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Zhang L, Brennan K, Flemming JA, Nanji S, Djerboua M, Merchant SJ, Caycedo-Marulanda A, Patel SV. Emergency Colorectal Surgery in Those with Cirrhosis: A Population-based Study Assessing Practice Patterns, Outcomes and Predictors of Mortality. J Can Assoc Gastroenterol 2024; 7:160-168. [PMID: 38596800 PMCID: PMC10999774 DOI: 10.1093/jcag/gwad040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Background Those with cirrhosis who require emergency colorectal surgery are at risk for poor outcomes. Although risk predictions models exists, these tools are not specific to colorectal surgery, nor were they developed in a contemporary setting. Thus, the objective of this study was to assess the outcomes in this population and determine whether cirrhosis etiology and/or the Model for End Stage Liver Disease (MELD-Na) is associated with mortality. Methods This population-based study included those with cirrhosis undergoing emergent colorectal surgery between 2009 and 2017. All eligible individuals in Ontario were identified using administrative databases. The primary outcome was 90-day mortality. Results Nine hundred and twenty-seven individuals (57%) (male) were included. The most common cirrhosis etiology was non-alcoholic fatty liver disease (NAFLD) (50%) and alcohol related (32%). Overall 90-day mortality was 32%. Multivariable survival analysis demonstrated those with alcohol-related disease were at increased risk of 90-day mortality (hazards ratio [HR] 1.53, 95% confidence interval [CI] 1.2-2.0 vs. NAFLD [ref]). Surgery for colorectal cancer was associated with better survival (HR 0.27, 95%CI 0.16-0.47). In the subgroup analysis of those with an available MELD-Na score (n = 348/927, 38%), there was a strong association between increasing MELD-Na and mortality (score 20+ HR 6.6, 95%CI 3.9-10.9; score 10-19 HR 1.8, 95%CI 1.1-3.0; score <10 [ref]). Conclusion Individuals with cirrhosis who require emergent colorectal surgery have a high risk of postoperative complications, including mortality. Increasing MELD-Na score is associated with mortality and can be used to risk stratify individuals.
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Affiliation(s)
- Lisa Zhang
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Kelly Brennan
- Department of Surgery, Queen’s University, Kingston, ON, Canada
| | | | - Sulaiman Nanji
- Department of Surgery, Queen’s University, Kingston, ON, Canada
| | - Maya Djerboua
- Department of Surgery, Queen’s University, Kingston, ON, Canada
| | | | | | - Sunil V Patel
- Department of Surgery, Queen’s University, Kingston, ON, Canada
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2
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Subramanian L, Coo H, Jane A, Flemming JA, Acker A, Hoggan B, Griffiths R, Sehgal A, Mulder D. Celiac Disease and Inflammatory Bowel Disease are Associated with Increased Risk of Eating Disorders: An Ontario Health Administrative Database Study. Clin Transl Gastroenterol 2024:01720094-990000000-00247. [PMID: 38557476 DOI: 10.14309/ctg.0000000000000700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/18/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Previous national registry studies have reported an increased risk of eating disorders in immune-mediated conditions (inflammatory bowel disease [IBD] and celiac disease). Our objective was to examine the association between immune-mediated GI diseases and incident eating disorders in Ontario. METHODS This was a retrospective matched cohort study of individuals <50 years of age with a diagnosis of an immune-mediated GI disease between 2002 and 2020 ("cases"). Those with a pre-existing eating disorder were excluded. Cases (n=83,920) were matched with controls (n=167,776) based on birth year, sex, and region of residence. Incidence rate ratio and hazard ratio were estimated using Poisson regression model and adjusted Cox proportional models, respectively. RESULTS Over the follow-up period (up to January 31, 2022), 161 cases and 160 controls were identified with eating disorders. The overall incidence rate ratio (95% CI, p-value) of eating disorders in immune-mediated GI disease was 1.99 (1.6-2.5, p<0.001). The adjusted hazard ratios for eating disorder in cases with immune-mediated GI diseases was 1.98 (1.6-2.5, p<0.001). In the pediatric group of incident cases (≤18 years of age), overall adjusted hazard ratio was 2.62 (1.9-3.7, p<0.001)) compared to 1.56 (1.02-2.4, p=0.041) for adults (>18 years of age). The largest hazard ratio of 4.11 (1.6-10.3, p=0.003) was observed for pediatric incident cases of ulcerative colitis. CONCLUSION IBD and celiac disease are associated with the development of eating disorders. The magnitude of the association was stronger in the pediatric age group, underscoring the need for early screening and detection.
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Affiliation(s)
| | - Helen Coo
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Alanna Jane
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Jennifer A Flemming
- Gastrointestinal Diseases Research Unit, Faculty of Health Sciences, Queen's University, Ontario, Canada
- Institute of Clinical Evaluative Sciences (ICES), Ontario, Canada
| | - Amy Acker
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Benjamin Hoggan
- Institute of Clinical Evaluative Sciences (ICES), Ontario, Canada
| | | | - Anupam Sehgal
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Daniel Mulder
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
- Gastrointestinal Diseases Research Unit, Faculty of Health Sciences, Queen's University, Ontario, Canada
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3
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Plagiannakos CG, Hirschfield GM, Lytvyak E, Roberts SB, Ismail M, Gulamhusein AF, Selzner N, Qumosani KM, Worobetz L, Hercun J, Vincent C, Flemming JA, Swain MG, Cheung A, Chen T, Grbic D, Peltekain K, Mason AL, Montano-Loza AJ, Hansen BE. Treatment response and clinical event-free survival in autoimmune hepatitis: a Canadian multicentre cohort study. J Hepatol 2024:S0168-8278(24)00205-8. [PMID: 38527524 DOI: 10.1016/j.jhep.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND & AIMS We sought to identify predictors of outcome for people living with autoimmune hepatitis (AIH). METHODS We evaluated the clinical course of people with AIH across 11 Canadian centres. Biochemical changes were analysed using linear mixed-effect and logistic regression. Clinical outcome was dynamically modelled using time-varying Cox proportional hazard modelling and landmark analysis. RESULTS In 691 patients (median age 49 years, 75.4% female), with a median follow-up of 6 years (25th-75th percentile, 2.5-11), 118 clinical events occurred. Alanine aminotransferase (ALT) normalisation occurred in 63.8% of the cohort by 12-months. Older age at diagnosis (odd ratio [OR] 1.19, 95% CI 1.06-1.35) and female sex (OR 1.94, 95% CI 1.18-3.19) were associated with ALT normalisation at 6 months, whilst baseline cirrhosis status was associated with reduced chance of normalisation at 12 months (OR 0.52, 95% CI 0.33-0.82). Baseline total bilirubin, aminotransferases, and immunoglobulin G (IgG) values, as well as initial prednisone dose, did not predict average ALT reduction. At baseline, older age (hazard ratio [HR] 1.25, 95% CI 1.12-1.40), cirrhosis at diagnosis (HR 3.67, 95% CI 2.48-5.43), and elevated baseline total bilirubin (HR 1.36, 95% CI 1.17-1.58) increased risk of clinical events. Prolonged elevations in ALT (HR 1.07, 95% CI 1.00-1.13) and aspartate aminotransferase (HR 1.13, 95% CI 1.06-1.21), but not IgG (HR 1.01, 95% CI 0.95-1.07), were associated with higher risk of clinical events. Higher ALT at 6 months was associated with worse clinical event-free survival. CONCLUSION In people living with AIH, sustained elevated aminotransferase values, but not IgG, are associated with poorer long-term outcomes. Biochemical response and long-term survival are not associated with starting prednisone dose. IMPACT AND IMPLICATIONS Using clinical data from multiple Canadian liver clinics treating autoimmune hepatitis (AIH), we evaluate treatment response and clinical outcomes. For the first time, we apply mixed-effect and time-varying survival statistical methods to rigorously examine treatment response and the impact of fluctuating liver biochemistry on clinical event-free survival. Key to the study impact, our data is 'real-world', represents a diverse population across Canada, uses continuous measurements over follow-up, and our findings help inform risk stratification of patients. We provide evidence for treating clinicians, as well as those developing and evaluating new therapies, to seek evidence of good treatment response by keeping aminotransferase activity values within the reference range. Our results challenge the role of IgG as a marker of treatment response and if normalisation of IgG should remain an important part of the definition of biochemical remission. Our analysis further highlights that baseline markers of disease severity may not prognosticate early treatment response. Additionally, the initial prednisone dose may be less relevant for achieving aminotransferase normalisation. This is important for patients and treating clinicians given the relevance and importance of side-effects of treatment for patients.
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Affiliation(s)
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, University Health Network, Toronto, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.
| | - Ellina Lytvyak
- Division of Preventive Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Surain B Roberts
- Toronto Centre for Liver Disease, University Health Network, Toronto, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Marwa Ismail
- Toronto Centre for Liver Disease, University Health Network, Toronto, Canada
| | - Aliya F Gulamhusein
- Toronto Centre for Liver Disease, University Health Network, Toronto, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Nazia Selzner
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | | | - Lawrence Worobetz
- Department of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Julian Hercun
- Liver Unit, Department of Medicine, Centre Hospitalier De l'Université De Montréal, Montréal, Canada
| | - Catherine Vincent
- Liver Unit, Department of Medicine, Centre Hospitalier De l'Université De Montréal, Montréal, Canada
| | | | - Mark G Swain
- Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Angela Cheung
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Tianyan Chen
- Department of Medicine, McGill University Health Centre, Montréal, Canada
| | | | - Kevork Peltekain
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Andrew L Mason
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Canada
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Canada; Department of Epidemiology, Erasmus University Medical Center, Rotterdam, Netherlands
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4
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Chen VL, Flemming JA. Pour some sugar on me: Glycemic control and the prevention of liver disease. Hepatol Commun 2024; 8:e0400. [PMID: 38437057 PMCID: PMC10914224 DOI: 10.1097/hc9.0000000000000400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/24/2024] [Indexed: 03/06/2024] Open
Affiliation(s)
- Vincent L. Chen
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jennifer A. Flemming
- Departments of Medicine and Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
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5
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Foley MK, Djerboua M, Kushner T, Biondi MJ, Feld JJ, Terrault NA, Flemming JA. Maternal neighbourhood-level social determinants of health and their association with paediatric hepatitis C screening among children exposed to hepatitis C in pregnancy. Paediatr Perinat Epidemiol 2024; 38:152-160. [PMID: 38273801 DOI: 10.1111/ppe.13042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 12/27/2023] [Accepted: 12/29/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Current guidelines recommend HCV screening by 18 months of age for those exposed to HCV in utero; yet, screening occurs in the minority of children. OBJECTIVES To evaluate the association between maternal neighbourhood-level social determinants of health (SDOH) and paediatric HCV screening in the general population in a publicly funded healthcare system in Canada. METHODS Retrospective cohort study using administrative healthcare data held at ICES. Children born to individuals positive for HCV RNA in pregnancy from 2000 to 2016 were identified and followed for 2 years. Major SDOH were identified, and the primary outcome was HCV screening in exposed children (HCV antibody and/or RNA). Associations between SDOH and HCV screening were determined using multivariate Poisson regression models adjusting for confounding. RESULTS A total of 1780 children born to persons with +HCV RNA were identified, and 29% (n = 516) were screened for HCV by age two. Most mothers resided in the lowest income quintile (42%), and most vulnerable quintiles for material deprivation (41%), housing instability (38%) and ethnic diversity (26%) with 11% living in rural locations. After adjustment for confounding, maternal rural residence (risk ratio [RR] 0.82, 95% confidence interval [CI] 0.62, 1.07) and living in the highest dependency quintile (RR 0.83, 95% CI 0.65, 1.07) were the SDOH most associated with paediatric HCV screening. Younger maternal age (RR 0.98 per 1-year increase, 95% CI 0.97, 0.99), HIV co-infection (RR 1.69, 95% CI 1.16, 2.48) and GI specialist involvement (RR 1.18, 95% CI 1.00, 1.39) were associated with higher probabilities of screening. CONCLUSIONS Among children exposed to HCV during pregnancy, rural residences and living in highly dependent neighbourhoods showed a potential association with a lower probability of HCV screening by the age of 2. Future work evaluating barriers to paediatric HCV screening among rural residing and dependent residents is needed to enhance the screening.
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Affiliation(s)
- Mary K Foley
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | | | - Tatyana Kushner
- Division of Liver Diseases, Icahn School of Medicine, New York, New York, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, Icahn School of Medicine, New York, New York, USA
| | - Mia J Biondi
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- School of Nursing, Faculty of Health Sciences, York University, Toronto, Ontario, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Sandra Rotman Centre for Global Health, University of Toronto, Toronto, Ontario, Canada
| | - Norah A Terrault
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine at University of Southern California, Los Angeles, California, USA
| | - Jennifer A Flemming
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
- ICES Queens, Kingston, Ontario, Canada
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
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6
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Holdsworth MB, Djerboua M, Flemming JA. Impact of neighbourhood-level social determinants of health on healthcare utilisation and perinatal outcomes in pregnant women with NAFLD cirrhosis: a population-based study in Ontario, Canada. J Epidemiol Community Health 2023; 77:809-815. [PMID: 37666651 DOI: 10.1136/jech-2022-220234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 08/07/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Cirrhosis is rising in North America, driven partly by the epidemic of non-alcoholic fatty liver disease (NAFLD), most in women of reproductive age. Little is known about factors that impact perinatal outcomes and healthcare utilisation in pregnant women with NAFLD cirrhosis. OBJECTIVES We investigated the association between population-level social determinants, health outcomes and healthcare utilisation. METHODS We retrospectively analysed healthcare utilisation and perinatal outcomes in a cohort of pregnant women with NAFLD cirrhosis from Ontario, Canada from 2000 to 2016 and followed for 90 days postdelivery. We compared utilisation and health outcomes according to income, residential instability, material deprivation, dependency and ethnic diversity. A Cochran-Armitage test for trend was done to assess whether utilisation patterns were linear across quintiles. RESULTS 3320 pregnant women with NAFLD cirrhosis formed the study cohort. Decreasing income quintile associated with a higher proportion of women with at least one emergency department (ED) visit. Increasing residential instability, material deprivation and dependency were associated with a higher frequency of ED visitation, with no compelling differences in the rates of perinatal complications or adverse outcomes in pregnant women with NAFLD cirrhosis. Using multiple population-level proxies for social determinants of health, this study demonstrates an association between marginalisation and increased ED visitation. CONCLUSIONS As the incidence rate of pregnancies among women with NAFLD cirrhosis continues to rise, understanding how this population uses healthcare services will help coordinate care for these patients.
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Affiliation(s)
| | | | - Jennifer A Flemming
- Department of Medicine, Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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7
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Sayed N, Flemming JA. Cirrhosis in pregnancy. Clin Liver Dis (Hoboken) 2023; 22:167-170. [PMID: 38026123 PMCID: PMC10653565 DOI: 10.1097/cld.0000000000000087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 07/12/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Nawid Sayed
- Departments of Medicine, Queen’s University, Kingston, ON K7L 3N6, Canada
| | - Jennifer A. Flemming
- Departments of Medicine, Queen’s University, Kingston, ON K7L 3N6, Canada
- Public Health Sciences, Queen’s University, Kingston, ON K7L 3N6, Canada
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8
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Feld LD, Sarkar M, Au JS, Flemming JA, Gripshover J, Kardashian A, Muir AJ, Nephew L, Orloff SL, Terrault N, Rabinowitz L, Volerman A, Arora V, Farnan J, Villa E. Parental leave, childcare policies, and workplace bias for hepatology professionals: A national survey. Hepatol Commun 2023; 7:e0214. [PMID: 37639705 PMCID: PMC10461944 DOI: 10.1097/hc9.0000000000000214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/22/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The presence of workplace bias around child-rearing and inadequate parental leave may negatively impact childbearing decisions and sex equity in hepatology. This study aimed to understand the influence of parental leave and child-rearing on career advancement in hepatology. METHODS A cross-sectional survey of physician members of the American Association for the Study of Liver Diseases (AASLD) was distributed through email listserv in January 2021. The 33-item survey included demographic questions, questions about bias, altering training, career plans, family planning, parental leave, and work accommodations. RESULTS Among 199 US physician respondents, 65.3% were women, and 83.4% (n = 166) were attendings. Sex and racial differences were reported in several domains, including paid leave, perceptions of bias, and child-rearing. Most women (79.3%) took fewer than the recommended 12 paid weeks of parental leave for their first child (average paid leave 7.5 wk for women and 1.7 for men). A majority (75.2%) of women reported workplace discrimination, including 83.3% of Black and 62.5% of Hispanic women. Twenty percent of women were asked about their/their partners' pregnancy intentions or child-rearing plans during interviews for training. Women were more likely to alter career plans due to child-rearing (30.0% vs. 15.9%, p = 0.030). Women were also more likely to delay having children than men (69.5% vs.35.9%). CONCLUSIONS Women reported sex and maternity bias in the workplace and during training interviews, which was more frequently experienced by Black and Hispanic women. As two-thirds of women had children during training, it is a particularly influential time to reevaluate programmatic support to address long-term gender disparities in career advancement.
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Affiliation(s)
- Lauren D. Feld
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Massachusetts, Worcester, Massachusetts, USA
| | - Monika Sarkar
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Jennifer S. Au
- Department of Organ Transplant, Division of Gastroenterology and Hepatology, Scripps Clinic, La Jolla, California, USA
| | - Jennifer A. Flemming
- Department of Medicine and Public Health Sciences, Queen’s University, Ontario, Canada
| | - Janet Gripshover
- Department of Transplant Surgery, Ronald Regan UCLA Medical Center, Los Angeles, California, USA
| | - Ani Kardashian
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Andrew J. Muir
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lauren Nephew
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Susan L. Orloff
- Department of Surgery, Division of Abdominal Organ Transplantation, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Norah Terrault
- Department of Medicine, Division of Gastroenterology and Liver, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Loren Rabinowitz
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Volerman
- Departments of Medicine and Pediatrics, University of Chicago, Chicago, Illinois, USA
| | - Vineet Arora
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Jeanne Farnan
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Erica Villa
- Dipartimento di Specialità Mediche, Struttura Complessa di Gastroenterologia, Universita Degli Studi Di Modena E Reggio Emilia, Modena, Italy
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9
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Kardashian A, Kushner T, Au JS, Flemming JA, Gripshover J, Muir AJ, Orloff SL, Villa E, Sarkar M. The key role of hepatology providers in optimizing reproductive care in patients with liver disease: A call to action. Hepatology 2023; 78:363-367. [PMID: 37142412 DOI: 10.1097/hep.0000000000000275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 05/06/2023]
Affiliation(s)
- Ani Kardashian
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Tatyana Kushner
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jennifer S Au
- Department of Organ and Cell Transplant, Scripps Clinic, La Jolla, California, USA
| | - Jennifer A Flemming
- Department of Medicine and Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Janet Gripshover
- Department of Liver and Small Bowel Transplant, University of California, Los Angeles, Los Angeles, California, USA
| | - Andrew J Muir
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Susan L Orloff
- Department of Surgery, Division of Abdominal Transplant Surgery, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Erica Villa
- Chimomo Department, Gastroenterology Division, University of Modena and Reggio Emilia, Modena, Italy
- IRCCS Saverio de Bellis, Castellana Grotte, Italy
| | - Monika Sarkar
- Department of Medicine, Division of Gastroenterology, University of California, San Francisco, San Francisco, California, USA
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10
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Kehar M, Griffiths R, Flemming JA. Impact of decompensated cirrhosis in children: A population-based study. Can Liver J 2023; 6:278-282. [PMID: 37503518 PMCID: PMC10370729 DOI: 10.3138/canlivj-2022-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/02/2022] [Indexed: 07/29/2023]
Abstract
Background We describe the proportion of children with compensated cirrhosis who develop decompensation in Ontario, Canada over the past two decades. Methods This is a retrospective population-based cohort study using routinely collected health care data from Ontario, Canada held at ICES during 1997-2017. Diagnosis of cirrhosis was made using validated ICES definition, and decompensation events were defined according to validated coding. Rates of decompensation, type of decompensation, and incidence of liver transplantation after decompensation were analyzed. Databases were linked at the individual level and analyzed at ICES-Queen's. Results A total of 2,755 children with compensated cirrhosis were included and 9% (253) developed decompensation over a median follow-up of 7 years. Children most likely to suffer decompensation were younger (median age 10 versus 4 years, p < 0.001) and female (45% versus 52%, p = 0.03). Ascites (137/253, 54%) was the most frequent complication. 199/2755 (7%) of children with cirrhosis received liver transplantation, of which 64% (128/199) occurred after a decompensation event. Overall, a total of 132 (4.7%) deaths occurred during the study period, with 55 deaths following a decompensating event. Conclusion We present the first study to describe rates of decompensation, type, and rate of liver transplantation after decompensation in pediatric cirrhosis at the population level. To improve the care of children with liver disease, early detection of liver disease, early initiation of specific treatments as well as identification of children who are at risk of becoming decompensated are crucial.
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Affiliation(s)
- Mohit Kehar
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Jennifer A Flemming
- ICES-Queen’s
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
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11
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Wang PL, Djerboua M, Flemming JA. Cause-specific mortality among patients with cirrhosis in a population-based cohort study in Ontario (2000-2017). Hepatol Commun 2023; 7:e00194. [PMID: 37378630 DOI: 10.1097/hc9.0000000000000194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/12/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Although patients with cirrhosis are at increased risk of death, the exact causes of death have not been reported in the contemporary era. This study aimed to describe cause-specific mortality in patients with cirrhosis in the general population. METHODS Retrospective cohort study using administrative health care data from Ontario, Canada. Adult patients with cirrhosis from 2000-2017 were identified. Cirrhosis etiologies were defined as HCV, HBV, alcohol-associated liver disease (ALD), NAFLD, or autoimmune liver disease/other with validated algorithms. Patients were followed until death, liver transplant, or end of study. Primary outcome was the cause of death as liver-related, cardiovascular disease, non-hepatic malignancy, and external causes (accident/self-harm/suicide/homicide). Nonparametric analyses were used to describe the cumulative incidence of cause-specific death by cirrhosis etiology, sex, and compensation status. RESULTS Overall, 202,022 patients with cirrhosis were identified (60% male, median age 56 y (IQR 46-67), 52% NAFLD, 26% alcohol-associated liver disease, 11% HCV). After a median follow-up of 5 years (IQR 2-12), 81,428 patients died, and 3024 (2%) received liver transplant . Patients with compensated cirrhosis mostly died from non-hepatic malignancies and cardiovascular disease (30% and 27%, respectively, in NAFLD). The 10-year cumulative incidence of liver-related deaths was the highest among those with viral hepatitis (11%-18%) and alcohol-associated liver disease (25%), those with decompensation (37%) and/or HCC (50%-53%). Liver transplant occurred at low rates (< 5%), and in men more than women. CONCLUSIONS Cardiovascular disease and cancer-related mortality exceed liver-related mortality in patients with compensated cirrhosis.
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Affiliation(s)
- Peter L Wang
- Departments of Medicine, Kingston, Ontario, Canada
| | | | - Jennifer A Flemming
- Departments of Medicine, Kingston, Ontario, Canada
- ICES, Queen's University, Kingston, Ontario, Canada
- Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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12
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Sarkar M, Flemming JA. Letter to the Editor: Influence of maternal NAFLD on infant weight-the real precursor to NAFLD in offspring? Hepatology 2023; 77:E180. [PMID: 36930760 DOI: 10.1097/hep.0000000000000274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 12/05/2022] [Indexed: 03/19/2023]
Affiliation(s)
- Monika Sarkar
- Division of GI/Hepatology, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer A Flemming
- ICES, Queen's University, Kingston, Ontario, Canada
- Division of GI/Hepatology, Queen's University, Kingston, Ontario, Canada
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13
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Sedarous M, Flemming JA. Culture, stigma, and inequities creating barriers in alcohol use disorder management in alcohol-associated liver disease. Clin Liver Dis (Hoboken) 2023; 21:130-133. [PMID: 37274951 PMCID: PMC10238042 DOI: 10.1097/cld.0000000000000026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/21/2023] [Indexed: 06/07/2023] Open
Affiliation(s)
- Mary Sedarous
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Jennifer A. Flemming
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
- Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
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14
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Plagiannakos CG, Montano-Loza AJ, Lytvyak E, Pallotta J, Mason AL, Qumosani KM, Worobetz L, Flemming JA, Hercun J, Vincent C, Cheung A, Chen T, Grbic D, Swain MG, Gulamhusein A, Hansen BE, Hirschfield GM. A44 A 1000 PATIENT CANADIAN NETWORK FOR AUTOIMMUNE LIVER DISEASE EVALUATION OF CLINICAL AND DEMOGRAPHIC PATTERNS OF AUTOIMMUNE HEPATITIS. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991181 DOI: 10.1093/jcag/gwac036.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background We sought to understand how the demographics of autoimmune hepatitis (AIH) have changed over time in Canada. Purpose Using a large multi-centre Canadian cohort of patients with AIH, we describe the trends in patient and disease characteristics at presentation across 30 years of clinical practice. Method Patients from the Canadian Network for Autoimmune Liver Disease with a confirmed diagnosis of AIH (simplified score ≥6) were included for analysis. Patients were grouped into five cohorts according to the year of diagnosis (i.e., <2000, 2000-2004, 2005-2009, 2010-2014, ≥2015). Patient demographics and baseline clinical and biochemistry features of disease activity were investigated using Chi-square tests and Kruskal-Wallis tests adjusted for multiple comparisons. Logistic and linear regression models with estimated means were utilized to further investigate relationships with time and to adjust for confounding. Result(s) 1016 patients followed across 10 Canadian health centres with AIH were diagnosed between November 1965 and December 2021. Overall, 76.4% (n=776) of patients were female, and the median age at diagnosis was 46 years (IQR 28.2 - 58.3). Cirrhosis at presentation was seen in 20.6% of patients (n=209). The median age at diagnosis increased significantly from 31.8 years [IQR 17.9 - 46.8] pre-2000 to 54 years [IQR 9.0 - 95.2] after 2014 (p<0.001; Figure 1a). This effect of time persisted after adjusting for sex and cirrhosis status at diagnosis. Female sex and the presence of cirrhosis at diagnosis were factors independently associated with older age at presentation (p<0.0001). The proportion of patients that presented with cirrhosis at diagnosis increased significantly over calendar time, from 13.7% (n=23) pre-2000 to 30.8% (n=69) after 2014 (p=0.003; Figure 1b). Male sex was independently associated with an increased odds of having cirrhosis at presentation (OR= 1.46, CI 1.02 - 2.07) and higher baseline ALT levels compared to females (p=0.036). The proportion of patients that identified as non-white ethnicity increased significantly from 15.2% (n= 24) pre-2000, to 32% (n= 86) after 2014 (p<0.001, Figure 1b). This effect of time on ethnicity was most pronounced after the year 2010 (OR= 2.32, CI 1.39 - 3.98) and persisted after adjusting for sex. There was no significant pattern of change in sex over calendar time. Image ![]()
Conclusion(s) In Canada, patients with AIH at presentation are now older, have more advanced disease, and are more ethnically diverse than when compared to 30 years ago. Please acknowledge all funding agencies by checking the applicable boxes below Other Please indicate your source of funding; industry Disclosure of Interest None Declared
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Affiliation(s)
- C G Plagiannakos
- Toronto Centre for Liver Disease, Toronto Western and General Hospital, University Health Network,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto
| | - A J Montano-Loza
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton
| | - E Lytvyak
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton
| | - J Pallotta
- Toronto Centre for Liver Disease, Toronto Western and General Hospital, University Health Network
| | - A L Mason
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton
| | - K M Qumosani
- Department of Medicine, Western University, London
| | - L Worobetz
- Department of Medicine, University of Saskatchewan, Saskatoon
| | - J A Flemming
- Medicine and Public Health Sciences, Queen's University, Kingston
| | - J Hercun
- Département De Médecins, Centre Hospitalier De l’Université De Montréal, Montréal
| | - C Vincent
- Département De Médecins, Centre Hospitalier De l’Université De Montréal, Montréal
| | - A Cheung
- Department of Medicine, University of Ottawa, Ottawa
| | - T Chen
- Department of Medicine, McGill University Health Centre, Montréal
| | - D Grbic
- Université De Sherbrooke, Sherbrooke
| | - M G Swain
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - A Gulamhusein
- Toronto Centre for Liver Disease, Toronto Western and General Hospital, University Health Network,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto
| | - B E Hansen
- Toronto Centre for Liver Disease, Toronto Western and General Hospital, University Health Network,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto,Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - G M Hirschfield
- Toronto Centre for Liver Disease, Toronto Western and General Hospital, University Health Network,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto
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15
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Kushner T, Djerboua M, Biondi MJ, Feld JJ, Terrault N, Flemming JA. Influence of hepatitis C viral parameters on pregnancy complications and risk of mother-to-child transmission. J Hepatol 2022; 77:1256-1264. [PMID: 35643203 DOI: 10.1016/j.jhep.2022.05.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 05/05/2022] [Accepted: 05/16/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS With the World Health Organization plan for hepatitis C elimination by the year 2030, and recent guideline recommendations to screen all women during pregnancy for HCV, data on HCV in pregnancy are needed to determine the association of HCV viremia with adverse pregnancy outcomes and mother-to-child transmission (MTCT). METHODS This retrospective cohort study was performed in Ontario, Canada, using population-based administrative healthcare data. Individuals were stratified based on whether they had active HCV viremia during pregnancy or resolved viremia at time of pregnancy. Peak HCV viral load was determined. Logistic regression was used to determine the association of viremia with adverse pregnancy outcomes; maternal HCV RNA levels were evaluated as a predictor of MTCT. RESULTS We identified a total of 2,170 pregnancies in 1,636 women who were HCV RNA positive prior to pregnancy; 1,780 (82%) pregnancies occurred in women who were HCV RNA positive during pregnancy. Patients who were HCV RNA positive during pregnancy were more likely to have preterm delivery (18% vs. 12%, p = 0.002), intrahepatic cholestasis of pregnancy (4% vs. <2%, p = 0.003), and post-partum hemorrhage (9% vs. 5%, p = 0.013), and less likely to have gestational diabetes (6% vs. 10%, p = 0.008) than those with resolved infection. Only 511 (29%) infants had screening consistent with guidelines after birth; there was an estimated 3.5% risk of MTCT. HCV RNA ≥6.0 log10 IU/ml was significantly associated with MTCT (exact odds ratio 3.4, p = 0.04). CONCLUSION Active HCV viremia among individuals with a history of HCV infection significantly increases adverse pregnancy outcomes. Few infants are screened for MTCT. Higher HCV RNA is associated with increased risk of MTCT. LAY SUMMARY The prevalence of hepatitis C has increased in women of child-bearing age and has important implications for women who become pregnant and their infants. We evaluated the effect that hepatitis C has on pregnancy outcomes as well as the rate of hepatitis C transmission to infants in a large database with linked mother-infant records. We found that active hepatitis C during pregnancy increased the risk of pregnancy complications. We also identified very low rates of testing of infants born to mothers with hepatitis C, but found higher rates of hepatitis C transmission to infants in mothers with higher virus levels.
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Affiliation(s)
- Tatyana Kushner
- Division of Liver Diseases, Icahn School of Medicine, New York, NY USA; Department of Obstetrics, Gynecology and Reproductive Sciences, Icahn School of Medicine, New York, NY USA.
| | | | - Mia J Biondi
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON Canada; School of Nursing, Faculty of Health Sciences, York University, Toronto ON Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Sandra Rotman Centre for Global Health, University of Toronto, Toronto, Canada
| | - Norah Terrault
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Jennifer A Flemming
- ICES, Queen's University, Kingston, Ontario, Canada; Departments of Medicine and Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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16
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Flemming JA, Muaddi H, Djerboua M, Neves P, Sapisochin G, Selzner N. Association between social determinants of health and rates of liver transplantation in individuals with cirrhosis. Hepatology 2022; 76:1079-1089. [PMID: 35313040 DOI: 10.1002/hep.32469] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS This study evaluated the association between neighborhood-level social determinants of health (SDOH) and liver transplantation (LT) among patients with cirrhosis who have universal access to health care. APPROACH AND RESULTS This was a retrospective population-based cohort study from 2000-2019 using administrative health care data from Ontario, Canada. Adults aged 18-70 years with newly decompensated cirrhosis and/or HCC were identified using validated coding. The associations between five neighborhood level SDOH quintiles and LT were assessed with multivariate Fine-Gray competing risks regression to generate subdistribution HRs (sHRs) where death competes with LT. Overall, n = 38,719 individuals formed the cohort (median age 57 years, 67% male), and n = 2788 (7%) received LT after a median of 23 months (interquartile range 3-68). Due to an interaction, results were stratified by sex. After multivariable regression and comparing those in the lowest versus highest quintiles, individuals living in the most materially resource-deprived areas (female sHR, 0.61; 95% CI, 0.49-0.76; male sHR, 0.55; 95% CI, 0.48-0.64), most residentially unstable neighborhoods (female sHR, 0.61; 95% CI, 0.49-0.75; male sHR, 0.56; 95% CI, 0.49-0.65), and lowest-income neighborhoods (female sHR, 0.57; 95% CI, 0.46-0.7; male sHR, 0.58; 95% CI, 0.50-0.67) had ~40% reduced subhazard for LT (p < 0.01 for all). No associations were found between neighborhoods with the most diverse immigrant or racial minority populations or age and labor force quintiles and LT. CONCLUSIONS This information highlights an urgent need to evaluate how SDOH influence rates of LT, with the overarching goal to develop strategies to overcome inequalities.
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Affiliation(s)
- Jennifer A Flemming
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.,Public Health Sciences, Queen's University, Kingston, Ontario, Canada.,ICES Queen's, Kingston, Ontario, Canada
| | - Hala Muaddi
- Department of Surgery, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Paula Neves
- Center for Living Organ Donation, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Department of Surgery, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada.,Ajmera Transplant Centre, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Nazia Selzner
- Ajmera Transplant Centre, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
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17
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Roberts SB, Hirschfield GM, Worobetz LJ, Vincent C, Flemming JA, Cheung A, Qumosani K, Swain M, Grbic D, Ko HH, Peltekian K, Selzner N, Abrahamyan L, Aziz B, Lytvyak E, Tirona K, Gulamhusein AF, Janssen HLA, Montano-Loza AJ, Mason AL, Hansen BE. Ethnicity, disease severity, and survival in Canadian patients with primary biliary cholangitis. Hepatology 2022; 76:303-316. [PMID: 35220609 DOI: 10.1002/hep.32426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/21/2022] [Accepted: 02/16/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS We investigated associations between ethnicity, survival, and disease severity in a diverse Canadian cohort of patients with primary biliary cholangitis (PBC). APPROACH AND RESULTS Patients with PBC were included from the Canadian Network for Autoimmune Liver Disease. Ethnicity was defined using a modified list adopted from Statistics Canada, and ethnicities with small samples were grouped. Clinical events were defined as liver decompensation, HCC, liver transplantation, or death. Clinical event-free and liver transplantation-free survival were analyzed using Cox regression. Trajectories of serum liver function tests were assessed over time using mixed-effects regression. Health-related quality of life was assessed using the Short Form 36, the PBC-40 questionnaire, and the 5-D Itch scale and analyzed using mixed-effects regression. The cohort included 1538 patients with PBC from six sites and was comprised of 82% White, 4.7% Indigenous, 5.5% East Asian, 2.6% South Asian, and 5.1% miscellaneous ethnicities. Indigenous patients were the only ethnic group with impaired liver transplant-free and event-free survival compared to White patients (HR, 3.66; 95% CI, 2.23-6.01; HR, 3.09; 95% CI, 1.94-4.92). Indigenous patients were more likely to have a clinical event before diagnosis (10%) than all other ethnic groups despite similar age at diagnosis. Indigenous patients presented with higher alkaline phosphatase, total bilirubin, and GLOBE scores than White patients; and these relative elevations persisted during follow-up. CONCLUSIONS Indigenous Canadians with PBC present with advanced disease and have worse long-term outcomes compared to White patients.
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Affiliation(s)
- Surain B Roberts
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lawrence J Worobetz
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Catherine Vincent
- Département de Médecine, Université de Montréal, Montréal, Quebec, Canada
| | | | - Angela Cheung
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Karim Qumosani
- Department of Medicine, Western University, London, Ontario, Canada
| | - Mark Swain
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dusanka Grbic
- Department de Médecine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Hin Hin Ko
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kevork Peltekian
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Nazia Selzner
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Lusine Abrahamyan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Bishoi Aziz
- Department of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Ellina Lytvyak
- Department of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Kattleya Tirona
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Aliya F Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Aldo J Montano-Loza
- Department of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew L Mason
- Department of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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18
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Webber C, Flemming JA, Birtwhistle R, Rosenberg M, Groome PA. Regional variations and associations between colonoscopy resource availability and colonoscopy utilisation: a population-based descriptive study in Ontario, Canada. BMJ Open Gastroenterol 2022; 9:bmjgast-2022-000929. [PMID: 35680174 PMCID: PMC9185399 DOI: 10.1136/bmjgast-2022-000929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/23/2022] [Indexed: 11/25/2022] Open
Abstract
Objective There is substantial variation in colonoscopy use and evidence of long wait times for the procedure. Understanding the role of system-level resources in colonoscopy utilisation may point to a potential intervention target to improve colonoscopy use. This study characterises colonoscopy resource availability in Ontario, Canada and evaluates its relationship with colonoscopy utilisation. Design We conducted a population-based study using administrative health data to describe regional variation in colonoscopy availability for Ontario residents (age 18–99) in 2013. We identified 43 colonoscopy networks in the province in which we described variations across three colonoscopy availability measures: colonoscopist density, private clinic access and distance to colonoscopy. We evaluated associations between colonoscopy resource availability and colonoscopy utilisation rates using Pearson correlation and log binomial regression, adjusting for age and sex. Results There were 9.4 full-time equivalent colonoscopists per 100 000 Ontario residents (range across 43 networks 0.0 to 21.8); 29.5% of colonoscopies performed in the province were done in private clinics (range 1.2%–55.9%). The median distance to colonoscopy was 3.7 km, with 5.9% travelling at least 50 km. Lower colonoscopist density was correlated with lower colonoscopy utilisation rates (r=0.53, p<0.001). Colonoscopy utilisation rates were 4% lower in individuals travelling 50 to <200 km and 11% lower in individuals travelling ≥200 km to colonoscopy, compared to <10 km. There was no association between private clinic access and colonoscopy utilisation. Conclusion The substantial variations in colonoscopy resource availability and the relationship demonstrated between colonoscopy resource availability and use provides impetus for health service planners and decision-makers to address these potential inequalities in access in order to support the use of this medically necessary procedure.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada .,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Jennifer A Flemming
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada.,ICES, Kingston, Ontario, Canada.,Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Richard Birtwhistle
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.,ICES, Kingston, Ontario, Canada.,Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Mark Rosenberg
- Department of Geography, Queen's University, Kingston, Ontario, Canada
| | - Patti A Groome
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada.,ICES, Kingston, Ontario, Canada
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19
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Guan Z, Webber C, Flemming JA, Mavor ME, Whitehead M, Chen BE, Groome PA. Real-world colorectal cancer diagnostic pathways in Ontario, Canada: A population-based study. Eur J Cancer Care (Engl) 2022; 31:e13603. [PMID: 35502982 DOI: 10.1111/ecc.13603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 01/21/2022] [Accepted: 04/18/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE This study aimed to identify colorectal cancer (CRC) diagnostic pathways and describe patients in those pathway groups. METHODS This was a cross-sectional study of CRC patients in Ontario, Canada, diagnosed 2009-2012 that used linked administrative data at ICES. We used cluster analysis on 11 pathway variables characterising patient presentation, symptoms, procedures and referrals. We assessed associations between patient- and disease-related characteristics and diagnostic pathway group. We further characterised the pathways by diagnostic interval and number of related physician visits. RESULTS Six diagnostic pathways were identified, with three adhering to provincial diagnostic guidelines: screening (N = 4494), colonoscopy (N = 10,066) and imaging plus colonoscopy (N = 3427). Non-adherent pathways were imaging alone (N = 2238), imaging and emergency presentation (N = 2849) and no pre-diagnostic workup (N = 887). Patients in adherent pathways were younger, had fewer comorbidities, lived in less deprived areas and had earlier stage disease. The median diagnostic interval length varied across pathways from 12 to 126 days, correlating with the number of CRC-related visits. CONCLUSIONS This study demonstrated substantial variations in real-world CRC diagnostic pathways and 25% were diagnosed through non-adherent pathways. Those patients were older, had more comorbid disease and had higher stage cancer. Further research needs to identify and describe the reasons for divergent diagnostic processes.
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Affiliation(s)
- Zhen Guan
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Queen's University, Kingston, Ontario, Canada
| | - Colleen Webber
- Bruyère Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jennifer A Flemming
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Queen's University, Kingston, Ontario, Canada.,Department of Medicine, Queen's University, Kingston, Ontario, Canada.,ICES Queen's, Kingston, Ontario, Canada
| | - Meaghan E Mavor
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Queen's University, Kingston, Ontario, Canada
| | | | - Bingshu E Chen
- Canadian Cancer Trials Group (CCTG), Queen's Cancer Research Institute, Queen's University, Kingston, Ontario, Canada
| | - Patti A Groome
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Queen's University, Kingston, Ontario, Canada.,ICES Queen's, Kingston, Ontario, Canada
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20
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Lee-Kim V, Morkem R, Barber D, Flemming JA, Kehar M. Awareness, management, and practice patterns of pediatric NAFLD by primary care physicians. Paediatr Child Health 2022; 27:93-98. [PMID: 35599680 DOI: 10.1093/pch/pxab057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 07/25/2021] [Indexed: 11/15/2022] Open
Abstract
Background Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in children. Primary-care physicians (PCPs) play a key role in identifying patients requiring specialist referral. In this study, we aim to determine PCPs' practice patterns for paediatric NAFLD, as knowledge gaps have been reported for adult NAFLD. Methods A survey was sent to 60 PCPs in the Eastern Ontario Network from July 2019 to January 2020. Results Thirty-seven (62%) PCPs responded to the survey. Twenty-one incorrectly considered the prevalence of paediatric NAFLD to be ≤10%. The majority (35/36) cared for less than five paediatric NAFLD patients. Thirty-four (92%) were only 'slightly familiar' or 'not familiar at all' with paediatric NAFLD. Only one PCP routinely screens for NAFLD. Only one PCP was aware of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) clinical guidelines for paediatric NAFLD. Twenty-five (68%) correctly selected lifestyle modifications as a treatment option. Lack of confidence in the knowledge of NAFLD was the most common barrier for managing paediatric cases. Conclusion The majority of PCPs are not screening for paediatric NAFLD and are not familiar with its clinical spectrum, citing a lack of knowledge regarding NAFLD as the greatest barrier. This may cause delays in diagnosis and a presentation with advanced fibrosis at the time of specialist referral. Dissemination and implementation of clinical guidelines have the potential to improve knowledge and screening rates for NAFLD in children at the primary-care level.
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Affiliation(s)
- Victoria Lee-Kim
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rachael Morkem
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - David Barber
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Jennifer A Flemming
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Mohit Kehar
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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21
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Sarkar M, Djerboua M, Flemming JA. NAFLD Cirrhosis Is Rising Among Childbearing Women and Is the Most Common Cause of Cirrhosis in Pregnancy. Clin Gastroenterol Hepatol 2022; 20:e315-e318. [PMID: 33465483 DOI: 10.1016/j.cgh.2021.01.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 02/07/2023]
Abstract
Rates of pregnancies affected by nonalcoholic fatty liver disease (NAFLD) in the United States have nearly tripled in the last decade and NAFLD confers increased perinatal risks, such as hypertensive complications, postpartum hemorrhage, and preterm birth.1 Rates of cirrhosis in pregnancy are also rising,2 although estimates specific to NAFLD cirrhosis are lacking. Whether NAFLD cirrhosis confers differential perinatal risks than other causes of cirrhosis in pregnancy is also unknown.
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Affiliation(s)
- Monika Sarkar
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California.
| | | | - Jennifer A Flemming
- ICES, Queen's University, Kingston, Ontario, Canada; Division of Gastroenterology and Hepatology, Queen's University, Kingston, Ontario, Canada
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22
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Rubino JG, Flemming JA. Menopausal hormone therapy and risk of biliary tract cancers: Addressing the ant, not the elephant in the room. Hepatology 2022; 75:243-245. [PMID: 34821403 DOI: 10.1002/hep.32254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 11/20/2021] [Indexed: 12/08/2022]
Affiliation(s)
- Julian G Rubino
- Department of MedicineQueen's UniversityKingstonOntarioCanada
| | - Jennifer A Flemming
- Department of MedicineQueen's UniversityKingstonOntarioCanada.,Department of Public Health SciencesQueen's UniversityKingstonOntarioCanada
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23
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Mir ZM, Golding H, McKeown S, Nanji S, Flemming JA, Groome PA. Appraisal of multivariable prognostic models for post-operative liver decompensation following partial hepatectomy: a systematic review. HPB (Oxford) 2021; 23:1773-1788. [PMID: 34332894 DOI: 10.1016/j.hpb.2021.06.430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 06/20/2021] [Accepted: 06/28/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Few reports have evaluated prognostic modelling studies of tools used for surgical decision-making. This systematic review aimed to describe and critically appraise studies that have developed or validated multivariable prognostic models for post-operative liver decompensation following partial hepatectomy. METHODS This study was designed using the CHARMS checklist. Following a comprehensive literature search, two reviewers independently screened candidate references for inclusion and abstracted relevant study details. Qualitative assessment was performed using the PROBAST tool. RESULTS We identified 36 prognostic modelling studies; 25 focused on development only, 3 developed and validated models, and 8 validated pre-existing models. None compared routine use of a prognostic model against standard clinical practice. Most studies used single-institution, retrospective cohort designs, conducted in Eastern populations. In total, 15 different outcome definitions for post-operative liver decompensation events were used. Statistical concerns surrounding model overfitting, performance assessment, and internal validation led to high risk of bias for all studies. CONCLUSIONS Current prognostic models for post-operative liver decompensation following partial hepatectomy may not be valid for routine clinical use due to design and methodologic concerns. Landmark resources and reporting guidelines such as the TRIPOD statement may assist researchers, and additionally, model impact assessment studies represent opportunities for future research.
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Affiliation(s)
- Zuhaib M Mir
- Department of Surgery, Division of General Surgery, Queen's University, Kingston, ON, Canada; Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.
| | - Haley Golding
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Sandra McKeown
- Bracken Health Sciences Library, Queen's University, Kingston, ON, Canada
| | - Sulaiman Nanji
- Department of Surgery, Division of General Surgery, Queen's University, Kingston, ON, Canada
| | - Jennifer A Flemming
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada; Department of Medicine, Division of Gastroenterology, Queen's University, Kingston, ON, Canada; Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Patti A Groome
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada; Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
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24
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Flemming JA, Djerboua M, Groome PA, Booth CM, Terrault NA. NAFLD and Alcohol-Associated Liver Disease Will Be Responsible for Almost All New Diagnoses of Cirrhosis in Canada by 2040. Hepatology 2021; 74:3330-3344. [PMID: 34174003 DOI: 10.1002/hep.32032] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 06/02/2021] [Accepted: 06/08/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Mortality secondary to cirrhosis in North America is increasing. We describe the incidence of cirrhosis stratified by birth cohort and cirrhosis etiology and project disease burden to 2040. APPROACH AND RESULTS This is a retrospective cohort study in Ontario, Canada, using population-based administrative health care data. Individuals with incident cirrhosis (2000-2017) were identified, and etiology was defined as HCV, HBV, NAFLD, alcohol-associated liver disease (ALD), or autoimmune liver disease/other using validated case definitions. Annual age/sex-adjusted cirrhosis incidence rate per 100,000 person-years was calculated with incidence projection to 2040 using age-period-cohort modeling along with average annual percent change (AAPC) in cirrhosis incidence stratified by birth cohort and etiology. In total, 159,549 incident cases of cirrhosis were identified. Incidence increased by 26% with an AAPC of 2%/year (95% CI, 1.6-2.4; P < 0.001). The largest increases were for HCV (AAPC, 4.1%/year; 95% CI, 2.6-5.7; P < 0.001) and NAFLD (AAPC, 3.3%/year; 95% CI, 2.6-4.1%; P < 0.001). ALD and HCV cirrhosis in those born >1980 increased by 11.6%/year (95% CI, 9.3-13.9; P < 0.001) and 9.5%/year (95% CI, 6.2-13.0; P < 0.001), respectively. However, by 2040, cirrhosis incidence is projected to continue to increase, driven mostly by NAFLD, especially in postmenopausal women, and ALD in individuals born >1980. CONCLUSIONS Cirrhosis incidence will continue to increase over the next two decades secondary to NAFLD with a worrisome rapid rise in ALD cirrhosis among young adults. Public education, policy, and intervention targeting NAFLD risk factors and alcohol use in young adults are urgently needed.
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Affiliation(s)
- Jennifer A Flemming
- Department of Medicine, Queen's University, Kingston, ON, Canada.,ICES, Queen's University, Kingston, ON, Canada.,Public Health Sciences, Queen's University, Kingston, ON, Canada.,Cancer Care and Epidemiology, Queen's University, Kingston, ON, Canada
| | | | - Patti A Groome
- ICES, Queen's University, Kingston, ON, Canada.,Public Health Sciences, Queen's University, Kingston, ON, Canada.,Cancer Care and Epidemiology, Queen's University, Kingston, ON, Canada
| | - Christopher M Booth
- ICES, Queen's University, Kingston, ON, Canada.,Public Health Sciences, Queen's University, Kingston, ON, Canada.,Cancer Care and Epidemiology, Queen's University, Kingston, ON, Canada
| | - Norah A Terrault
- Keck School of Medicine, University of Southern California, Los Angeles, CA
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25
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Wang PL, Silver SA, Djerboua M, Thanabalasingam S, Zarnke S, Flemming JA. Recovery From Acute Kidney Injury Requiring Dialysis in Patients With Cirrhosis: A Population-Based Study. Am J Kidney Dis 2021; 80:55-64.e1. [PMID: 34808296 DOI: 10.1053/j.ajkd.2021.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/21/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE The decision to initiate kidney replacement therapy (KRT) for acute kidney injury (AKI) in cirrhosis remains controversial as it is unclear which patients will benefit. We sought to characterize factors associated with recovery from AKI requiring KRT in patients with cirrhosis to inform shared clinical decision-making. STUDY DESIGN Population-based retrospective cohort study. SETTING & PARTICIPANTS Adult patients from Ontario, Canada identified, using administrative data, to have cirrhosis at the time of admission to hospital with AKI (based on serum creatinine) requiring KRT (01/01/2009-12/31/2016) and followed until 12/31/2017. EXPOSURES Demographics and comorbidities prior to admission. OUTCOMES Kidney recovery defined as the absence of KRT for at least 30 days. ANALYTICAL APPROACH The cumulative incidences of kidney recovery, death, and liver transplantation were calculated at 1, 3, 6, and 12 months and independent predictors of kidney recovery were evaluated using Fine and Gray competing risk regression models that generated subdistribution hazards ratios (sHR). RESULTS Overall, 722 patients were included (median age 61 years [IQR 54-68]; MELD-Na 26 [IQR 22-34]; 66% male; 52% had viral hepatitis, 25% non-alcoholic fatty liver disease, 18% alcohol-associated liver disease). The cumulative incidences of kidney recovery at 1, 3, 6, and 12 months were 3%, 22%, 25%, and 26%, respectively. Higher MELD-Na score (sHR 0.72 per 5 units, 95%CI 0.65-0.80), acute-on-chronic liver failure (sHR 0.61, 95%CI 0.43-0.86), and sepsis (sHR 0.57, 95%CI 0.41-0.81) were associated with a lower hazard of kidney recovery while those on a liver transplant waitlist (sHR 3.10, 95% CI 1.96-4.88) and who were admitted to a teaching hospital (sHR 1.48, 95%CI 1.05-2.08) were more likely to experience kidney recovery. LIMITATIONS Observational design, AKI etiology not identified. CONCLUSIONS Kidney recovery from KRT occurred in only one-quarter of patients and was very unlikely after 3-months. These findings provide information regarding prognosis that may guide decisions regarding KRT initiation and continuation.
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Affiliation(s)
| | | | | | | | | | - Jennifer A Flemming
- Department of Medicine; ICES, Queen's University; Department of Public Health Sciences, Queen's University.
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26
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Wang PL, Flemming JA. Bears, beets, rifaximin. CanLivJ 2021; 4:438-442. [DOI: 10.3138/canlivj-2021-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Peter L Wang
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Jennifer A Flemming
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
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27
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Mir ZM, Djerboua M, Nanji S, Flemming JA, Groome PA. ASO Visual Abstract: Predictors of Postoperative Liver Decompensation Events Following Resection in Patients with Cirrhosis and Hepatocellular Carcinoma: A Population-Based Study. Ann Surg Oncol 2021. [PMID: 34671882 DOI: 10.1245/s10434-021-10934-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Zuhaib M Mir
- Division of General Surgery, Department of Surgery, Kingston General Hospital, Queen's University, Kingston, ON, Canada. .,Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.
| | - Maya Djerboua
- ICES Queen's, Queen's University, Kingston, ON, Canada
| | - Sulaiman Nanji
- Division of General Surgery, Department of Surgery, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Jennifer A Flemming
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,ICES Queen's, Queen's University, Kingston, ON, Canada.,Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Patti A Groome
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,ICES Queen's, Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
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28
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Mir ZM, Djerboua M, Nanji S, Flemming JA, Groome PA. Predictors of Postoperative Liver Decompensation Events After Resection in Patients with Cirrhosis and Hepatocellular Carcinoma: A Population-Based Study. Ann Surg Oncol 2021; 29:288-299. [PMID: 34549362 DOI: 10.1245/s10434-021-10801-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/10/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Appropriate patient selection for liver resection in hepatocellular carcinoma (HCC) is critical to mitigation of major liver-related postoperative complications. Currently, no standard prognostic tool exists to predict the risk of postoperative liver decompensation events (POLDEs) after partial hepatectomy for patients with cirrhosis and HCC. This study aimed to identify independent preoperative predictors of POLDEs for future development of prognostic tools to improve surgical decision-making. METHODS This population-based, retrospective cohort study investigated patients with cirrhosis and incident HCC between 2007 and 2017, identified using administrative health data from Ontario, Canada. The occurrence of a POLDE or death within 2 years after surgery was described. Multivariable Cox regression identified independent predictors of POLDE-free survival, as well as cause-specific hazards for POLDEs and death. RESULTS Among 611 patients with cirrhosis and HCC who underwent liver resection, 160 (26.2%) experienced at least one POLDE, and 189 (30.9%) died within 2 years after surgery. Diabetes, cirrhosis etiology, major liver resection, and previous non-malignant decompensation were independent predictors of POLDE-free survival. Except for extent of resection, the same risk factors were associated with POLDEs in the cause-specific analysis. In contrast, only age and history of previous non-malignant decompensation were independent predictors of mortality. CONCLUSIONS Among patients with cirrhosis undergoing resection for HCC, patient and disease-related factors are associated with POLDEs and POLDE-free survival. These factors can be used both to inform clinical practice and to advance the development of preoperative prognostic tools, which may lead to improved outcomes for this population.
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Affiliation(s)
- Zuhaib M Mir
- Division of General Surgery, Department of Surgery, Victory 3, Kingston General Hospital, Queen's University, Kingston, ON, Canada. .,Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.
| | | | - Sulaiman Nanji
- Division of General Surgery, Department of Surgery, Victory 3, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Jennifer A Flemming
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,ICES Queen's University, Kingston, ON, Canada.,Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Patti A Groome
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,ICES Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
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29
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Rai M, Lowe C, Flemming JA. Screening for hepatitis C in an outpatient endoscopy unit. CanLivJ 2021; 4:311-316. [DOI: 10.3138/canlivj-2020-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 12/20/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND: The Canadian Liver Foundation recommends routine hepatitis C (HCV) screening for Canadians born between 1945 and 1975. This study aimed to determine the feasibility and outcomes of targeted birth cohort HCV screening during routine outpatient endoscopic procedures in a tertiary care hospital. METHODS: We conducted a prospective cohort study of individuals born between 1945 and 1975 who attended outpatient endoscopy procedures at Kingston Health Sciences Centre from 2017 to 2019. Patients who consented received the HCV OraSure point-of-care test for the HCV antibody (HCV Ab). If positive, serum for HCV RNA was sent, and patients were linked to care with a hepatologist. RESULTS: 2,179 patients met birth cohort criteria for HCV screening. Of those, 1,079 (49.5%) were approached for study inclusion, and 160 (15.0%) declined participation, leaving 912 patients who provided consent. The median age was 62 years (IQR 55–67). Overall, 6/912 (0.7%) of participants were HCV Ab positive and 5/912 (0.6%) were HCV RNA positive. Four were linked to care for consideration of direct-acting antiviral (DAA) therapy, 3 received DAA treatment, and all 3 achieved sustained virologic response (SVR). CONCLUSIONS: Birth cohort screening for HCV in an outpatient endoscopy unit identified an HCV prevalence similar to population estimates. In this model, however, 50% of eligible patients were not approached for screening. Linkage to care for assessment of treatment was high at 80%, and of those who received therapy, all achieved SVR. These results suggest this cohort is a suitable population for HCV screening; however, we need strategies to increase recruitment of all eligible individuals.
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Affiliation(s)
- Mandip Rai
- Department of Medicine Queen’s University, Kingston, Ontario, Canada
| | - Catherine Lowe
- Department of Medicine Queen’s University, Kingston, Ontario, Canada
| | - Jennifer A Flemming
- Department of Medicine Queen’s University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
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30
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Flemming JA, Velez MP. The ART of medicine: Counselling women with liver disease about assisted reproductive technology. J Hepatol 2021; 74:1283-1285. [PMID: 33810873 DOI: 10.1016/j.jhep.2021.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/05/2021] [Accepted: 03/11/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Jennifer A Flemming
- Department of Medicine, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.
| | - Maria P Velez
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; Department of Obstetrics and Gynecology, Queen's University, Kingston, Ontario, Canada
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31
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Rodrigues DM, Djerboua M, Flemming JA. Intravenous Albumin in Patients With Cirrhosis: Evaluation of Practice Patterns and Secular Trends of Usage in Ontario 2000 to 2017. J Can Assoc Gastroenterol 2020; 4:179-185. [PMID: 34337318 PMCID: PMC8320267 DOI: 10.1093/jcag/gwaa027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/20/2020] [Indexed: 11/14/2022] Open
Abstract
Background Intravenous (IV) albumin has evidence-based indications in cirrhosis that are limited in most guidelines to spontaneous bacterial peritonitis (SBP), type 1 hepatorenal syndrome (HRS) and large volume paracentesis (LVP). This study aimed to describe the trends of IV albumin usage in patients with cirrhosis at the population level and evaluate indications for IV albumin in the hospital setting. Methods A retrospective study identified albumin infusions in health care data from Ontario, Canada between 2000 and 2017 in those with and without cirrhosis. Annual rates of IV albumin by cirrhosis status were calculated per 10,000 person-years (PY) and described using Poisson regression and rate ratios. Secondly, patients with cirrhosis receiving IV albumin while hospitalized at Kingston Health Sciences Centre (KHSC) in 2017 were identified and underwent detailed chart abstraction to determine the reason for IV albumin administration. Results The overall rate of provincial IV albumin usage doubled over the study period (2000: 8.4/10,000 PY versus 2017: 16.3/10,000 PY; rate ratio 1.94, 95% confidence interval 1.90 to 1.99, P <0.001). The majority of albumin was used during hospitalization (88%) and 22% was used in patients with cirrhosis. At KHSC, there were134 admissions where a patient with cirrhosis received IV albumin. Of these, 49% of prescriptions were for evidence-based indications (LVP 30%, type 1 HRS 10%, SBP 10%), whereas other indications included non-HRS renal failure, hypovolemia and sepsis. Conclusion IV albumin use has doubled over two decades and is frequently used in hospitalized patients with cirrhosis with only 50% being prescribed for evidence-based indications. These results highlight the impact of cirrhosis on albumin use and highlight potential quality improvement opportunities.
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Affiliation(s)
| | | | - Jennifer A Flemming
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.,ICES, Queen's University, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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32
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Motomura D, Baetz T, Grin A, Flemming JA. Severe Refractory Checkpoint Inhibitor-Related Hepatitis Reversed With Anti-Thymocyte Globulin and n-Acetylcysteine. Hepatology 2020; 72:2235-2238. [PMID: 32484945 DOI: 10.1002/hep.31396] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/23/2020] [Accepted: 05/05/2020] [Indexed: 12/07/2022]
Affiliation(s)
- Douglas Motomura
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Tara Baetz
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Andrea Grin
- Department of Pathology, Queen's University, Kingston, Ontario, Canada
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33
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Mah JM, Djerboua M, Groome PA, Booth CM, Flemming JA. Transjugular intrahepatic portosystemic shunt for the treatment of refractory ascites: A population-based cohort study. CanLivJ 2020; 3:334-347. [DOI: 10.3138/canlivj-2020-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/22/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND: Randomized trials have shown that transjugular intrahepatic portosystemic shunt (TIPS) improves control of ascites compared with serial large volume paracentesis (LVP) in patients with refractory ascites. However, the effect of TIPS on liver transplant-free (LTF) survival is controversial. Our objective was to compare TIPS versus serial LVP on LTF survival in the general population of patients with refractory ascites. METHODS: This is a retrospective, population-based cohort study using linked administrative health data from Ontario, Canada. Adult patients identified with refractory ascites from January 1, 2008 to December 31, 2016 were included and followed until December 31, 2017. A propensity score was used to match patients treated with serial LVP to those who received TIPS in a 2:1 ratio. LTF survival was evaluated using Kaplan–Meier analysis and Cox proportional hazards regression with TIPS treated as a time-varying exposure. RESULTS: Overall, 4,935 patients with refractory ascites were identified and 488 patients were matched (325 serial LVP, 163 TIPS). The mean age was 58 years, 70% were male, 50% had viral hepatitis, the median model for end-stage liver disease (MELD) score was 12, 13% received liver transplant and the 1-year LTF survival was 72%. After TIPS, 80 patients (49%) had no further requirement for LVP by 6 months and 61 patients (37%) never required a repeat paracentesis. In survival analysis, there was marginally worse LTF survival in patients receiving TIPS (TIPS HR 1.29, 95% CI 1.00–1.67; p = .052). CONCLUSION: In this population-based study of patients with refractory ascites, TIPS was associated with improved control of ascites but not improved LTF survival.
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Affiliation(s)
- Jeffrey M Mah
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | | | - Patti A Groome
- ICES, Queen’s University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Christopher M Booth
- ICES, Queen’s University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Jennifer A Flemming
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
- ICES, Queen’s University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
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34
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Flemming JA, Mullin M, Lu J, Sarkar MA, Djerboua M, Velez MP, Brogly S, Terrault NA. Outcomes of Pregnant Women With Cirrhosis and Their Infants in a Population-Based Study. Gastroenterology 2020; 159:1752-1762.e10. [PMID: 32781083 DOI: 10.1053/j.gastro.2020.07.052] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/30/2020] [Accepted: 07/30/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS The incidence of cirrhosis is increasing among women of childbearing age. Contemporary outcomes of pregnant women with cirrhosis and their infants, as well as liver-related complications, have not been described in North America, to our knowledge. We investigated the association between cirrhosis and perinatal outcomes and evaluated perinatal liver-related events. METHODS We performed a retrospective cohort study using population-based administrative health care data from Ontario, Canada (2000-2017). We identified pregnant women with compensated cirrhosis (n = 2022) using validated case definitions and routine mother-infant linkage; the women were matched to 10,110 pregnant women in the general population (1:5) based on birth year and socioeconomic status. Maternal and infant outcomes up to 6 weeks postpartum and liver-related complications up to 1 year postpartum were evaluated by using multivariate log-binomial regression. RESULTS After we adjusted for demographic and metabolic risk factors, cirrhosis was independently associated with intrahepatic cholestasis of pregnancy (relative risk [RR], 10.64; 95% confidence interval [CI], 7.49-15.12), induction of labor (RR, 1.15; 95% CI, 1.03-1.28), puerperal infections (RR, 1.32; 95% CI, 1.02-1.70), preterm birth (RR, 1.60; 95% CI, 1.35-1.89), infants who were large for gestational age (RR, 1.24; 95% CI, 1.05-1.46), and neonatal respiratory distress (RR, 1.20; 95% CI, 1.02-1.42). Fewer than 2% of pregnant women with cirrhosis had liver-related complications, but these occurred in a significantly higher proportion of women with a history of hepatic decompensation (13%) than women with compensated cirrhosis (1.2%) (P < .001). CONCLUSIONS In a population-based study, we found that cirrhosis is an independent risk factor for adverse perinatal outcomes. However, liver-related complications are rare. Multidisciplinary teams are needed to coordinate care for pregnant women with cirrhosis during pregnancy and postpartum to optimize outcomes.
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Affiliation(s)
- Jennifer A Flemming
- Department of Medicine, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; Department of Medicine, University of California San Francisco, San Francisco, California.
| | - Monica Mullin
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Jacquie Lu
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Monika A Sarkar
- Department of Medicine, University of California San Francisco, San Francisco, California
| | | | - Maria P Velez
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; ICES, Queen's University, Kingston, Ontario, Canada; Department of Obstetrics and Gynecology, Queen's University, Kingston, Ontario, Canada
| | - Susan Brogly
- ICES, Queen's University, Kingston, Ontario, Canada; Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Norah A Terrault
- Keck Medicine of University of Southern California, Los Angeles, California
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Roberts SB, Ismail M, Kanagalingam G, Mason AL, Swain MG, Vincent C, Yoshida EM, Tsien C, Flemming JA, Janssen HLA, Hirschfield GM, Hansen BE, Gulamhusein AF. Real-World Effectiveness of Obeticholic Acid in Patients with Primary Biliary Cholangitis. Hepatol Commun 2020; 4:1332-1345. [PMID: 32923836 PMCID: PMC7471421 DOI: 10.1002/hep4.1518] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/07/2020] [Accepted: 03/26/2020] [Indexed: 12/30/2022] Open
Abstract
Patients with primary biliary cholangitis (PBC) with incomplete response to ursodeoxycholic acid are at risk of disease progression and need additional therapy. Obeticholic acid (OCA) was approved in Canada in May 2017, but its effectiveness in a real‐world setting has not been described. We sought to describe our experience with OCA in a Canadian cohort. OCA‐naive patients treated at two Canadian centers were included. Clinical and biochemical data were collected at OCA initiation and during follow‐up. Primary outcomes were changes in serum alkaline phosphatase (ALP), gamma‐glutamyl transferase (GGT), and total bilirubin (TB) over the duration of therapy. Secondary outcomes were changes in alanine aminotransferase (ALT), aspartate aminotransferase (AST), immunoglobulin M (IgM), platelets, and albumin; and achievement of the primary endpoint of the original phase 3 study that led to OCA approval (A Placebo‐Controlled Trial of Obeticholic Acid in Primary Biliary Cholangitis [POISE]), dose reductions, discontinuations, and tolerability. Repeated‐measures models were used to assess changes in biochemistry over time. Sixty‐four patients were included; 4 carried a diagnosis of overlap with autoimmune hepatitis. Mean age was 54.6 years, median ALP was 250 U/L, TB was 13 µmol/L, platelet count was 225 × 109/L, and 24% had liver stiffness measurements ≥16.9 kPa. There was a significant reduction in mean ALP of 55 U/L (P < 0.001), GGT of 138 U/L (P < 0.001), ALT of 11.9 U/L (P < 0.001), AST of 5.7 U/L (P < 0.05), and IgM of 0.70 g/L (P < 0.001) over 12 months; TB remained stable (P = 0.98). Forty‐four patients met POISE‐inclusion criteria, 39% (n = 17) of whom had 12‐month biochemical measurements. In this subset, 18% (n = 3/17) met the 12‐month POISE primary endpoint, but considering follow‐up to 19 months, 43% achieved this target (n = 9/21). Pruritus was the most commonly reported complaint. Conclusion: Use of OCA was associated with improvement in biochemical surrogates of outcome in PBC in a real‐world setting.
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Affiliation(s)
- Surain B Roberts
- Toronto Centre for Liver Disease Toronto General Hospital University Health Network Toronto ON Canada.,Institute of Health Policy, Management and Evaluation University of Toronto Toronto ON Canada
| | - Marwa Ismail
- Toronto Centre for Liver Disease Toronto General Hospital University Health Network Toronto ON Canada
| | - Gowthami Kanagalingam
- Toronto Centre for Liver Disease Toronto General Hospital University Health Network Toronto ON Canada
| | - Andrew L Mason
- Department of Medicine University of Alberta Edmonton AB Canada
| | - Mark G Swain
- Department of Medicine University of Calgary Calgary AB Canada
| | | | - Eric M Yoshida
- Department of Medicine University of British Columbia Vancouver BC Canada
| | - Cynthia Tsien
- Department of Medicine University of Ottawa Ottawa ON Canada
| | | | - Harry L A Janssen
- Toronto Centre for Liver Disease Toronto General Hospital University Health Network Toronto ON Canada
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease Toronto General Hospital University Health Network Toronto ON Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease Toronto General Hospital University Health Network Toronto ON Canada.,Institute of Health Policy, Management and Evaluation University of Toronto Toronto ON Canada
| | - Aliya F Gulamhusein
- Toronto Centre for Liver Disease Toronto General Hospital University Health Network Toronto ON Canada.,Institute of Health Policy, Management and Evaluation University of Toronto Toronto ON Canada
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Philip G, Djerboua M, Carlone D, Flemming JA. Validation of a hierarchical algorithm to define chronic liver disease and cirrhosis etiology in administrative healthcare data. PLoS One 2020; 15:e0229218. [PMID: 32069337 PMCID: PMC7028265 DOI: 10.1371/journal.pone.0229218] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/31/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Chronic liver disease (CLD) and cirrhosis are leading causes of death globally with the burden of disease rising significantly over the past several decades. Defining the etiology of liver disease is important for understanding liver disease epidemiology, healthcare planning, and outcomes. The aim of this study was to validate a hierarchical algorithm for CLD and cirrhosis etiology in administrative healthcare data. METHODS Consecutive patients with CLD or cirrhosis attending an outpatient hepatology clinic in Ontario, Canada from 05/01/2013-08/31/2013 underwent detailed chart abstraction. Gold standard liver disease etiology was determined by an attending hepatologist as hepatitis C (HCV), hepatitis B (HBV), alcohol-related, non-alcoholic fatty liver disease (NAFLD)/cryptogenic, autoimmune or hemochromatosis. Individual data was linked to routinely collected administrative healthcare data at ICES. Diagnostic accuracy of a hierarchical algorithm incorporating both laboratory and administrative codes to define etiology was evaluated by calculating sensitivity, specificity, positive (PPV) and negative predictive values (NPV), and kappa's agreement. RESULTS 442 individuals underwent chart abstraction (median age 53 years, 53% cirrhosis, 45% HCV, 26% NAFLD, 10% alcohol-related). In patients with cirrhosis, the algorithm had adequate sensitivity/PPV (>75%) and excellent specificity/NPV (>90%) for all etiologies. In those without cirrhosis, the algorithm was excellent for all etiologies except for hemochromatosis and autoimmune diseases. CONCLUSIONS A hierarchical algorithm incorporating laboratory and administrative coding can accurately define cirrhosis etiology in routinely collected healthcare data. These results should facilitate health services research in this growing patient population.
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Affiliation(s)
- George Philip
- Translational Institute of Medicine, Queen’s University, Kingston, Ontario, Canada
| | | | - David Carlone
- Departments of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Jennifer A. Flemming
- Translational Institute of Medicine, Queen’s University, Kingston, Ontario, Canada
- ICES, Queen’s University, Kingston, Ontario, Canada
- Departments of Medicine, Queen’s University, Kingston, Ontario, Canada
- Departments of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
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Affiliation(s)
- Peter L Wang
- Department of Medicine, Queen's University, Kingston, ON K7L 5M2, Canada
| | - Jennifer A Flemming
- Department of Medicine, Queen's University, Kingston, ON K7L 5M2, Canada; Department of Public Health Sciences, Queen's University, Kingston, ON K7L 5M2, Canada.
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Flemming JA, Terrault NA. Tenofovir vs Entecavir for Hepatocellular Carcinoma Prevention in Patients With Chronic Hepatitis B: One of These Things Is Not Like the Other. JAMA Oncol 2019; 5:17-18. [PMID: 30267036 DOI: 10.1001/jamaoncol.2018.4039] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Jennifer A Flemming
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Norah A Terrault
- Department of Medicine, University of California, San Francisco.,Department of Transplant Surgery, University of California, San Francisco
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Webber C, Flemming JA, Birtwhistle R, Rosenberg M, Groome PA. Colonoscopy resource availability and its association with the colorectal cancer diagnostic interval: A population-based cross-sectional study. Eur J Cancer Care (Engl) 2019; 29:e13187. [PMID: 31707733 DOI: 10.1111/ecc.13187] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 07/29/2019] [Accepted: 10/14/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Colonoscopy is a key resource used to diagnose colorectal cancer (CRC). This study evaluated the relationship between colonoscopy availability and the length of the CRC diagnostic interval. METHODS This is a cross-sectional study of CRC patients diagnosed in Ontario, Canada, in 2008-2012. We used administrative health data to characterise colonoscopist density, private colonoscopy clinic access, distance to the closest colonoscopist and the diagnostic interval, defined as the time from patients' first cancer-related healthcare encounter to their cancer diagnosis date. We used multivariable quantile regression to evaluate the association between colonoscopy availability and the diagnostic interval, modelling the median and 90th percentile. RESULTS The median diagnostic interval was 84 days (90th percentile 323 days). The diagnostic interval was longer in patients residing in areas with lower colonoscopists density or private clinic access (adjusted median difference = 9 and 19 days, respectively), with evidence of effect modification by symptom status. Increased distance to a colonoscopist was associated with a longer diagnostic interval in asymptomatic patients, but a shorter diagnostic interval in symptomatic patients (adjusted median difference = 29 and -25 days, respectively). CONCLUSIONS This study demonstrated that reduced colonoscopy resource availability is associated with longer diagnostic intervals for CRC patients.
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Affiliation(s)
- Colleen Webber
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Jennifer A Flemming
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada.,ICES, Ontario, Canada.,Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Richard Birtwhistle
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,ICES, Ontario, Canada.,Department of Family Medicine, Queen's University, Kingston, ON, Canada
| | - Mark Rosenberg
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,Department of Geography, Queen's University, Kingston, ON, Canada
| | - Patti A Groome
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada.,ICES, Ontario, Canada
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Mah JM, DeWit Y, Djerboua M, Menard A, Booth CM, Flemming JA. Association Between Institutional Factors and Long-Term Survival Following Transjugular Intrahepatic Portosystemic Shunt. Hepatol Commun 2019; 3:838-846. [PMID: 31168517 PMCID: PMC6545870 DOI: 10.1002/hep4.1345] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 03/04/2019] [Indexed: 12/18/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure designed to treat portal hypertension. Hospital teaching status is an institutional factor found to be predictive of outcomes following several complex procedures; however, its impact on outcomes following TIPS is unknown. The aim of this study was to determine the association between hospital teaching status and long‐term survival in patients with cirrhosis receiving TIPS. We performed a retrospective population‐based cohort study using linked administrative health data from Ontario, Canada. Adult patients with cirrhosis who received TIPS between January 1, 1998, and December 31, 2016, with follow‐up until December 31, 2017, were included. Hospital teaching status was defined based on hospital participation in the instruction of medical students and/or resident physicians. Liver transplant‐free (LTF) survival was evaluated using Kaplan‐Meier analysis, and overall survival was assessed using competing risks regression analysis, which accounted for hospital clustering. A total of 857 unique patients were included (mean age 57.1 years; 69.1% male). The TIPS procedures were performed in teaching hospitals (84.3%) as well as nonteaching hospitals (15.7%). Median LTF survival was more than twice as long for procedures performed in teaching hospitals compared to nonteaching hospitals (2.2 years versus 0.9 year, respectively; P < 0.001). After adjusting for confounders and clustering, hospital teaching status was not independently associated with mortality (nonteaching subdistribution hazard ratio [sHR], 1.32; 95% confidence interval [CI], 0.97‐1.81; P = 0.08); however, annual hospital procedure volume was (per unit increase sHR, 0.96; 95% CI, 0.93‐0.99; P = 0.003). Conclusion: Hospital procedure volume is associated with long‐term survival following TIPS. These results further support the centralization of TIPS to high‐volume hospitals to improve long‐term outcomes in this population.
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Affiliation(s)
- Jeffrey M Mah
- Department of Medicine Queen's University Kingston Canada
| | - Yvonne DeWit
- Institute for Clinical Evaluative Sciences Queen's University Kingston Canada
| | - Maya Djerboua
- Institute for Clinical Evaluative Sciences Queen's University Kingston Canada
| | | | - Christopher M Booth
- Department of Medicine Queen's University Kingston Canada.,Institute for Clinical Evaluative Sciences Queen's University Kingston Canada.,Department of Public Health Sciences Queen's University Kingston Canada
| | - Jennifer A Flemming
- Department of Medicine Queen's University Kingston Canada.,Institute for Clinical Evaluative Sciences Queen's University Kingston Canada.,Department of Public Health Sciences Queen's University Kingston Canada
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Mishra S, Dewit Y, Djerboua M, Flemming JA. A259 TREATMENTS AND OUTCOMES IN PATIENTS WITH LUNG CANCER AND CO-MORBID CIRRHOSIS IN ONTARIO FROM 2007–2016: A POPULATION-BASED STUDY. J Can Assoc Gastroenterol 2019. [DOI: 10.1093/jcag/gwz006.258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- S Mishra
- School of Medicine, Queen’s University, Mississauga, ON, Canada
| | | | | | - J A Flemming
- School of Medicine, Queen’s University, Mississauga, ON, Canada
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Mah JM, Dewit Y, Groome P, Djerboua M, Booth CM, Flemming JA. Early hospital readmission and survival in patients with cirrhosis: A population-based study. Can Liver J 2019; 2:109-120. [PMID: 35990219 PMCID: PMC9202749 DOI: 10.3138/canlivj.2018-0025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 01/08/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND Readmission in patients with cirrhosis is common. We aimed to determine the association between early hospital readmission and survival in the general population of patients with cirrhosis. METHODS This retrospective cohort study used routinely collected health care data from Ontario. We identified adults with cirrhosis using a validated case definition, and included those with at least one hospital admission between 1992 and 2016 resulting in discharge. Patients were classified into two groups based on timing of readmission after index admission: 1) ≤90 days, or 2) >90 days or no readmission. We described overall survival (OS) 90 days after the index hospitalization by readmission status using Kaplan-Meier curves and the log-rank test. The association between readmission and OS was evaluated using a multivariate Cox proportional hazards regression model. RESULTS Our study included 115,081 patients. The median OS was shorter in patients readmitted in ≤90 days (4.1 years, IQR 0.9, 13.1) compared with those readmitted in >90 days or not readmitted during the study period (9.6 years, IQR 3.2, 21.9, p <0.001). Adjusting for potential confounders, those readmitted in ≤90 days had a higher hazard of death than those not readmitted (hazard ratio [HR] 1.56, 95% CI 1.53 to 1.59, p <0.001). CONCLUSIONS Early readmission in patients with cirrhosis is a strong predictor of decreased OS. Our results suggest that patients with cirrhosis who have an early readmission should be further studied to determine whether this risk is modifiable. They can also be used to discuss long-term prognosis with patients and family members.
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Affiliation(s)
- Jeffrey M Mah
- Department of Medicine, Queen’s University, Kingston, Ontario;
| | | | - Patti Groome
- ICES, Queen’s University, Kingston, Ontario;
- Department of Public Health Sciences, Queen’s University, Kingston Ontario;
| | | | - Christopher M Booth
- ICES, Queen’s University, Kingston, Ontario;
- Department of Public Health Sciences, Queen’s University, Kingston Ontario;
- Department of Oncology, Queen’s University, Kingston, Ontario
| | - Jennifer A Flemming
- Department of Medicine, Queen’s University, Kingston, Ontario;
- ICES, Queen’s University, Kingston, Ontario;
- Department of Public Health Sciences, Queen’s University, Kingston Ontario;
- Correspondence: Jennifer A Flemming, Assistant Professor, Departments of Medicine and Public Health Sciences, Queen’s University, Kingston Health Sciences Centre, 166 Brock Street, S4-012, Kingston, Ontario K7L 5G2. Telephone: 613-544-3400 ext 2483. Fax: 613-544-3114. E-mail:
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Flemming JA, Dewit Y, Mah JM, Saperia J, Groome PA, Booth CM. Incidence of cirrhosis in young birth cohorts in Canada from 1997 to 2016: a retrospective population-based study. Lancet Gastroenterol Hepatol 2018; 4:217-226. [PMID: 30573390 DOI: 10.1016/s2468-1253(18)30339-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 09/27/2018] [Accepted: 10/01/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recent data show that the prevalence of chronic liver disease and cirrhosis is increasing in adolescents and young adults in the USA. We aimed to describe the epidemiology of cirrhosis using an age-period-cohort approach to define birth-cohort effects on the incidence of cirrhosis in Ontario, Canada. METHODS We did a retrospective population-based cohort study in Ontario, Canada, using linked administrative health data from the databases of ICES, formerly the Institute for Clinical Evaluative Sciences. Patients aged at least 18 years with cirrhosis were identified by use of a validated case definition (defined as at least one inpatient or outpatient visit with a diagnosis of cirrhosis or oesophageal varices without bleeding). We calculated annual standardised incidence and prevalence in the general population. We used an age-period-cohort approach to assess the independent association between birth cohort and incidence of cirrhosis in men and women. FINDINGS Between Jan 1, 1997, and Dec 31, 2016, 165 979 individuals with cirrhosis were identified. The age-standardised incidence increased over the study (from 70·6 per 100 000 person-years in 1997 to 89·6 per 100 000 person-years in 2016) as did the prevalence (from 0·42% in 1997 to 0·84% in 2016). Using age-period-cohort modelling and the median birth year as the reference, the incidence of cirrhosis was higher in participants born in 1980 (incidence rate ratio 1·55, 95% CI 1·50-1·59, p<0·0001); and in participants born in 1990 (2·16, 95% CI 2·06-2·27, p<0·0001) compared with a person of the same age born in 1951. The increase in incidence of cirrhosis was greater in women than in men (eg, women born in 1990: 2·60, 95% CI 2·41-2·79; men born in 1990: 1·98, 1·85-2·12). INTERPRETATION The incidence of cirrhosis has increased over the past two decades, and more so in younger birth cohorts and in women. Future studies to define the cause and natural history of cirrhosis in these groups are essential to develop strategies that could reverse these trends for future generations. FUNDING Southeastern Ontario Academic Medical Association New Clinician Scientist Award; American Association for the Study of Liver Disease (AASLD) Foundation Clinical, Translational and Outcomes Research Award in Liver Disease (JAF).
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Affiliation(s)
- Jennifer A Flemming
- Departments of Medicine, Queen's University, Kingston, ON, Canada; Public Health Sciences, Queen's University, Kingston, ON, Canada; ICES, Queen's University, Kingston, ON, Canada.
| | | | - Jeffrey M Mah
- Departments of Medicine, Queen's University, Kingston, ON, Canada
| | - James Saperia
- Departments of Medicine, Queen's University, Kingston, ON, Canada
| | - Patti A Groome
- Public Health Sciences, Queen's University, Kingston, ON, Canada; ICES, Queen's University, Kingston, ON, Canada
| | - Christopher M Booth
- Public Health Sciences, Queen's University, Kingston, ON, Canada; Oncology, Queen's University, Kingston, ON, Canada; ICES, Queen's University, Kingston, ON, Canada
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Kwong AJ, Kim WR, Flemming JA. De Novo Hepatocellular Carcinoma Among Liver Transplant Registrants in the Direct Acting Antiviral Era. Hepatology 2018; 68:1288-1297. [PMID: 29672886 PMCID: PMC6173633 DOI: 10.1002/hep.30045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/09/2018] [Indexed: 12/11/2022]
Abstract
The risk of hepatocellular carcinoma (HCC) in patients with hepatitis C virus (HCV) receiving direct acting antivirals (DAAs) has been debated. This study aims to describe the incidence of HCC among patients listed for liver transplantation (LT) in the DAA era. Individuals with cirrhosis listed for LT from January 2003 to December 2015 were identified using the Scientific Registry for Transplant Recipients database. Patients with HCC at listing or HCC exception within 180 days were excluded. Patients were divided into three eras based on listing date: eras 1 (2003-2010), 2 (2011-2013), and 3 (2014-2015). Incidence rates of HCC were calculated by era and compared using incident rate ratios (IRRs). The association between HCC and listing era was evaluated using Cox regression and competing risk analyses, the latter considering death and LT as competing events. Of the 48,158 eligible wait-list registrants, 3112 (6.5%) received HCC exceptions after a median of 493 days. In 20,039 individuals with HCV, the incidence of HCC was 49% higher in era 3 versus era 1 (IRR 1.49, 95% confidence interval [CI] 1.24-1.79). In multivariate analysis, those in era 3 had a higher hazard of HCC compared with era 1 (hazard ratio 1.22, 95% CI 1.01-1.48). However, in multivariable competing risks analysis, with death and LT considered as competing events for de novo HCC, era was no longer associated with HCC (subdistribution hazard ratio 0.83, 95% CI 0.69-1.00). CONCLUSION In this large population-based cohort of LT registrants, the incidence of HCC among HCV patients has increased in the DAA era. Competing risks analysis suggests that this may be explained by changes in rates of LT and wait-list mortality in the HCV population during this time. (Hepatology 2018; 00:000-000).
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Affiliation(s)
- Allison J. Kwong
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, United States
| | - W. Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, United States
| | - Jennifer A. Flemming
- Departments of Medicine and Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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Lapointe-Shaw L, Georgie F, Carlone D, Cerocchi O, Chung H, Dewit Y, Feld JJ, Holder L, Kwong JC, Sander B, Flemming JA. Identifying cirrhosis, decompensated cirrhosis and hepatocellular carcinoma in health administrative data: A validation study. PLoS One 2018; 13:e0201120. [PMID: 30133446 PMCID: PMC6104931 DOI: 10.1371/journal.pone.0201120] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/08/2018] [Indexed: 12/20/2022] Open
Abstract
Background To evaluate screening and treatment strategies, large-scale real-world data on liver disease-related outcomes are needed. We sought to validate health administrative data for identification of cirrhosis, decompensated cirrhosis and hepatocellular carcinoma among patients with known liver disease. Methods Primary patient data were abstracted from patients of the Toronto Center for Liver Disease with viral hepatitis (2006–2014), and all patients with liver disease from the Kingston Health Sciences Centre Hepatology Clinic (2013). We linked clinical information to health administrative data and tested a range of coding algorithms against the clinical reference standard. Results A total of 6,714 patients had primary chart data abstracted. A single physician visit code for cirrhosis was sensitive (98–99%), and a single hospital diagnostic code for cirrhosis was specific (91–96%). The most sensitive algorithm for decompensated cirrhosis was one cirrhosis code with any of: a hospital diagnostic code, death code, or procedure code for decompensation (range 88–99% across groups). The most specific was one cirrhosis code and one hospital diagnostic code (range 89–98% across groups). Two physician visit codes or a single hospital diagnostic code, death code, or procedure code combined with a code for cirrhosis were sensitive and specific for hepatocellular carcinoma (sensitivity 94–96%, specificity 93–98%). Conclusion These sensitive and specific algorithms can be used to define patient cohorts or detect clinical outcomes using health administrative data. Our results will facilitate research into the adequacy of screening and treatment for patients with chronic viral hepatitis or other liver diseases.
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Affiliation(s)
- Lauren Lapointe-Shaw
- Department of Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- * E-mail:
| | | | - David Carlone
- Queen’s University School of Medicine, Kingston, Canada
| | | | - Hannah Chung
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Yvonne Dewit
- Institute for Clinical Evaluative Sciences, Kingston, Canada
| | - Jordan J. Feld
- Department of Medicine, University of Toronto, Toronto, Canada
- University Health Network, Toronto, Canada
| | - Laura Holder
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Jeffrey C. Kwong
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Kingston, Canada
- Public Health Ontario, Toronto, Canada
- Dalla Lana School of Public Health, Toronto, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- University Health Network, Toronto, Canada
- Public Health Ontario, Toronto, Canada
- Toronto Health Economics and Technology Assessment Collaborative, Toronto, Canada
| | - Jennifer A. Flemming
- Institute for Clinical Evaluative Sciences, Kingston, Canada
- Department of Medicine and Department of Public Health Sciences, Queen`s University, Kingston, Canada
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Lemke M, DeWit Y, Nanji S, Booth CM, Flemming JA. The role of sex in the outcomes of patients with biliary tract cancers remains unclear: A population-based study. Am J Surg 2018; 216:1118-1121. [PMID: 29934122 DOI: 10.1016/j.amjsurg.2018.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/07/2018] [Accepted: 05/28/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Differences in outcomes between males and females with biliary tract cancer (BTC) has been previously reported but not studied. METHODS This was a population-based retrospective cohort study of patients undergoing BTC resection in Ontario between 2002 and 2012. Descriptive statistics on patient, disease, and treatment-related factors in each BTC subtype were reported. Kaplan Meier Curves and Cox Proportional Hazards analysis were used to examine the univariate relationship between sex and overall survival. RESULTS 714 patients underwent resection of a BTC. Kaplan Meier Curves shows trends towards different survival for males and females in different BTC subtypes: improved for females with intrahepatic and ampullary cancers and poorer survival for females with perhilar and distal cholangiocarcinomas. These trends were not statistically significant. CONCLUSIONS Sex may be an important factor in overall survival following resection of BTC. Further work is needed to better characterize the relationship between sex and outcomes of BTC.
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Affiliation(s)
- Madeline Lemke
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Yvonne DeWit
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Queen's University, Kingston, Ontario, Canada
| | - Sulaiman Nanji
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Christopher M Booth
- Department of Medicine, Queen's University, Kingston, Ontario, Canada; Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Jennifer A Flemming
- Department of Medicine, Queen's University, Kingston, Ontario, Canada; Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.
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Chakraborty D, Akbari A, Knoll GA, Flemming JA, Lowe C, Akbari S, White CA. Serum BTP concentrations are not affected by hepatic dysfunction. BMC Nephrol 2018; 19:87. [PMID: 29653513 PMCID: PMC5899361 DOI: 10.1186/s12882-018-0881-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/21/2018] [Indexed: 02/06/2023] Open
Abstract
Background Beta Trace Protein (BTP) is a promising marker of glomerular filtration rate (GFR). Equations to estimate GFR using BTP have been proposed. Very little is known about BTP’s production and metabolism. It has been hypothesized that the liver metabolizes certain BTP isoforms. As such, hepatic dysfunction may influence serum levels independently of GFR. This would impact on the accuracy and precision of GFR estimates using BTP. The purpose of this study was to assess the impact of cirrhosis on serum BTP concentrations. Methods BTP, cystatin C (cysC) and creatinine (Cr) were measured in 99 cirrhotic subjects and in matched controls. BTP/cysC and Cr/cysC ratios were compared between cases and controls. This was repeated after stratification by Child Pugh category. Comparisons of ratios between Child Pugh category A and combined B and C case subjects were also performed. Results There were no differences in BTP/cysC ratios between cases and controls for the entire cohort (0.80 vs 0.79) or for any of the Child Pugh categories (p > 0.10). There were significant differences between cases (1.09) and controls (0.73) for the BTP/Cr ratios (p < 0.001). The BTP/Cr ratio was higher in those with more advanced cirrhosis as compared to those with less severe cirrhosis (1.20 vs 1.03, p < 0.01). There were no differences in BTP/cysC ratios between those with less severe and more advanced cirrhosis (p = 0.25). Conclusions This study suggests that hepatic dysfunction does not influence serum BTP levels and argues against a significant role for the liver in BTP metabolism. Confirmation in a larger group of patients with advanced cirrhosis is required.
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Affiliation(s)
- Debarati Chakraborty
- Division of Nephrology, Department of Medicine, Queen's University, Etherington Hall, 94 Stuart Street, Kingston, ON, K7L 2N6, Canada
| | - Ayub Akbari
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Kidney Research Centre, Ottawa Health Research Institute, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, ON, Canada
| | - Greg A Knoll
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Kidney Research Centre, Ottawa Health Research Institute, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, ON, Canada
| | - Jennifer A Flemming
- Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, ON, Canada.,Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Catherine Lowe
- Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Shareef Akbari
- Kidney Research Centre, Ottawa Health Research Institute, Ottawa, ON, Canada
| | - Christine A White
- Division of Nephrology, Department of Medicine, Queen's University, Etherington Hall, 94 Stuart Street, Kingston, ON, K7L 2N6, Canada.
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Saperia J, DeWit Y, Booth CM, Groome P, Flemming JA. A222 INCREASING PREVALENCE OF CIRRHOSIS IN ONTARIO OVER THE LAST 20 YEARS: A POPULATION-BASED STUDY. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy008.223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- J Saperia
- Queen’s University, Kingston, ON, Canada
| | - Y DeWit
- Queen’s University, Kingston, ON, Canada
| | - C M Booth
- Queen’s University, Kingston, ON, Canada
| | - P Groome
- Queen’s University, Kingston, ON, Canada
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Flemming JA, Nanji S, Wei X, Webber C, Groome P, Booth CM. A241 TIME FROM DIAGNOSTIC ENDOSCOPY TO CURATIVE RESECTION IN PATIENTS WITH COLON CANCER: A POPULATION-BASED STUDY. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy008.242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - S Nanji
- Queen’s University, Kingston, ON, Canada
| | - X Wei
- Queen’s University, Kingston, ON, Canada
| | - C Webber
- Queen’s University, Kingston, ON, Canada
| | - P Groome
- Queen’s University, Kingston, ON, Canada
| | - C M Booth
- Queen’s University, Kingston, ON, Canada
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Flemming JA, Carlone D, DeWit Y, Lapointe-Shaw L, Kwong J, Feld J. A218 VALIDATION OF A CIRRHOSIS CASE DEFINITION IN CANADIAN ADMINISTRATIVE DATA. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy008.219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - D Carlone
- Queen’s University, Kingston, ON, Canada
| | - Y DeWit
- Institute for Clinical Evaluative Sciences, Kingston, ON, Canada
| | | | - J Kwong
- University of Toronto, Toronto, ON, Canada
| | - J Feld
- Medicine, University Health Network University of Toronto, Toronto, ON, Canada
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