn patients with IBS-D with intestinal hyperpermeability following an enteric infection, oral dietary glutamine supplements dramatically and safely reduced all major IBS-related endpoints. Large randomised clinical trials (RCTs) should now be done to validate these findings, assess quality of life benefits and explore pharmacological mechanisms.Trial registration numberNCT1414244; Results.

Frequency of SLK transplants is increasing among NASH patients. Overall graft and patient outcomes are good. However, SLK for NASH, HCV, and HCC do worse. Strategies are needed to improve outcomes for SLK in HCV and NASH patients.

Background and Aims: Acute kidney injury (AKI) is common in patients with cirrhosis but the incidence is heterogeneous among studies. We performed a meta-analysis to describe the incidence of AKI and its impact on patient mortality in patients with cirrhosis. We also evaluated the admission variables predicting development of AKI. Methods: A systematic search of various databases was performed up to November 2018. Meta-analyses were performed using random effects models. Results: Of 18,474 patients with cirrhosis from 30 selected studies, 5,648 developed AKI, with a pooled incidence of 29% (95% confidence interval [CI]: 28-30%, I 2 of 99%). In-hospital mortality assessed in eight studies was six-fold higher among AKI patients, as compared to those without AKI (odds ratio [OR] 6.72, 95% CI: 3.47-13, p<0.0001, I 2 of 70%). Three studies on patients admitted to intensive care showed about six-fold higher mortality among AKI patients (OR 5.90, 95% CI: 3.21-10.85, p>0.0001). Mortality remained significantly high, at days 30 and 90 and even at 1-year follow up after development of AKI. Of 12 admission variables analyzed, model for end-stage liver disease score, Child-Pugh-Turcotte stage C, presence of ascites, and presence of sepsis/septic shock were statistically significant risk factors for AKI. Conclusions: AKI occurred in about 29% of patients with cirrhosis and is associated with a six-fold increased risk of in-hospital mortality. Mortality remained high even in long-term follow-up of 1 year. Patients at risk for AKI development can be recognized at admission. Prospective studies are needed to develop strategies for improving outcome of these patients.

IMPORTANCE Substantial numbers of hospitalists are fresh graduates of residency training programs. Current data about the effect of hospitalist years of experience on patient outcomes are lacking.OBJECTIVE To describe the association of hospitalist years of experience with 30-day mortality and hospital mortality of their patients. DESIGN, SETTING, AND PARTICIPANTSWe used a 5% sample of national Medicare data of patient and hospital characteristics to build a multilevel logistic regression model to predict mortality as a function of years of experience of the hospitalists. We created 2 cohorts. The first was a cross-sectional cohort of 21 612 hospitalists working between July 1, 2013, and June 30, 2014, with a 5-year look-back period to assess their years of prior experience as a hospitalist, and the second was a longitudinal cohort of 3860 hospitalists in their first year of practice between July 1, 2008, and June 30, 2011, who continued practicing hospital medicine for at least 4 years.MAIN OUTCOMES AND MEASURES Thirty-day postadmission mortality adjusted for patient and hospital characteristics in a 3-level logistic regression model. Hospital mortality was a secondary outcome. RESULTS Among 21 612 hospitalists caring for Medicare inpatients from July 1, 2013, to June 30, 2014, 5445 (25%) had 1 year of experience or less, while 11 596 (54%) had 4 years of experience or more. We then identified 3860 physicians in their first year as hospitalists who continued to practice as hospitalists for 4 years. There was a significant association between hospitalist experience and mortality. Observed 30-day mortality was 10.50% for patients of first-year hospitalists vs 9.97% for patients of hospitalists in their second year. The mortality odds for patients of second-year hospitalists were 0.90 (95% CI, 0.84-0.96) compared with patients of first-year hospitalists. Observed hospital mortality was 3.33% for patients cared for by first-year hospitalists vs 2.96% for second-year hospitalists. (odds ratio, 0.84; 95% CI, 0.75-0.95). For both 30-day and hospital mortality, there was little change in odds of mortality between the second year and subsequent years of experience. CONCLUSIONS AND RELEVANCEPatients cared for by hospitalists in their first year of practice experience higher mortality. Early-career hospitalists may require additional support to ensure optimal outcomes for their patients.