Background Fibrosis impacts long-term outcomes among patients with nonalcoholic fatty liver disease (NAFLD). Due to well-documented flaws associated with liver biopsy, there has been a recent emphasis on prioritizing noninvasive testing over liver biopsy for the assessment of fibrosis. Methods A comprehensive systematic review and frequentist random effects network meta-analysis was performed among randomized controlled trials reporting pharmacologic intervention in NAFLD. The primary endpoint was the absolute change in liver stiffness measurement (LSM) via elastography. Secondary endpoints included changes in noninvasive serologic tests including APRI, fibrosis-4 index, NAFLD fibrosis score, enhanced liver fibrosis (ELF) and FibroTest (FibroSure in the USA). Results Forty-five randomized controlled trials enrolling 6932 patients were identified for this network meta-analysis. Across the primary endpoint, firsocostat, semaglutide, montelukast, cilofexor plus firsocostat, obeticholic acid and diacerein (change in LSM via vibration controlled transient elastography), in addition to lubiprostone and pemafibrate (change in LSM via magnetic resonance elastography) were found to be the most effective and statistically significant treatment interventions. Similarly, the following interventions were determined to be most effective as compared to placebo among secondary endpoints: saroglitazar, lubiprostone, and obeticholic acid (change in APRI); saroglitazar, semaglutide, firsocostat and cilofexor plus firsocostat (change in ELF); obeticholic acid and belapectin [change in FibroTest/FibroSure]. Conclusion This is the first systematic review and network meta-analysis reporting pharmacologic efficacy in the progression of fibrosis based on noninvasive testing among patients with NAFLD. Semaglutide, obeticholic acid, firsocostat, cilofexor plus firsocostat and lubiprostone were found to be the most effective treatments based on their consistent efficacy reproduced across multiple endpoints, both via elastography and noninvasive blood tests.
Background The spleen removes microorganisms from the bloodstream and produces antibodies for enhanced immune response. Patients with asplenia are at increased risk for infections caused by encapsulated organisms and have a 6-fold increased risk of sepsis compared to the general population. Those that acquire an infection have a mortality rate of 80%. The CDC recommends administering the meningococcal, influenza, pneumococcal, and Haemophilus influenzae type B (Hib) vaccine at least 2 weeks before or after splenectomy. Methods This retrospective chart review evaluated the appropriateness of vaccine administration for patients undergoing splenectomy at Long Island Jewish Medical Center (LIJMC) from January 2016 to June 2020. Patients were included if they were admitted to LIJMC, 18 years or older, and had splenectomy at LIJMC within previous 7 years. Patients were excluded if they were pregnant, admitted to an outside hospital for splenectomy, or had an unknown time of splenectomy. The primary objective was appropriateness of vaccine administration. Inappropriateness was defined as having at least 1 error with administration, including vaccine omissions, timing of vaccine, sequencing (Pneumovax®23 given before Prevnar13®), vaccine interaction (Menactra® given with Prevnar13®), or duplicated vaccines. Results Of the 174 patients screened, 29 patients were included in analysis, with a mean age of 58.2 ± 20.6 years. The splenectomy was elective in 69% of patients and emergent in 31% of patients. The vaccine regimen was given inappropriately in 96.6% of patients. The reasons for inappropriateness were vaccine selection (100%), timing (39.3%), vaccine sequence (39.3%), vaccine interaction (14.3%), and duplicate vaccines (7.1%). Excluding emergent splenectomies, 100% of patients received an inappropriate vaccine regimen. The vaccines were given at least 2 weeks before elective splenectomies in 40% of patients, peri-operatively in 30% of patients, and not given in 25% of patients. Conclusion Patients undergoing splenectomy received inappropriate vaccine regimens mainly due to omissions, timing, and sequencing. Prevnar13® should be given before Pneumovax®23 when both are indicated and vaccines should be administered at least 2 weeks before splenectomy. An orderset was created to mitigate errors with vaccine selection for patients undergoing splenectomy. Disclosures All Authors: No reported disclosures.
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