The burden of nonalcoholic steatohepatitis (NASH) in the United States

BACKGROUND

There is limited data on the comparative economic and humanistic burden of non-alcoholic steatohepatitis (NASH) in the United States. The objective was to examine the burden of disease comparing NASH to a representative sample of the general population and separately to a type 2 diabetes mellitus (T2DM) cohort by assessing health-related quality of life (HRQoL) measures, healthcare resource use (HRU) and work productivity and activity impairment (WPAI).

METHODS

Data came from the 2016 National Health and Wellness Survey, a nationally representative patient-reported outcomes survey conducted in the United States. Respondents with physician-diagnosed NASH, physician-diagnosed T2DM, and respondents from the general population were compared. Humanistic burden was examined with mental (MCS) and physical (PCS) component summary scores from the Short-Form (SF)-36v2, concomitant diagnosis of anxiety, depression, and sleep difficulties. Economic burden was analysed based on healthcare professional (HCP) and emergency room (ER) visits, hospitalizations in the past six months; absenteeism, presenteeism, overall work impairment, and activity impairment scores on WPAI questionnaire. Bivariate and multivariable analysis were conducted for each outcome and matched comparative group.

RESULTS

After adjusting for baseline demographics and characteristics, NASH (N = 136) compared to the matched general population cohort (N = 544), reported significantly lower (worse) mental (MCS 43.19 vs. 46.22, p = 0.010) and physical (PCS 42.04 vs. 47.10, p < 0.001) status, higher % with anxiety (37.5% vs 25.5%, p = 0.006) and depression (43.4% vs 30.1%, p = 0.004), more HCP visits (8.43 vs. 5.17), ER visits (0.73 vs. 0.38), and hospitalizations (0.43 vs. 0.2) all p's < 0.05, and higher WPAI scores (e.g. overall work impairment 39.64% vs. 26.19%, p = 0.011). NASH cohort did not differ from matched T2DM cohort (N = 272) on mental or work-related WPAI scores, but had significantly worse physical status (PCS 40.52 vs. 44.58, p = 0.001), higher % with anxiety (39.9% vs 27.8%, p = 0.043), more HCP visits (8.63 vs. 5.68, p = 0.003) and greater activity impairment (47.14% vs. 36.07%, p = 0.010).

CONCLUSION

This real-world study suggests that burden of disease is higher for all outcomes assessed among NASH compared to matched general controls. When comparing to T2DM, NASH cohort has comparable mental and work-related impairment but worse physical status, daily activities impairment and more HRU.

MO233: Real-World Signs and Symptoms at Diagnosis in Patients With IGA Nephropathy

BACKGROUND AND AIMS

Immunoglobulin A nephropathy (IgAN) is the most common form of primary glomerulonephritis worldwide, with an estimated annual incidence of 25 per million. Patients with persistent proteinuria ≥ 1 g/day are at increased risk of disease progression, with 30% or more progressing to kidney failure within 10 years. Hematuria and proteinuria are among the most common clinical manifestations of IgAN. The aim of this analysis was to better understand the clinical characteristics of IgAN patients from Europe, Asia and the USA, at the time of diagnosis.

METHOD

A retrospective analysis was conducted using data from the Adelphi IgAN Disease Specific Programme (DSP), a cross-sectional survey of IgAN-treating nephrologists in EU4 (France, Germany, Italy, UK), USA, China and Japan between June and October 2021. Nephrologists completed structured forms administered via online links for successive patients presenting with IgAN in their practice. The forms included demographic and clinical information including signs, symptoms and lab values amongst others.

RESULTS

A total of 269 nephrologists completed records for 1685 patients in this survey. Mean patient age was 43.3 years, and most were male (58%). The diagnosis was confirmed by biopsy in 86% of the patients. The mean eGFR at diagnosis ranged from 58.1 (median 55.5) in the USA to 78.3 (median 79.0) mL/min/1.73 m2, in China and Japan. Mean proteinuria ranged from 2.7 (median 2.0) in the USA to 3.4 (median 2.1) g/day in EU4 (Table 1). The main clinical signs at diagnosis were proteinuria (75%) and visible hematuria (63%). Edema and fatigue were reported in 38% and 27% of patients; 10% and 9% of patients reported appetite loss and sleep problems. A sizable proportion of patients (31%) also experienced pain in various parts of the body.

CONCLUSION

This comprehensive study of IgAN patients across varied geographies presents evidence that patients experience substantial symptomatic and clinical burden at diagnosis, irrespective of the region. The relatively high levels of proteinuria and low eGFR levels, especially in the USA, suggest that the disease is often severe and advanced by the time of diagnosis. Facilitating early diagnosis of IgAN—perhaps through better recognition of clinical signs and symptoms—could be beneficial in optimizing early treatment and preventing disease progression.

MO273A NOVEL APPROACH TO ASSESS THE DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF IMMUNOGLOBULIN A NEPHROPATHY (IGAN) PATIENTS IN A US REAL-WORLD SETTING

Background and Aims

Immunoglobulin A nephropathy (IgAN) is a chronic glomerular disease that affects approximately 100,000-200,000 people in the US. Approximately 15-40% of IgAN patients will eventually progress to end stage kidney disease (ESKD) within 10-20 years of diagnosis, and there is currently no targeted therapy for this disease. Decreased kidney function, persistent proteinuria and hypertension are some of the clinical manifestations of IgAN, and with demographic aspects (e.g. ethnicity) are considered as predictors of disease progression. The aim of this study is to better understand the demographic and clinical characteristics of IgAN patients in the US identified via physician notes.

Method

This is a descriptive, retrospective study of adult (≥ 18 years) IgAN patients in Optum® Electronic Health Records (EHRs), between January 2007 and December 2019. Optum® EHRs contain de-identified clinical and medical administrative data from 96 million people in 50 states that come from more than 140,000 providers at 740 hospitals and over 7,000 clinics. Identification of IgAN patients is challenging because there are no specific ICD codes for this disease so we used natural language processing of physician notes and chose patients with at least two IgAN records with the first one considered to be the index date, and no negative mention, as well as a biopsy procedure. Here, we present the baseline demographic and clinical characteristics of the identified patients up to 12 months before and at the index date.

Results

A total of 1803 patients with a biopsy record (22% of all patients with at least two IgAN records in their EHRs in our study) were included in this analysis; results are presented in Table 1. The mean age was 48 years, and the majority of patients were male (60.9%) and white (75.7%). Proteinuria levels of ≥1 g/day were found in 34% of patients. The mean eGFR was 45 ml/min/1.73m2 and 21.6% of patients had severe deterioration of kidney function (eGFR &lt;15). The mean creatinine level was 3 mg/dL. Pain, edema and fatigue/tiredness were reported in 39.6%, 18.1% and 13.4% of patients, respectively. Hypertension was reported in 73% of patients. Based on the ICD 9 (585.6) and ICD-10 (N18.6) codes for diagnosis, 17.5% of patients had ESKD in our study.

Conclusion

In our cohort, a significant proportion of patients were found to have high proteinuria levels and severe deterioration of kidney function or ESKD. Moreover, edema and fatigue were recorded for a noticeable proportion of patients. In addition to the commonly reported symptoms, our study also found that pain was reported in a high proportion of patients. These findings highlight the clinical and symptom burden to patients with IgAN, suggesting that future targeted interventions are needed to reduce the burden and delay the progression of this disease.

Systemic treatment of hormone receptor positive, human epidermal growth factor 2 negative metastatic breast cancer: retrospective analysis from Leeds Cancer Centre

Background

Study aimed to characterise treatment and outcomes for patients with hormone receptor positive (HR+), human epidermal growth factor 2 negative (HER2-) metastatic breast cancer (MBC) within a large regional cancer centre, as a benchmark for evaluating real-world impact of novel therapies.

Methods

Retrospective longitudinal cohort, using electronic patient records of adult females with a first diagnosis of HR+/HER2- MBC January 2012–March 2018.

Results

One hundred ninety-six women were identified with HR+/HER2- MBC. Median age was 67 years, 85.2% were post-menopausal and median time between primary diagnosis and metastasis was 5.4 years. Most (75.1%) patients received endocrine therapy as first line systemic treatment (1st LoT); use of 1st LoT chemotherapy halved between 2012 and 2017. Patients receiving 1st LoT chemotherapy were younger and more likely to have visceral metastasis (p < 0.01). Median OS was 29.5 months and significantly greater for patients with exclusively non-visceral metastasis (p < 0.01). The adjusted hazard ratio for death of patients with visceral (or CNS) metastasis was 1.91 relative to those with exclusively non-visceral metastasis.

Conclusions

Diverse endocrine therapies predominate as 1st LoT for patients with HR+/HER2- MBC, chemotherapy being associated with more aggressive disease in younger patients, emphasising the importance of using effective and tolerable therapies early.

The burden of non-alcoholic steatohepatitis (NASH) among patients from Europe: A real-world patient-reported outcomes study

Data on the economic and humanistic burden of non-alcoholic steatohepatitis (NASH) are scarce. This study assessed the comparative burden of NASH, relative to a representative sample from the general population and a type 2 diabetes mellitus (T2DM) cohort, in terms of health-related quality of life, work productivity and activity impairment (WPAI), and healthcare resource use.

Methods

Data across 5 European countries came from the 2016 National Health and Wellness Survey, a nationally representative patient-reported outcomes survey. Outcomes included mental (MCS) and physical (PCS) component scores from the Short-Form (SF)-36v2, WPAI scores, self-reported physician diagnosis of sleep difficulties, anxiety, and depression, and healthcare resource use: healthcare professional visits, hospital visits, and emergency room visits in the previous 6 months. Bivariate and multivariable analyses were conducted for each outcome and comparative group.

Results

After adjusting for matching criteria and covariates, patients with NASH (n = 184) reported significantly worse health-related quality of life, worse WPAI scores, and more healthcare resource use than the general population (n = 736) (MCS 39.22 vs. 45.16, PCS 42.84 vs. 47.76; overall work impairment 49.15% vs. 30.77%, healthcare professional visits 10.73 vs. 6.01, emergency room visits 0.57 vs. 0.22, hospitalizations 0.47 vs. 0.17, p ≪0.05 for all). Patients with NASH did not differ from patients with T2DM (n = 368) on PCS and WPAI scores, suggesting a similar impairment on work and daily activities, but did report significantly worse mental status (MCS 39.64 vs. 43.64, p ≪0.05) and more healthcare resource use than those with T2DM (healthcare professional visits 10.85 vs. 7.86, emergency room visits 0.65 vs. 0.23, hospitalizations 0.39 vs. 0.19, p ≪0.05 for all).

Conclusions

These findings suggest that the burden of NASH may be underestimated, highlighting the unmet needs of patients with NASH.

Lay summary

These findings show that patients with non-alcoholic steatohepatitis (NASH) experience a significant burden of illness, in terms of health-related quality of life, work productivity and activity impairment, and healthcare resource use. As there is currently no approved treatment for NASH, these findings highlight the unmet medical need of patients with NASH.

•

Non-alcoholic steatohepatitis (NASH) is a progressive form of non-alcoholic fatty liver disease.

•

NASH imposes a significant humanistic and economic burden on individuals and society.

•

NASH impairs health-related quality of life, work productivity and activity, while increasing healthcare resource use.

•

This study highlights the unmet need of patients with NASH in the absence of any approved treatment.

Identification and mapping of worldwide sources of generic real-world data

PURPOSE

The demand for real-world data as supportive evidence to traditional clinical studies has increased in the past few years. The present study aimed to identify worldwide generic sources of real-world data and to assess completeness and suitability of selected real-world evidence (RWE) data sources to conduct prespecified research.

METHODS

A systematic literature review was conducted to identify generic (non-disease specific) sources of real-world data in Medline and Embase from January 1, 2010 to September 8, 2015. Data sources used in observational studies were identified and summarized based on their geographical distribution and the type of data. In the next step, the selected data sources were critically evaluated for their completeness.

RESULTS

A total of 10,069 identified publications were screened, leading to 2635 unique data sources across 102 countries. Europe had the maximum number of data sources (n = 1163) followed by United States (n = 578), and Asia, Middle East, and African Countries (n = 374). The most common type of identified data sources across all countries was structured data sources, ie, administrative databases and registries. Of the identified data sources, 300 were selected for further investigation. From the selected databases, ~50% had confirmed information on over 60% of the investigated variables, ~61% were suitable for epidemiological research, and 60% had possibility of linkage.

CONCLUSIONS

The present study applied a systematic literature review approach and identified available generic sources of real-world data worldwide, in addition to the United States and Europe, which are suitable for conducting pre-defined researches and support future RWE studies.

Abstract 229: Real-world hsCRP Testing, With a Potential to Evaluate Residual Inflammatory Cardiovascular Risk, Among Patients With History of Myocardial Infarction in the United States: A Retrospective Database Analysis

Background: C-reactive protein can be measured by a high-sensitivity assay (hsCRP) to detect persistent low grade vascular inflammation predictive of cardiovascular (CV) risk in patients with history of myocardial infarction (MI). However, the real-world use of hsCRP testing among patient with history of MI, and hence the contemporary usage to address residual inflammatory risk, is unknown

Methods: Patients with ≥1 claim with an inpatient, primary diagnosis for MI (ICD-9-CM code: 410.xx) between 01 October 2011 to 30 September 2014 (the most recent set as an index) in MarketScan and 1 year continuous enrolment pre- and post-hospital admission were included

Results: A total of 71,071 patients (mean age 63.6 years, 67.6% males) were included. The hsCRP measurement was performed in 3.3% patients (CCAE: 4.7%; Medicare: 1.3%) with a mean time of 4.3 months after the index MI; 81.7% of patients were tested ≥30 days after the index MI. Patient characteristics and resource uses were similar among hsCRP tested and non-tested patients (Table 1)

Conclusion: hsCRP testing with a potential to evaluate residual inflammatory CV risk is not used widely in routine clinical practice in US patients with history of MI. No systematic effect of hsCRP testing was observed with respect to patient characteristics and resource use. Further research is warranted to understand and describe the real-world usage of hsCRP testing to evaluate residual inflammatory risk and the associated patient characteristics, outcomes and burden of disease

Evaluation of CT and MRI scanning among cancer patients in Ontario

BACKGROUND

Computed tomography (CT) and magnetic resonance imaging (MRI) utilization in Ontario increased drastically since the early 1990s. The effect of an increased number of cancer diagnoses, and an increase in indications for scans has not been assessed. This study was conducted to determine trends in utilization of CT and MRI in cancer patients in Ontario over a period of 9 years.

METHODS

Using Ontario Health Insurance Plan billing data linked to the Ontario Cancer Registry, rates of CT and MRI were analyzed by region, year, scan type and socioeconomic status.

RESULTS

CT in cancer patients increased 2.3-fold and accounted for approximately 24% of these scans. MRI in cancer patients increased by 4.2-fold and accounted for approximately 10% of these scans. Imaging rates for cancer patients increased more gradually than that of the general population. Substantial variation in the rate of both scans by region of patient residence existed. Even greater variation by the location of the scanner was demonstrated, indicating that many cancer patients traveled outside their region for imaging. There was little evidence of variation in scanning rates by socioeconomic status.

CONCLUSION

A minority of CT and MRI performed in Ontario are for cancer care. Regional variation in imaging rates suggest that utilization guidelines be developed or knowledge transfer initiatives improve compliance to existing guidelines are needed. A significant number of cancer patients travel outside their region for diagnostic imaging; this should influence decisions about the location of new scanners.

CT, MRI and ultrasound scanning rates: evaluation of cancer diagnosis, staging and surveillance in Ontario

OBJECTIVE

To examine practice patterns and rates of computed tomography (CT), magnetic resonance imaging (MRI), and abdominal ultrasound (AUS) during staging, treatment and surveillance for cancer patients.

METHODS

Using Ontario Health Insurance Plan billing data linked to the Ontario Cancer Registry, we determined rates of CT, MRI, and AUS by body site for breast, colorectal, lung, lymphoma, and prostate cancer, from 1998 to 2002. Rates of scans were additionally examined by region of patient residence and time from cancer diagnosis.

RESULTS

The frequency of imaging increased in nearly all scans and tumors over the study period. Rates of peri-diagnosis scans varied substantially by region, ranging from 1.7-fold variation (CT for lung cancer) to 50-fold variation (MRI for breast cancer). For breast cancer, there is possible over-utilization of CT, but overall rates of scanning appear reasonable for the other four cancers.

CONCLUSIONS

Considerable regional variation in imaging rates suggests utilization guidelines should be developed or knowledge transfer initiatives are needed to improve compliance to existing guidelines. In breast cancer, there appears to be over-utilization of imaging. Further studies are necessary to determine utilization for each stage, the reason scans were obtained, and the impact of scans on patient outcomes.

Falls among top reasons for transfers from continuing care to acute care hospitals in Canada

There are limited data on the quality and safety of care for residents in continuing care settings. An analysis of the main reasons why residents, 75 and older, of continuing care facilities are transferred to acute care demonstrates that two of the top three reasons for transfers result from potentially avoidable events.

Thoracic cancer surgeries

In 2005, Cancer Care Ontario (CCO) released Thoracic Surgical Oncology Standards. These standards were aimed at providing the best level of care for those undergoing thoracic surgery and encompass surgeon training, hospital ancillary services and minimum volume thresholds for surgeries of the lung and esophagus. The objective of the current study was to explore variations in thoracic cancer surgical volumes at the hospital level across Canada. Using data from the Discharge Abstract Database for 2007-2008, the cohort included patients admitted to hospital with a most responsible diagnosis of cancer and who had a lung or esophageal surgery. To determine the volume of surgeries performed per facility, we grouped patients according to the hospital facility performing the surgery. In Canada (excluding Quebec and Prince Edward Island), there were a total 4,509 lung and 587 esophageal cancer procedures performed in 94 hospitals in 2007-2008. For both types of surgeries, Ontario hospitals performed approximately half of the procedures. Overall, 12 hospitals performed at or over the volume of surgeries for lung cancer as indentified by the CCO standards, while 10 did so for esophageal cancer. Nine hospitals performed both lung and esophageal cancer surgeries at or over the suggested volumes. Higher volumes of lung and esophageal cancer-related surgeries have been associated with improved patient outcomes. Here we present a snapshot of the distribution of cancer-related lung and esophageal surgeries across Canada (excluding Quebec and Prince Edward Island).

Indications for and results of outpatient computed tomography and magnetic resonance imaging in Ontario

OBJECTIVE

Population rates of computed tomography (CT) and magnetic resonance imaging (MRI) continue to increase markedly. However, little is known about the indications for and results of these imaging tests.

METHODS

A cross-sectional chart-abstraction study was used to determine the indications for and results of outpatient CT and MRI scans performed on or after January 1, 2005, at randomly selected Ontario hospitals.

RESULTS

We studied 11,824 CT and 11,867 MRI scans. Cancer-related indications accounted for over 50% of CT scans of the abdomen-pelvis and chest. Headache was the most frequent indication for CT of the brain. More than one-half of MRI scans of the extremities were for knee pain or suspected meniscal tear. Back pain and radiculopathy were the most frequent indications for MRI of the spine. There was considerable variation between institutions in ordering patterns, with as much as a 70-fold difference between hospitals in the frequency of scans ordered for a specific indication. Less than 2% of CT scans of the brain for headache found abnormalities that could explain the headache, while over 90% of MRI scans of the spine for back pain were abnormal, although the clinical importance of the abnormalities was unclear.

CONCLUSIONS

These data are a starting point for a discussion about appropriateness. Further information will be obtained by examining individual indications more closely, and linking these data to administrative databases to evaluate the impact of these imaging tests on clinical practice.

Waiting times for radiation therapy in Ontario

BACKGROUND

The mass media and clinical journals have reported lengthy waiting times after surgery before initiation of radiation therapy (RT) for cancer across Canada. We aimed to describe the length of time between the last date of surgery or biopsy or chemotherapy and first date of RT.

METHODS

This is a population-based study measuring waiting times for RT in Ontario among all patients with potentially curable cancer of the cervix, tonsil and larynx and a random sample of women who had had breast cancer resection, whose first date of RT fell between Sept. 1, 2001, and Aug. 31, 2002. Abstraction of original health care records provided each patient's demographics, cancer stage and cancer treatment (last surgery, consultation, simulation, first RT). Last dates of chemotherapy before RT were obtained from abstraction or from Ontario Health Insurance Plan (OHIP) files, and last dates of surgery before RT were compared with dates in the Canadian Institute for Health Information (CIHI) Discharge Abstract Database.

RESULTS

Waiting times between the last date of surgery or chemotherapy and the first date of RT varied significantly among the health regions of Ontario. Increasing age, but not the presence of comorbidity, was associated with longer waiting times. Women who did not receive postoperative chemotherapy before RT for breast cancer waited significantly longer than all others.

CONCLUSION

Measurement of waiting times for cancer RT must discount time during which adjuvant intravenous chemotherapy is administered after surgery and before RT. There appears to be a formal or informal process by which those at highest risk begin RT most rapidly.

Outcomes in surgery for ovarian cancer

OBJECTIVE

Theobjective was to determine the relationship among hospital volume of ovarian cancer surgery,academic status of institution, surgical specialty, and outcomes of care (30-day postoperative mortality, reoperation rate, and overall survival).

METHODS

This population-based cohort study included all newly diagnosed ovarian cancer patients treated from 1992 to 1998 in Ontario, Canada. Hospitalization and surgical billing databases were used. Logistic regression was used to evaluate the importance of hospital type, hospital volume, surgical specialty, and surgeon volume of ovarian cancer operations on postoperative mortality, reoperation rates, and survival.

RESULTS

Ovarian cancer surgery was performed on 3815 women between April 1992 and March 1998. When adjusted for age, comorbidity, acuity of the operation, and metastatic disease, no factors influenced postoperative mortality. The adjusted relative risk for reoperation within 3 months of the initial surgery showed that patients were less likely to have a repeat operation if the initial operation was done in a high- or intermediate-volume hospital (RR 0.24 95% CI 0.12-0.48, RR 0.29 95% CI 0.20-0.42, respectively), a hospital with a gynecologic oncologist (RR 0.29 95% CI 0.15-0.56), by a gynecologic oncologist (RR 0.04 95% CI 0.01-0.12) or gynecologist (RR 0.37 95% CI 0.21-0.66), or by a high-volume surgeon (RR 0.09 95% CI 0.03-0.23). The adjusted survival was improved if the initial surgery was done by a gynecologic oncologist (HR 0.70 95% CI 0.57-0.85) or gynecologist (HR 0.65 95% CI 0.53-0.79).

CONCLUSIONS

There is a relationship between hospital volume and reoperation rate. Institution type only influenced reoperation rate. Statistically significant associations were found between surgical specialty and all three outcome variables. The volume of surgery performed by an individual surgeon only influenced reoperation rate. Our results are preliminary but support the need for further studies examining factors such as stage.

Contaminant exposure among women of childbearing age who eat St. Lawrence River sport fish

Little information is available concerning the level of consumption and degree of contaminant exposure for North American women of childbearing age who eat sport fish. The authors reanalyzed a 1995-1996 study of Montreal-area (Canada) sport fishers. The authors focused on women sport fishers of childbearing age and male sport fishers who had spouses of childbearing age. The primary research involved an on-site questionnaire about fish consumption, with follow-up assessment of sport fishers estimated to have either the highest or lowest levels of fish-based contaminant exposure. Among the 1,654 interviewees were 100 women less than 45 yr of age who had eaten sport fish for an average of 11 yr; 45% ate fish less than once a month. From the follow-up subsample of high- and low-level consumers, the authors identified 17 women less than 45 yr of age and 25 males whose spouses who were less than 45 yr of age and who consumed similar quantities of sport fish. Among this group of 42, the high-exposure women differed from the low-exposure women with respect to their yearly consumption of freshwater fish, blood mercury levels (median = 6.4 vs. 1.4 microgram/l), and plasma polychlorinated biphenyl congener 99 (median = 10.5 vs. 5.9 microgram/kg plasma lipids). Few Montreal-area women of childbearing age consume local sport fish frequently or for extended periods. However, among the small proportion that consumes sport fish frequently or for extended periods, blood mercury concentrations approach levels of concern for fetal protection.

Puzzling elevation of blood lead levels among consumers of freshwater sportfish

The authors evaluated lead exposure of Canadians (Montreal) who fished the nearby St. Lawrence River. From screening interviews conducted with 1,118 fishers on-site during the winter and fall of 1996, the authors selected 60 Montrealers who consumed at least one sportfish meal per week and 72 who consumed less than one sportfish meal per week. Fishers at the higher level of sportfish consumption had elevated blood lead concentrations, compared with fishers who ate little sportfish (geometric mean = 57.4 microg/l vs. 48.2 microg/l, respectively; p < .05). This result was surprising inasmuch as fish is not considered a significant source of lead. In addition to sportfish consumption, age, sex, occupation, smoking, and waterfowl consumption also showed independent associations with blood lead levels. Among frequent (i.e., > or = 1 meal/wk) consumers of sportfish, ingestion of waterfowl was associated with higher blood lead levels (geometric mean = 69.4 microg/l vs. 51.8 microg/l, respectively; p < .05); this association was not present for infrequent consumers. In multivariate analysis, the association of higher blood lead levels with sportfish consumption could be accounted for in large part by waterfowl consumption among frequent consumers of sportfish.

Mercury exposure in Montrealers who eat St. Lawrence River sportfish

We assessed levels and determinants of mercury biomarkers among residents of Montreal and surroundings who eat sportfish from the nearby St. Lawrence River. Participants were selected from 1118 adult fishers responding to a 1996 screening questionnaire; the study sample (n=132) overrepresented respondents expected to have the greatest and the least exposure to mercury. Tissue mercury concentrations were associated with sportfish consumption: among participants who ate sportfish at least once weekly, hair geometric mean (GM)=0.82+/-2.54 microg/g and blood mercury GM=3.03+/-2.43 microg/L, compared to hair GM=0.38+/-2.28 microg/g and blood mercury GM=1.44+/-2.23 microg/L for those who ate sportfish less than once weekly. While these levels are somewhat higher than those shown for other Greater Lakes and St. Lawrence River fishers, only one participant surpassed the Canadian recommended population mercury limit of 6 microg/g for hair and 20 microg/L for blood. Consumption of several sportfish species independently explained much of the variation in measured blood mercury; the predatory species pike was the most important in multivariable regression. Coincident consumption of waterfowl, fishing during the longer summer/fall rather than the brief winter season, and fishers' age were independently associated with blood mercury. Serum selenium related neither to the level of fish consumption nor to the participants' blood mercury.

Contaminant exposure in Montrealers of Asian origin fishing the St. Lawrence River: exploratory assessment

Fishing and fish consumption are widely practiced among members of certain ethnocultural groups. Informal assessment led us to ascribe high levels of consumption of locally caught sportfish to Montrealers of Asian origin and to hypothesize that their choices of species and fish organs differ from those of the majority group. An exploratory assessment of contaminant bioindicators reflective of St. Lawrence River fish consumption was conducted in late 1995 among nine Vietnamese and nine Bangladeshi Montreal sportfishers identified by community contacts. Vietnamese participants, six men and three women, were 27-70 (median 36) years of age and had immigrated to Canada 3-20 (median 7) years earlier. In contrast, the nine Bangladeshi males aged 28-41 (median 34) years had been in Canada for 2-13 (median 4) years. Bio-indicator concentrations among Bangladeshi and Vietnamese participants are compared to those found for majority-community Montreal-area high-level consumers recruited on the St. Lawrence River during winter 1995. All results are presented as the median and 90th percentile. Hair mercury concentrations were higher for both Vietnamese (1.2, 4.6 microgram/g) and Bangladeshis (1.1, 2.3 microgram/g) than for majority-community sportfishers (0.7, 1.9 microgram/g). Certain organochlorine levels, specifically total PCB (estimated by plasma Aroclor 1260), p,p'-DDT, p,p'-DDE, and B-BHC, were highest in the Bangladeshis compared to Vietnamese and to majority-community sportfishers. In contrast, plasma levels of other pesticides were low in all three groups, including mirex, chlordane, and cis-nonachlor. A correlation between plasma p,p'-DDT levels and recency of arrival in Canada was found for the Bangladeshis. These data suggest a distinct pattern of tissue organochlorines, which we postulate relates to exposure prior to arrival in Canada and perhaps to the ongoing consumption of foods (other than St. Lawrence River sportfish) specific to these groups.

Fish consumption and contaminant exposure among Montreal-area sportfishers: pilot study

A 1995 pilot study assessed sport fish consumption and contaminant exposure among Montreal-area residents fishing the frozen St. Lawrence River. Interviews conducted among 223 ice fishers met on-site were used to create an index of estimated exposure to fish-borne contaminants. A second-stage assessment of sport fish consumption and tissue contaminant burdens included 25 interviewees at the highest level of estimated contaminant exposure (of 38, or 66% of those solicited) and 15 low-exposure fishers (of 41, or 37% of those solicited). High-level fisher-consumers reported eating 0. 92+/-0.99 sport fish meals/week during the previous 3 weeks compared to 0.38+/-0.21 (P<0.05) for the low-level group. Based on the product of consumption frequency times mass of sport fish meals consumed, high-level consumers ate a mean of 18.3 kg of sport fish annually versus 3.3 kg for the low-level consumers. Tissue contaminant assessments showed significant (P<0.05) groupwise differences: 0-1 cm hair mercury (median 0.73 microgram/g for the high versus 0.23 microgram/g for the low group), lipid-adjusted plasma PCB congeners (Aroclor 1260: median 0.77 microgram/g versus 0.47 microgram/g), and lipid-adjusted plasma DDE (median 0.35 microgram/g versus 0.26 microgram/g). No participant had a hair mercury or plasma DDE concentration above Health Canada recommendations but 2/25 high-level participants (8%) had plasma Aroclor 1260 concentrations above recommended limits. The results of this pilot study suggest that a small number of Montreal-area sportfishers consume their catch as often as three times weekly and that those consuming sport fish frequently have significantly higher tissue levels of mercury, PCBs, and DDE than do infrequent consumers. On the other hand, compared to other groups in Quebec, such as the Inuit or commercial fishers on the North Shore of the Gulf of St. Lawrence, Montreal-area sportfishers eat less fish and have lower tissue concentrations of fish-related contaminants.