BACKGROUND & AIMS:Objectives of this retrospective cohort study were to assess differences in patient survival between etiologies of cirrhosis while on the waitlist for liver transplantation (LT), and to identify cardiac risk factors that predict survival failure while on the waitlist for LT.METHODS:This single-center retrospective cohort design included adult patients who were listed for LT at a tertiary academic hospital with a high-volume liver transplant center.RESULTS:Of the 653 patients listed for LT during the study period, 507 (77.6%) survived to transplant and 146 (22.4%) died or clinically deteriorated prior to transplant. Cumulative incidence of death or clinical deterioration did not differ statistically between patient groups (log rank p = .11). In multivariate analysis, compared to patients with NAFLD, there were no significant differences between patients with alcoholic cirrhosis (HR .95, 95%, CI, .62-1.45), cryptogenic cirrhosis (HR 1.31, 95%, CI, .77-2.23), or hepatitis C cirrhosis (HR 1.12, 95%, CI, .66-1.90). However, higher MELD scores (HR = 1.52, 95% CI, 1.12-1.19), severe coronary artery disease (HR = 2.09 95% CI, 1.23-3.55), and tricuspid regurgitation (HR = 2.62, 95% CI, 1.31-5.26) were independently associated with increased risk for survival failure to LT.CONCLUSIONS:The presence of severe coronary artery disease and tricuspid regurgitation at the time of listing for transplant are associated with survival failure while on the LT waitlist across etiologies of liver disease. Diagnostic assessment of coronary and valvular disease should be considered in all patients undergoing evaluation for LT, such as cardiac catheterization and/or stress echocardiogram.

Introduction: A foundational knowledge in nutrition is necessary for internal medicine (IM) residents to identify patients with malnutrition and translate basic nutrition guidelines to improve patient care. However, the majority of medical schools and residency programs do not offer clinical training in nutrition. Therefore, it is imperative that residents have nutrition education incorporated into their training. Methods: IM residents at our institution were surveyed to assess exposure to nutrition education, baseline knowledge in areas of nutrition, interest in learning specific nutrition topics and desire to complete a clinical nutrition elective. A two-week curriculum covering inpatient and outpatient nutrition care was developed in collaboration with the Center for Human Nutrition. Results: Forty residents completed the survey. Responders were from all years of training with various career plans after residency. 55% of residents had no prior exposure to clinical nutrition. Only 10% of residents felt they possessed the knowledge to diagnose malnutrition, and only 3% felt confident determining the nutritional needs of their patients. A minority of residents felt comfortable identifying indications for enteral nutrition (30%) and parenteral nutrition (25%), or making nutritional recommendations in a primary care setting (18%). Residents were most interested in learning how to perform a nutrition assessment and determine nutritional requirements (93%), as well as initiate and manage enteral nutrition (93%) and parenteral nutrition (85%). 90% of residents were interested in completing a clinical nutrition elective during their training (Table 1). The 2-week nutrition elective was designed to allow didactic training through e-learning modules and hands on training with registered dietitians (RD). Rotations involved working with RDs for education and direct care in the intensive care unit, regular nursing floor, enteral access team, nutrition support team and ambulatory setting. Clear objectives were developed for each nutrition area which included how to identify and diagnose malnutrition, estimate energy and protein needs and how to choose optimal nutritional interventions for patients based on their disease process. Conclusion: Internal medicine residents lack the exposure and knowledge required to address a majority of nutrition related care. Residents are interested in learning various nutrition topics. Implementing a clinical nutrition elective may be effective in addressing this gap in training. Table 1. - Clinical Nutrition Elective Needs Assessment Results N (%) Total Responses 40 (100%) Current PGY level PGY-1 16 (40%) PGY-2 11 (28%) PGY-3 13 (33%) Career plans after residency Hospital Medicine or Primary Care 6 (15%) Gastroenterology / Hepatology 13 (33%) Cardiology 9 (23%) Other Internal Medicine Subspeciality 12 (30%) Previous exposure to clinical nutrition Medical school course 14 (35%) Clinical rotation during medical school 3 (8%) None 22 (55%) I currently possess the knowledge / skills to address the following clinical scenarios: Strongly Disagree Disagree Neutral Agree Strongly Agree Diagnosing protein-calorie malnutrition 33% 43% 15% 10% 0% Determining protein, calorie and micronutrient requirements 38% 45% 15% 3% 0% Identifying indications for enteral nutrition 20% 28% 23% 30% 0% Managing complications of enteral nutrition 23% 38% 20% 20% 0% Identifying indications for parenteral nutrition 20% 25% 30% 25% 0% Managing complications of parenteral nutrition 20% 45% 28% 8% 0% Making nutritional recommendations in a primary care setting 18% 40% 25% 18% 0% Nutrition topics of interest Nutrition assessment & determination of nutritional needs 37 (93%) Inpatient general nutrition 31 (78%) Enteral nutrition: initiation & management 37 (93%) Parenteral nutrition: initiation & management 34 (85%) ICU nutrition 26 (65%) Outpatient general nutrition 27 (68%) Outpatient subspeciality nutrition (I.e., Gastroenterology, obesity) 26 (65%) Residents interested in completing a clinical nutrition elective Yes 36 (90%) No 0 (0%) Unsure 4 (10%)

BACKGROUND Nonalcoholic fatty liver disease (NAFLD) describes the hepatic manifestations of metabolic syndrome, which is estimated to affect 25% of adults, and currently represents the second most common indication for liver transplant in the United States. Studies have shown that patients with NAFLD are at an increased risk for heart failure, arrhythmia, and coronary artery disease (CAD), which may impact outcomes of liver transplantation. However, it remains unclear whether the presence of cardiac disease affects survival prior to liver transplant. If so, this would represent an important opportunity to optimize cardiac status and improve outcomes before liver transplant. AIM To identify cardiac factors that impact survival to liver transplantation in patients with NAFLD and on the transplant waitlist. METHODS The aim of this study was to identify cardiac risk factors that limit survival to transplant in patients with NAFLD. We performed a retrospective analysis of patients with NAFLD listed for liver transplant at a tertiary academic medical center in the United States from January 2015 to January 2021, identified through United Network of Organ Sharing registry. Exclusion criteria included a concurrent etiology of liver disease and removal from the transplant list due to chemical dependency, lack of social support, improvement in liver disease, or being lost to follow-up. We manually reviewed patient charts including electrocardiogram, echocardiogram, and cardiac catheterization reports as well as physician notes to identify cardiac disease states (i.e., heart failure, arrhythmia, valvular disease and CAD) and other related diagnoses. We performed a survival analysis by Cox proportional hazards regression model to analyze the association between cardiac factors at the time listed for transplant and death or clinical deterioration prior to transplant. RESULTS Between January 2015 and January 2021, 265 patients with nonalcoholic fatty liver disease were listed for liver transplant at our institution. Our patient sample had a median age of 63 and an even distribution between sexes. The median Model for End-Stage Liver Disease (MELD) score was 17 and the median body mass index was 31.6. Of these 265 patients, 197 (74.3%) survived to transplant and 68 (25.7%) died or clinically deteriorated prior to transplant. The presence of mild or moderate CAD represented a hazard ratio of 2.013 (95%CI 1.078-3.759, P = 0.029) for death or clinical deterioration when compared to patients without CAD, after adjustment for age, sex, and MELD. MELD represented an adjusted hazard ratio of 1.188. CONCLUSION Mild or moderate CAD represents a hazard for waitlist mortality prior to liver transplant in patients with NAFLD. Aggressive management of CAD may be needed to improve patient outcomes.

Introduction: Roux-en-Y gastric bypass (RYGB) is among the most common bariatric surgeries for treatment of morbid obesity, with >450,000 RYGB performed in the United States since 2011. Formation of an excluded stomach and duodenum that are difficult to access via conventional endoscopy can pose a unique challenge for diagnosis and treatment of gastrointestinal (GI) bleeding in post-RYGB patients. Case Description/Methods: A 60-year-old man with a history of morbid obesity and status post RYGB in 2017 presented in January 2021 with black tarry stools and a hemoglobin of 7.4 from a baseline of 13 g/dL without recent NSAID or tobacco use. He underwent upper endoscopy, colonoscopy, push enteroscopy and video capsule endoscopy without identification of a bleeding source. He was ultimately discharged home after stabilization and no further bleeding. Due to concern for an unidentified source of bleeding, further outpatient workup was pursued. CT enterography was unrevealing. Attempted endoscopic ultrasound (EUS)-guided gastrotomy to access the excluded stomach was unsuccessful due to inability to pass an Axios stent into the excluded stomach. Antegrade balloon enteroscopy failed to reach the jejuno-jejunal anastomosis. The patient was re-admitted in April 2021 for recurrent melena and a hemoglobin of 8.3 g/dL. Laparoscopic gastrotomy was performed with intraoperative transgastric endoscopy which revealed blood in the excluded stomach and duodenum. An ulcer in the excluded stomach was discovered and excised via subtotal gastrectomy. Pathology revealed focal transmural ulceration without dysplasia; H. pylori testing was negative. The patient was discharged home without recurrence of bleeding. Discussion: Alteration in GI anatomy after RYGB impedes access to excluded segments of the upper GI tract. Access to the excluded segments may be achieved by balloon enteroscopy depending on the length of the alimentary limb, EUS-assisted gastrotomy or laparoscopic formation of a temporary gastrotomy with transgastric endoscopy. A review of post-RYGB cases of excluded segment ulceration found that 93% of patients required surgery for definitive treatment. The most common interventions were remnant gastrectomy and oversewing of perforated ulcers with a 94% cure rate at short-term follow-up. Our case demonstrates that a high degree of suspicion for bleeding from the excluded gastric or small bowel segments should be maintained in patients with RYGB presenting with upper GI bleeding and initial negative GI tract evaluation.Figure 1.: Transmural ulceration in the remnant stomach status post subtotal gastrectomy

Introduction: Acute upper gastrointestinal bleeding (UGIB) is a medical emergency requiring a timely diagnosis with prompt intervention. Patient’s usually present with signs of hemorrhagic shock such as hematemesis/melena, tachycardia, and hypotension. Here, we report a patient with an unusual presentation of UGIB with ST-segment myocardial infarction (STEMI) before the development of conventional symptoms. Case Description/Methods: A 37-year-old male with alcohol use disorder was hospitalized in the medical intensive care unit (ICU) for acute on chronic liver failure, resolving circulatory shock, and acute kidney injury. He complained of retrosternal chest pain and nausea following extubation. He had no fever or cough; chest examination revealed no abnormal findings. Chest X-ray was unremarkable. EKG revealed acute ST elevation in leads II, III, and avF with reciprocal depressions in V2 and V3 (1A). A bedside echocardiogram revealed no focal wall motion abnormalities. Point-of-care ultrasound revealed a distended stomach filled with heterogeneous contents (1C). He was intubated for airway protection in the context of worsening encephalopathy. Intravenous fluid resuscitation was initiated given decreasing BP, and ST-segment changes resolved (1B). Upper GI endoscopy examination revealed clotted blood in the entire examined stomach with an adherent clot at the cardia. The patient underwent massive transfusion protocol with emergent percutaneous portal venography with gastric and esophageal variceal embolization. The next day, his cardiac enzymes normalized and he eventually received a liver transplant and was transferred out of the ICU. Discussion: UGIB complicating STEMI’s (secondary to CAD) are uncommon and can be associated with excess morbidity and mortality. However, patients with STEMI’s from UGIB are seldom reported. Patients with hemorrhagic shock are prone to developing some degree of subendocardial ischemia causing Type 2 NSTEMI’s. In rare instances, patients may develop STEMI due to severe ischemia of the myocardium in the context of hemorrhagic shock and concurrent vasopressor use for mixed circulatory shock. Though common practice to activate the cardiac catheterization lab reflexively to patients with chest pain, STEMI, and elevated cardiac enzymes, it is worth being mindful of the other rarer etiologies that may cloud the clinical picture. Clinicians need to be cognizant of unusual presentations of hemorrhagic shock secondary to GIB to avoid delay in diagnosis and to provide timely intervention.Figure 1.: (A) ST Elevation in II, III, avF with reciprocal ST depression in V1 and V2. (B) Resolved EKG, normal sinus rhythm, (C) Point-of-care ultrasound of stomach filled with heterogeneous contents, (D) UGI endoscopy showed stomach filled with blood, (E) Esophageal and gastric embolization.

Introduction: Patients with Crohn’s disease (CD) that fail to respond to anti-TNF agents are frequently switched to non-anti-TNF agents like Vedolizumab (VEDO) or Ustekinumab (USK). However, the clinical characteristics of CD patients that are associated with an increased risk of primary non-response are unknown. We aimed to investigate the clinical characteristics of CD patients switched to a non-anti-TNF agent after initial treatment with either Adalimumab (ADA) or Infliximab (IFX). Methods: We queried a multi-center database (Explorys Inc, Cleveland, OH), an aggregated data from 26 major integrated healthcare systems in the US. Patients with a diagnosis of “Crohn’s disease” between December 2015 and 2020, based on Systemized Nomenclature of Medicine–Clinical Terms were identified. The demographic and clinical characteristics of patients started on either ADA or IFX then switched to a non-anti-TNF after at least 90 days to within 180 days of induction, to patients who were not switched (responders) were compared utilizing logistic regression. Results: We identified 175,100 patients with CD in the database. Of these, 12,020 patients were started on ADA and 11,840 patients were started on IFX. Table 1 shows the clinical characteristics of CD patients switched from ADA or IFX to USK or VEDO. Adults between age18-65 years were significantly associated with higher odds of class switching in either group. The presence of anal fissure significantly increased the odds of switching to VEDO, while those with a perianal abscess and who underwent drainage of perirectal abscesses were at higher odds of being switched to USK. Patients who underwent total colectomy were at significantly higher odds of being switched to either USK or VEDO. In the IFX group, the presence of intestinal fistulae and small intestinal surgery had higher odds of class switching in both groups. CD patients with anal fissures or anorectal fistulae had significantly higher odds of switching to USK. While patients with drainage of abscess, total or partial colectomy had significantly higher odds of class switching to VEDO. Conclusion: We found patients with CD with severe phenotype (fistulizing, peri-anal disease) and history of CD-related surgery were at a higher risk of primary non-response to Anti-TNF agents requiring switch to VEDO or USK. Further exploration is required to determine if the severe CD phenotype is refractory to any medication and would benefit from surgery early after the failure of anti-TNF therapy.Table 1.: This table represents the distribution of anti-TNF medications associated with ONJ as reported to the FAERS database from 2010 to present along with respective indications for use and the number of individual case reports.

Introduction: For decades, low-dose aspirin (ASA) has been used for the primary prevention of atherosclerotic cardiovascular disease and colorectal cancer. ASA use in primary prevention lacks net benefit due to the greater risk of gastrointestinal bleeding. Several guidelines now recommend risk assessment and shared decision-making in the use of ASA for primary prevention. We aimed to increase the percentage of patients appropriately on ASA by 20% in 6 months in the intern-run internal medicine ambulatory clinic. Methods: We determined the baseline prevalence of inappropriate ASA usage for primary prophylaxis through chart review in our electronic medical record system (Epic). We assessed the clinic workflow as it relates to addressing ASA usage in our patients through process mapping. A fishbone diagram was used for root-cause analysis which revealed key causes of inappropriate ASA use among our patient panels: insufficient resident knowledge of new ASA guidelines, lack of EMR notification of inappropriate ASA usage, and lack of visits with patients on ASA for primary prophylaxis. Our first PDSA cycle involved the creation of a dot phrase to remind the note writer to assess for ASA appropriateness. A second PDSA cycle identified that many of the patients on ASA had not yet been seen by their new resident PCPs. We used the clinic scheduling system to request follow-up appointments within 10 weeks to address ASA usage for patients inappropriately on ASA across 5 resident-run ambulatory clinics. Results: A total of 78 patients who were on aspirin for primary prophylaxis were identified. Of those, 25% (20/78) were found to be inappropriately on ASA using the ASA guide smartphone application created at Brigham and Women’s Hospital. Follow-up appointments to discuss deprescribing were scheduled for 16 patients. A total of 12 patients were successfully deprescribed from inappropriate ASA use across 5 clinic sites. Conclusion: Our experience demonstrates the prevalence of inappropriate ASA use for primary prophylaxis among resident patient panels. This is a resident-led effort to improve patient safety by deprescribing ASA when indicated and thereby reducing the risk of iatrogenic adverse events such as gastrointestinal bleeding. We have focused on this important primary care issue by addressing clinic workflow and also patient outreach. Our project is ongoing with active implementation and ongoing PDSA cycles to track ASA appropriateness and deprescribing.Figure 1.: Time course of patients with appropriate aspirin use.Table 1.: Summary of Data.