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Thornton CS, Waddell BJ, Congly SE, Svishchuk J, Somayaji R, Fatovich L, Isaac D, Doucette K, Fonseca K, Drews SJ, Borlang J, Osiowy C, Parkins MD. Porcine-derived pancreatic enzyme replacement therapy may be linked to chronic hepatitis E virus infection in cystic fibrosis lung transplant recipients. Gut 2024:gutjnl-2023-330602. [PMID: 38621922 DOI: 10.1136/gutjnl-2023-330602] [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: 07/01/2023] [Accepted: 04/02/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVES In high-income countries hepatitis E virus (HEV) is an uncommonly diagnosed porcine-derived zoonoses. After identifying disproportionate chronic HEV infections in persons with cystic fibrosis (pwCF) postlung transplant, we sought to understand its epidemiology and potential drivers. DESIGN All pwCF post-transplant attending our regional CF centre were screened for HEV. HEV prevalence was compared against non-transplanted pwCF and with all persons screened for suspected HEV infection from 2016 to 2022 in Alberta, Canada. Those with chronic HEV infection underwent genomic sequencing and phylogenetic analysis. Owing to their swine derivation, independently sourced pancreatic enzyme replacement therapy (PERT) capsules were screened for HEV. RESULTS HEV seropositivity was similar between transplanted and non-transplanted pwCF (6/29 (21%) vs 16/83 (19%); p=0.89). Relative to all other Albertans investigated for HEV as a cause of hepatitis (n=115/1079, 10.7%), pwCF had a twofold higher seropositivity relative risk and this was four times higher than the Canadian average. Only three chronic HEV infection cases were identified in all of Alberta, all in CF lung transplant recipients (n=3/29, 10.3%). Phylogenetics confirmed cases were unrelated porcine-derived HEV genotype 3a. Ninety-one per cent of pwCF were taking PERT (median 8760 capsules/person/year). HEV RNA was detected by RT-qPCR in 44% (47/107) of PERT capsules, and sequences clustered with chronic HEV cases. CONCLUSION PwCF had disproportionate rates of HEV seropositivity, regardless of transplant status. Chronic HEV infection was evident only in CF transplant recipients. HEV may represent a significant risk for pwCF, particularly post-transplant. Studies to assess HEV incidence and prevalence in pwCF, and potential role of PERT are required.
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Affiliation(s)
- Christina S Thornton
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Barbara J Waddell
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E Congly
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Julianna Svishchuk
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Linda Fatovich
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Debra Isaac
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karen Doucette
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin Fonseca
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Steven J Drews
- Canadian Blood Services, Edmonton, Alberta, Canada
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Jamie Borlang
- Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Carla Osiowy
- Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Michael D Parkins
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
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Tkachuk B, Congly SE. Quality standards on management of alcohol-related liver disease from the UK-targets and tribulations. Hepatobiliary Surg Nutr 2024; 13:336-342. [PMID: 38617494 PMCID: PMC11007324 DOI: 10.21037/hbsn-24-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/08/2024] [Indexed: 04/16/2024]
Affiliation(s)
- Bryce Tkachuk
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E. Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Division of Transplant Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
- Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, Alberta, Canada
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Congly SE, Brahmania M, Coffin CS. Medicare Part D Spending for Hepatitis B Virus Drugs: Completing the Picture and Extending the Dataset. Gastroenterology 2024; 166:359-360. [PMID: 37595648 DOI: 10.1053/j.gastro.2023.08.012] [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: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/20/2023]
Affiliation(s)
- Stephen E Congly
- Divisions of Gastroenterology and Hepatology and Medical Transplant, Department of Medicine, O'Brien Institute of Public Health; Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mayur Brahmania
- Divisions of Gastroenterology and Hepatology and Medical Transplant, Department of Medicine; O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Carla S Coffin
- Department of Microbiology, Immunology and Infectious Diseases, Snyder Institute; Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Congly SE, Syed A, Haylock-Jacobs S, Israelson H, Pinto J, Williams S, Lee SS, Coffin CS. A real-world retrospective single-centre study of the cost-effectiveness and long-term outcomes of pegylated interferon for chronic hepatitis B. Can Liver J 2023; 6:305-313. [PMID: 38020196 PMCID: PMC10652987 DOI: 10.3138/canlivj-2022-0043] [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: 11/09/2022] [Accepted: 11/20/2022] [Indexed: 12/01/2023]
Abstract
Background Pegylated interferon (Peg-IFN) is recommended as first-line therapy for chronic hepatitis B (CHB) but has significant side effects and is rarely used compared to oral nucleos(t)ide analogues (NA). There are limited recent clinical efficacy or economic analysis data comparing approved CHB therapy in North America. Methods This retrospective study examined clinical outcomes, off-treatment durability, and cost-effectiveness of Peg-IFN versus NA for CHB. Demographic (age, sex, ethnicity), clinical data (i.e., liver tests, hepatitis B virus DNA, serology, transient elastography) and documented side effects were collected by retrospective chart review of patients followed in the University of Calgary Liver Unit who received Peg-IFN therapy from January 2007 to December 2020. The cost-effectiveness of Peg-IFN versus NA therapy was modelled over a 10-year time horizon. Results Sixty-eight CHB patients were treated with Peg-IFN (median age 45.65, 74% male, 84% Asian); 50/68 (74%) completed 48 weeks of treatment with a median follow-up of 6.54 years (interquartile range 5.07). At the last known follow-up, 23/68 (34%) have not required NA treatment and one had HBsAg loss; 27 have been started on NA. Predictors of obtaining a sustained virological response included being hepatitis B e antigen-negative at treatment end and a quantitative hepatitis B surface antigen <1000 IU/mL. Economic modelling showed that finite Peg-IFN was not cost-effective versus NA at a 10-year time horizon. Conclusions PEG-IFN remains a potential treatment for CHB although there is a significant intolerance/failure rate. Using PEG-IFN based on patient preference is reasonable and optimal patient selection may improve treatment cost-effectiveness.
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Affiliation(s)
- Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Ahsan Syed
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sarah Haylock-Jacobs
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Heidi Israelson
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jacqueline Pinto
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sarah Williams
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Samuel S Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Carla S Coffin
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Lei Y, Halasz J, Novak KL, Congly SE. Intermittent Proton Pump Inhibitor Therapy in Low-Risk Non-Variceal Upper Gastrointestinal Bleeding May Be Significantly Cost-Saving. Medicines (Basel) 2023; 10:44. [PMID: 37505065 PMCID: PMC10384205 DOI: 10.3390/medicines10070044] [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] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/09/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND High-dose proton pump inhibitor (PPI) therapy, given either intermittently or continuously for non-variceal upper gastrointestinal bleeding (NV-UGIB), is efficacious. Using intermittent PPI for low-risk patients may be cost-saving. Our objective was to estimate the annual cost savings if all low-risk NV-UGIB patients received intermittent PPI therapy. METHODS Patients who presented to hospital in Calgary, Alberta, who received a PPI for NV-UGIB from July 2015 to March 2017 were identified using ICD-10 codes. Patients were stratified into no endoscopy, high-risk, and low-risk lesion groups and further subdivided into no PPI, oral PPI, intermittent intravenous (IV), and continuous IV subgroups. Average length of stay (LOS) in each subgroup and costs were calculated. RESULTS We identified 4141 patients with NV-UGIBs, (median age 61, 57.4% male). One-thousand two-hundred and thirty-one low-risk patients received continuous IV PPI, with an average LOS of 6.8 days (95% CI 6.2-7.3) versus 4.9 days (95% CI 3.9-5.9) for intermittent IV patients. If continuous IV PPI patients instead received intermittent IV PPI, 3852 patient days and CAD 11,714,390 (2017 CAD)/year could be saved. CONCLUSIONS Using real-world administrative data, we demonstrate that a sizable portion of low-risk patients with NV-UGIB who were given continuous IV PPI if switched to intermittent IV therapy could generate significant potential cost savings.
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Affiliation(s)
- Yang Lei
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Jennifer Halasz
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB T2N 4Z6, Canada
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Frolkis AD, Congly SE. Editorial: Alcohol-related liver disease is the primary driver of cirrhosis-related hospital admissions in the COVID-19 era-What can be done? Aliment Pharmacol Ther 2023; 58:260-261. [PMID: 37352155 DOI: 10.1111/apt.17560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2023]
Affiliation(s)
- Alexandra D Frolkis
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E Congly
- Divisions of Gastroenterology and Hepatology and Medical Transplant, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Arnie Charbonneau Cancer Institute and O'Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
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Congly SE, Marquez V, Bhanji RA, Bhat M, Wong P, Huard G, Zhu JH, Brahmania M. Exception points for liver transplantation: A Canadian review. Can Liver J 2023; 6:201-214. [PMID: 37503519 PMCID: PMC10370721 DOI: 10.3138/canlivj-2022-0026] [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: 09/05/2022] [Accepted: 09/11/2022] [Indexed: 07/29/2023]
Abstract
Background Exception points for liver transplant (LT) allocation are used to account for mortality risk not reflected by scoring systems such as the Model for End-Stage Liver Disease with sodium (MELD-Na). Currently, there is no formal policy regarding exception points in Canada, and differences across the country are not well understood. As such, a review of the criteria and exception points granted throughout the country for LT was conducted. Methods Seven LT centres in five provinces were surveyed (Vancouver, Edmonton, London, Toronto, Montréal, Halifax) regarding the indications and criteria for exception points granted, the number of points granted, how points would be accrued, and the maximum points granted. Results Programs in British Columbia and Nova Scotia grant variable exception points based on the median MELD-Na score with modifications; Alberta, Ontario, and Quebec grant exception points using specific values based on the indication. Overall, there was significant heterogeneity regarding exception points granted nationally with agreement only for awarding exception points for hepatopulmonary syndrome and polycystic liver disease. The second most common agreed-upon indications for exception points were portopulmonary hypertension and recurrent cholangitis offered by four provinces. Quebec had the most formal criteria for non-cirrhosis-based conditions. Conclusions There is substantial variance across the country regarding the indications for granting exception points as well as the number of points granted. Future work on developing a national consensus will be important for the development of equity in LT across Canada.
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Affiliation(s)
- Stephen E Congly
- Divisions of Gastroenterology and Hepatology and Transplant Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Vladimir Marquez
- Division of Gastroenterology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Rahima A Bhanji
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Mamatha Bhat
- Ajmera Transplant Program, University Health Network and Division of Gastroenterology & Hepatology, University of Toronto, Toronto, Ontario, Canada
| | - Philip Wong
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Royal Victoria Hospital, Montréal, Quebec, Canada
| | - Geneviève Huard
- Department of Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, Quebec, Canada
| | - Julie H Zhu
- Division of Digestive Care & Endoscopy, Dalhousie University and Atlantic Multi-Organ Transplantation Program, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Mayur Brahmania
- Division of Gastroenterology, Department of Medicine, and Multi Organ Transplant Unit, London Health Sciences Centre, Western University, London, Ontario, Canada
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Burak KW, Douglas L, Congly SE. Comparing Magnetic Resonance Imaging and Contrast-Enhanced Ultrasound (CEUS) for the Characterization of Nodules Found on Hepatocellular Carcinoma Surveillance: CEUS is Our Clear Choice. J Ultrasound Med 2023; 42:1175-1180. [PMID: 36880711 DOI: 10.1002/jum.16200] [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] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 05/18/2023]
Affiliation(s)
- Kelly W Burak
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Division of Transplant Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Division of Medical Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lisa Douglas
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E Congly
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Division of Transplant Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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El-Kassas M, Emadeldeen M, Hassany M, Esmat G, Gomaa AA, El-Raey F, Congly SE, Liu H, Lee SS. A randomized controlled trial of SOF/VEL/VOX with or without ribavirin for retreatment of chronic hepatitis C. J Hepatol 2023:S0168-8278(23)00234-9. [PMID: 37088312 DOI: 10.1016/j.jhep.2023.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 12/25/2022] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND & AIMS The combination of sofosbuvir, velpatasvir and voxilaprevir (SOF/VEL/VOX) is recommended retreatment for patients with hepatitis C virus (HCV) infection who failed previous direct-acting antiviral (DAA) treatment. However, whether ribavirin further increases the therapeutic efficacy of SOF/VEL/VOX retreatment remains unclear. We aimed to test this hypothesis by a randomized controlled trial. METHODS We randomly assigned 315 patients with DAA treatment failure from 5 Egyptian sites into two groups. Group A (n=158) received SOF/VEL/VOX for 12 weeks, and group B (n=157) received SOF/VEL/VOX + weight-based ribavirin for 12 weeks. Therapeutic efficacy was defined as SVR12 (undetectable HCV RNA 12 weeks after treatment completion). Safety and tolerability were evaluated by monitoring treatment-related adverse events (AEs) and laboratory abnormalities. RESULTS Seventeen patients in each group were lost to follow-up. SVR12 rates by intention-to-treat (ITT) were 87.3% (138/158), and by per-protocol analysis, 97.8% (138/141) in group A; and 87.9% (138/157) and 98.5% (138/140) in group B (p=NS for ITT and PP). Males comprised 53.9% of group A, and 57.1% in group B (p=0.58), with mean ages of 51.8 and 47.3 years in group A and B, respectively. Both regimens were well-tolerated, with no deaths and only one serious AE (anemia) in group B requiring ribavirin discontinuation. Fifty-five patients in group A vs. 77 in group B experienced any adverse events (p=0.002). CONCLUSION This randomized controlled trial showed equal, high efficacy of both regiments in retreating previous DAA failures, although ribavirin was associated with more adverse events. Therefore SOF/VEL/VOX monotherapy should be the preferred retreatment strategy. IMPACT AND IMPLICATIONS HCV treatment guidelines recommend retreating DAA treatment failures with the combination of sofosbuvir, velpatasvir and voxilaprevir (SOF/VEL/VOX) for 12 weeks. However, whether ribavirin exerts an additional/synergistic effect remains unclear. The present study confirmed that SOF/VEL/VOX without ribavirin is the best regimen for retreating DAA treatment failures, and thus will help clinicians caring for patients who are not cured with a first course of DAA therapy. CLINCIALTRIALS. GOV NUMBER NCT04695769.
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Affiliation(s)
- Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohammed Emadeldeen
- Gastroenterology and Hepatology Department, National Hepatology & Tropical Medicine Research Institute (NHTMRI), Cairo, Egypt
| | - Mohamed Hassany
- Gastroenterology and Hepatology Department, National Hepatology & Tropical Medicine Research Institute (NHTMRI), Cairo, Egypt
| | - Gamal Esmat
- Hepatology and Endemic Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Ali Gomaa
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Fathiya El-Raey
- Department of Hepatology, Gastroenterology and Infectious Disease, Damietta Faculty of Medicine, Al-Azhar University, Damietta, Egypt
| | - Stephen E Congly
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Hongqun Liu
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Samuel S Lee
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.
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Azhari H, Frolkis AD, Shaheen AA, Israelson H, Pinto J, Congly SE, Borman MA, Aspinall AA, Stinton LM, Nguyen HH, Swain MG, Burak KW, Lee SS, Sadler MD, Coffin CS. Real-world tertiary referral centre experience stopping nucleos(t)ide analogue therapy in patients with chronic hepatitis B. Can Liver J 2022; 5:453-465. [PMID: 38144400 PMCID: PMC10735201 DOI: 10.3138/canlivj-2022-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 04/12/2022] [Accepted: 04/18/2022] [Indexed: 12/26/2023]
Abstract
BACKGROUND: Identifying strategies for stopping nucleos(t)ide analogues (NUC) in patients with chronic hepatitis B (CHB) is a major goal in CHB management. Our study describes our tertiary-centre experience stopping nucleos(t)ide analogues (NUC) in CHB. METHODS: We conducted a retrospective cohort study of all individuals with CHB seen at the Calgary Liver Unit between January 2009 and May 2020 who stopped NUC. We collected baseline demographics and HBV lab parameters before and after stopping NUC with results stratified by off-treatment durability. Clinical flare was defined as alanine aminotransferase (ALT) over twice the upper limit of normal and virological flare as HBV DNA >2000 IU/mL. RESULTS: Forty-seven (3.5%) of the 1337 individuals with CHB stopped NUC therapy. During follow-up, six patients (12.8%) restarted NUCs because of a flare. All flares occurred within six months of discontinuation. Median time to restart treatment was 90 days (Q1 65, Q3 133). Upon restarting, all showed suppression of HBV DNA and ALT normalization. Factors associated with restarting NUC therapy included hepatitis B e antigen (HBeAg) positive status at first appointment and longer NUC consolidation therapy. Age, sex, ethnicity, liver stiffness measurement, choice of NUC, and quantitative hepatitis B surface antigen (qHBsAg) level at stopping were not associated with sustained response off-treatment. Six patients had functional cure with HBsAg loss. CONCLUSIONS: Stopping long-term NUC is feasible in HBeAg negative CHB. Hepatic flares can occur despite low levels of qHBsAg. Finite NUC therapy can be considered in eligible patients who are adherent to close monitoring and follow-up, particularly in the first six months after stopping NUC therapy.
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Riazi K, Swain MG, Congly SE, Kaplan GG, Shaheen AA. Race and Ethnicity in Non-Alcoholic Fatty Liver Disease (NAFLD): A Narrative Review. Nutrients 2022; 14:4556. [PMID: 36364818 PMCID: PMC9658200 DOI: 10.3390/nu14214556] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [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: 09/19/2022] [Revised: 10/21/2022] [Accepted: 10/24/2022] [Indexed: 07/25/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a significant public health concern worldwide with a complex etiology attributed to behavioural, environmental, and genetic causes. The worldwide prevalence of NAFLD is estimated to be 32.4% and constantly rising. Global data, however, indicate considerable heterogeneity among studies for both NAFLD prevalence and incidence. Identifying variables that affect the estimated epidemiological measures is essential to all stakeholders, including patients, researchers, healthcare providers, and policymakers. Besides helping with the research on disease etiology, it helps to identify individuals at risk of the disease, which in turn will outline the focus of the preventive measures and help to fittingly tailor individualized treatments, targeted prevention, screening, or treatment programs. Several studies suggest differences in the prevalence and severity of NAFLD by race or ethnicity, which may be linked to differences in lifestyle, diet, metabolic comorbidity profile, and genetic background, among others. Race/ethnicity research is essential as it can provide valuable information regarding biological and genetic differences among people with similar cultural, dietary, and geographical backgrounds. In this review, we examined the existing literature on race/ethnicity differences in susceptibility to NAFLD and discussed the contributing variables to such differences, including diet and physical activity, the comorbidity profile, and genetic susceptibility. We also reviewed the limitations of race/ethnicity studies in NAFLD.
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Affiliation(s)
- Kiarash Riazi
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Mark G. Swain
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Stephen E. Congly
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Gilaad G. Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Abdel-Aziz Shaheen
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
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Congly SE, Parkins MD, Doucette KE. Chronic hepatitis E: an important entity for clinicians to be aware of. CMAJ 2022; 194:E1292. [PMID: 36162837 PMCID: PMC9512156 DOI: 10.1503/cmaj.147045-l] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Stephen E Congly
- Transplant hepatologist, Divisions of Gastroenterology and Hepatology and Medical Transplant, Department of Medicine, University of Calgary, Calgary, Alta
| | - Michael D Parkins
- Infectious diseases physician, Division of Infectious Diseases, Department of Medicine, University of Calgary, Calgary, Alta
| | - Karen E Doucette
- Infectious diseases physician, Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alta
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Riazi K, Azhari H, Charette JH, Underwood FE, King JA, Afshar EE, Swain MG, Congly SE, Kaplan GG, Shaheen AA. The prevalence and incidence of NAFLD worldwide: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol 2022; 7:851-861. [PMID: 35798021 DOI: 10.1016/s2468-1253(22)00165-0] [Citation(s) in RCA: 497] [Impact Index Per Article: 248.5] [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: 01/05/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 05/12/2023]
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease worldwide and the leading cause of liver-related morbidity and mortality. We aimed to predict the burden of NAFLD by examining and estimating the temporal trends of its worldwide prevalence and incidence. METHODS In this systematic review and meta-analysis, we searched MEDLINE, EMBASE, Scopus, and Web of Science without language restrictions for reports published between date of database inception and May 25, 2021. We included observational cross-sectional or longitudinal studies done in study populations representative of the general adult population, in whom NAFLD was diagnosed using an imaging method in the absence of excessive alcohol consumption and viral hepatitis. Studies were excluded if conducted in paediatric populations (aged <18 years) or subgroups of the general population. Summary estimates were extracted from included reports by KR and independently verified by HA using the population, intervention, comparison, and outcomes framework. Primary outcomes were the prevalence and incidence of NAFLD. A random-effects meta-analysis was used to calculate overall and sex-specific pooled effect estimates and 95% CIs. FINDINGS The search identified 28 557 records, of which 13 577 records were screened; 299 records were also identified via other methods. In total, 72 publications with a sample population of 1 030 160 individuals from 17 countries were included in the prevalence analysis, and 16 publications with a sample population of 381 765 individuals from five countries were included in the incidence analysis. The overall prevalence of NAFLD worldwide was estimated to be 32·4% (95% CI 29·9-34·9). Prevalence increased significantly over time, from 25·5% (20·1-31·0) in or before 2005 to 37·8% (32·4-43·3) in 2016 or later (p=0·013). Overall prevalence of NAFLD was significantly higher in men than in women (39·7% [36·6-42·8] vs 25·6% [22·3-28·8]; p<0·0001). The overall incidence of NAFLD was estimated to be 46·9 cases per 1000 person-years (36·4-57·5); 70·8 cases per 1000 person-years (48·7-92·8) in men and 29·6 cases per 1000 person-years (20·2-38·9) in women (p<0·0001). There was considerable heterogeneity between studies of both NAFLD prevalence (I2=99·9%) and NAFLD incidence (I2=99·9%). INTERPRETATION Worldwide prevalence of NAFLD is considerably higher than previously estimated and is continuing to increase at an alarming rate. Incidence and prevalence of NAFLD are significantly higher among men than among women. Greater awareness of NAFLD and the development of cost-effective risk stratification strategies are warranted to address the growing burden of NAFLD. FUNDING Canadian Institutes of Health.
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Affiliation(s)
- Kiarash Riazi
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Hassan Azhari
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jacob H Charette
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Fox E Underwood
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - James A King
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Elnaz Ehteshami Afshar
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mark G Swain
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Abdel-Aziz Shaheen
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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14
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Ma C, Congly SE, Chyou DE, Ross-Driscoll K, Forbes N, Tsang ES, Sussman DA, Goldberg DS. Factors Associated With Geographic Disparities in Gastrointestinal Cancer Mortality in the United States. Gastroenterology 2022; 163:437-448.e1. [PMID: 35483444 PMCID: PMC9703359 DOI: 10.1053/j.gastro.2022.04.019] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/21/2022] [Accepted: 04/14/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND & AIMS Significant geographic variability in gastrointestinal (GI) cancer-related death has been reported in the United States. We aimed to evaluate both modifiable and nonmodifiable factors associated with intercounty differences in mortality due to GI cancer. METHODS Data from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research platform were used to calculate county-level mortality from esophageal, gastric, pancreatic, and colorectal cancers. Multivariable linear regression models were fit to adjust for county-level covariables, considering both patient (eg, sex, race, obesity, diabetes, alcohol, and smoking) and structural factors (eg, specialist density, poverty, insurance prevalence, and colon cancer screening prevalence). Intercounty variability in GI cancer-related mortality explained by these covariables was expressed as the multivariable model R2. RESULTS There were significant geographic disparities in GI cancer-related county-level mortality across the US from 2010-2019 with the ratio of mortality between 90th and 10th percentile counties ranging from 1.5 (pancreatic) to 2.1 (gastric cancer). Counties with the highest 5% mortality rates for gastric, pancreatic, and colorectal cancer were primarily in the Southeastern United States. Multivariable models explained 43%, 61%, 14%, and 39% of the intercounty variability in mortality rates for esophageal, gastric, pancreatic, and colorectal cancer, respectively. Cigarette smoking and rural residence (independent of specialist density) were most strongly associated with GI cancer-related mortality. CONCLUSIONS Both patient and structural factors contribute to significant geographic differences in mortality from GI cancers. Our findings support continued public health efforts to reduce smoking use and improve care for rural patients, which may contribute to a reduction in disparities in GI cancer-related death.
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Affiliation(s)
- Christopher Ma
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Stephen E. Congly
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Darius E. Chyou
- Miller School of Medicine, University of Miami, Miami, Florida
| | | | - Nauzer Forbes
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Erica S. Tsang
- Department of Medicine, Division of Hematology & Oncology, University of California, San Francisco, California,Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California
| | - Daniel A. Sussman
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
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15
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Congly SE. Is diabetes a risk factor for malignancy post-transplant in liver transplant recipients? Ann Hepatol 2022; 27:100703. [PMID: 35338011 DOI: 10.1016/j.aohep.2022.100703] [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: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Stephen E Congly
- Divisions of Gastroenterology and Hepatology and Transplant Medicine, Department of Medicine, Cumming School of Medicine, O'Brien Institute of Public Health, University of Calgary, 6th Floor, Teaching Research and Wellness Building, 3280 Hospital Drive NW, Calgary AB T2N 4N1 Canada.
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16
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Shaheen AA, Kong K, Ma C, Doktorchik C, Coffin CS, Swain MG, Burak KW, Congly SE, Lee SS, Sadler M, Borman M, Abraldes JG. Impact of the COVID-19 Pandemic on Hospitalizations for Alcoholic Hepatitis or Cirrhosis in Alberta, Canada. Clin Gastroenterol Hepatol 2022; 20:e1170-e1179. [PMID: 34715379 PMCID: PMC8547973 DOI: 10.1016/j.cgh.2021.10.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [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: 07/29/2021] [Revised: 09/20/2021] [Accepted: 10/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Coronavirus disease 2019 (COVID-19) pandemic lockdown and restrictions had significant disruption to patient care. We aimed to evaluate the impact of COVID-19 restrictions on hospitalizations of patients with alcoholic and nonalcoholic cirrhosis as well as alcoholic hepatitis (AH) in Alberta, Canada. METHODS We used validated International Classification of Diseases (ICD-9 and ICD-10) coding algorithms to identify liver-related hospitalizations for nonalcoholic cirrhosis, alcoholic cirrhosis, and AH in the province of Alberta between March 2018 and September 2020. We used the provincial inpatient discharge and laboratory databases to identify our cohorts. We used elevated alanine aminotransferase or aspartate aminotransferase, elevated international normalized ratio, or bilirubin to identify AH patients. We compared COVID-19 restrictions (April-September 2020) with prior study periods. Joinpoint regression was used to evaluate the temporal trends among the 3 cohorts. RESULTS We identified 2916 hospitalizations for nonalcoholic cirrhosis, 2318 hospitalizations for alcoholic cirrhosis, and 1408 AH hospitalizations during our study time. The in-hospital mortality rate was stable in relation to the pandemic for alcoholic cirrhosis and AH. However, nonalcoholic cirrhosis patients had lower in-hospital mortality rate after March 2020 (8.5% vs 11.5%; P = .033). There was a significant increase in average monthly admissions in the AH cohort (22.1/10,000 admissions during the pandemic vs 11.6/10,000 admissions before March 2020; P < .001). CONCLUSIONS Before and during COVID-19 monthly admission rates were stable for nonalcoholic and alcoholic cirrhosis; however, there was a significant increase in AH admissions. Because alcohol sales surged during the pandemic, future impact on alcoholic liver disease could be detrimental.
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Affiliation(s)
- Abdel Aziz Shaheen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta; Center for Health Informatics, University of Calgary, Calgary, Alberta.
| | - Kristine Kong
- Center for Health Informatics, University of Calgary, Calgary, Alberta
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta,Center for Health Informatics, University of Calgary, Calgary, Alberta
| | | | - Carla S. Coffin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Mark G. Swain
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Kelly W. Burak
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Stephen E. Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Samuel S. Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Matthew Sadler
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Meredith Borman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Juan G. Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Alberta, Canada
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17
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Rahman SH, Scharr Y, Jeyaparan J, Manko A, Coffin CS, Congly SE, Ramji A, Fung S, Cooper C, Ma M, Bailey R, Minuk G, Wong A, Doucette K, Elkhashab M, Wong P, Brahmania M. A217 TREATMENT ADHERENCE OF CHRONIC HEPATITIS B PATIENTS WITH HEPATOCELLULAR CARCINOMA FROM THE CANHEPB NETWORK. J Can Assoc Gastroenterol 2022. [PMCID: PMC8859274 DOI: 10.1093/jcag/gwab049.216] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Chronic hepatitis B (CHB) is the most common cause of hepatocellular carcinoma (HCC) worldwide. Aims The primary aim of this study is to explore the degree of treatment adherence to the American Association For The Study of Liver Disease (AASLD) HCC treatment guidelines for patients with CHB-HCC. Methods This is a retrospective, cross-sectional study of available data (2005–2020) in patients mono-infected with CHB collected from the Canadian HBV Network; a national consortium across 8 Canadian provinces. We analyzed data using descriptive statistics along with parametric and nonparametric statistical methods with a significance level of p < 0.05. Results Of the 6500 patients, 132 (2.0%) patients met inclusion criteria. The median age was 64 (IQR: 53.5- 71.5) with 101 (76%) being male. The median ALT was 40 (IQR: 26–59.5) and the median tumor number was 1(IQR: 1- 2) with a median tumor size of 2.6 cm (IQR: 1.9- 4.5). 98 (74.5%) patients were HBeAg negative with a median viral load of 3.8 logs (IQR 1.9 – 5.8). 58 (43%) patients had cirrhosis at diagnosis. 36% of patients were diagnosed with HCC on their first screening imaging whereas 39% were found to have HCC on repeated surveillance imaging. 116 (87.9%) were on treatment at the time of diagnosis or after (70 (60.3%) NA and 46 (39%) Combination therapy with double NA or NA plus interferon). Out of the 132 patients, BCLC stage 0, A, B, and C represented 30 (23%), 42 (32%), 17 (13%), and 5 (4%) patients, respectively, with 38 (28%) patients with unknown BCLC stage. The overall adherence to AASLD guidelines was 61%. The HCC treatment adherence rate for patients with BCLC stage 0, A, B were 63%, 97.5%, and 23.5%, respectively. BCLC stages C and D did not have a sufficient sample size for analysis. The adherence rate ranged from 53% (Eastern Canada) to 71% (Western Canada) across Canada. Conclusions In this retrospective nationwide cohort study of patients with CHB-related HCC, the overall treatment adherence rate to AASLD guidelines was low with notable regional differences. Further analysis will determine the cause of regional differences. Funding Agencies None
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Affiliation(s)
- S H Rahman
- internal medicine, Western University, London, ON, Canada
| | - Y Scharr
- internal medicine, Western University, London, ON, Canada
| | - J Jeyaparan
- internal medicine, Western University, London, ON, Canada
| | - A Manko
- Biological sciences, University of Calgary, Calgary, AB, Canada
| | - C S Coffin
- Medicine, University of Calgary, Calgary, AB, Canada
| | - S E Congly
- Liver Unit, Division of Gastroenterology, Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - A Ramji
- Gastrointestinal Research Institute, Vancouver, BC, Canada
| | - S Fung
- Toronto General Hospital, Toronto, ON, Canada
| | - C Cooper
- University of Ottawa Faculty of Medicine, Ottawa, ON, Canada
| | - M Ma
- University of Alberta, Edmonton, AB, Canada
| | - R Bailey
- Royal Alexandra Hospital, Edmonton, AB, Canada
| | - G Minuk
- University of Manitoba, Winnipeg, MB, Canada
| | - A Wong
- University of Saskatchewan, Saskatoon, SK, Canada
| | - K Doucette
- University of Alberta, Edmonton, AB, Canada
| | | | - P Wong
- Gastroenterology, McGill University, Brossard, QC, Canada
| | - M Brahmania
- internal medicine, Western University, London, ON, Canada
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Frolkis A, Borman M, Sadler MD, Congly SE, Nguyen HH, Lee S, Stinton L, Swain M, Coffin CS, Aspinall A, Burak KW, Shaheen AM. A202 IMPACT OF THE COVID-19 PANDEMIC ON THE EPIDEMIOLOGY OF ALCOHOL-RELATED HEPATITIS. J Can Assoc Gastroenterol 2022. [PMCID: PMC9383486 DOI: 10.1093/jcag/gwab049.201] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Alcohol-related hepatitis (AH) is the most severe form of alcohol-related liver disease, with rising incidence. Stay-at-home orders for the COVID-19 pandemic were associated with increased alcohol consumption. Online sales reported a 262% increase from March 2019 to 2020. Aims The purpose of this study was to track the epidemiology of hospitalizations for AH by sex before and after the COVID-19 pandemic. We hypothesized that AH would be more severe in females and younger individuals during the pandemic. Methods Using the Discharge Abstract Database, we identified all hospitalizations in Alberta with international classification of disease-10 codes for AH between March 2018 and September 2020. We merged this dataset with provincial laboratory data to identify all inpatient lab values. We calculated Model for End-Stage Liver Disease (MELD) and Maddrey scores and validated a laboratory-based algorithm for AH. Severe AH was defined as Maddrey score > 32. Onset of the pandemic was defined as March 2020. Stratified by pandemic onset, descriptive statistics were done with Chi-squared and Kruskal Wallis tests. Inpatient mortality was assessed as a primary outcome. Binomial regression was used to assess changes in frequency of admission for AH with the denominator as all cirrhosis-related admissions over the same time-period. Results We identified 991 hospitalizations for AH prior to the pandemic (n=381, 38.5% female) and 417 during the pandemic (n=144, 34.5% female). Hospitalizations for AH significantly increased during the pandemic (p = 0.04) (Figure 1). Median Maddrey score for females (30.5) before the pandemic was significantly higher than for males (22.9), p < 0.01. During the pandemic, median Maddrey for females (28.7) was higher than males 21.4, p = 0.07. Median age at admission was significantly lower for both males and females during the pandemic (age 44 and 41, respectively) as compared to prior (age 47 and 45, respectively) p < 0.05. There was no significant difference in MELD between sexes before (13.5 for females, 14.0 for males, p = 0.15) and during the pandemic (13.3 for females, 13.0 for males, p = 0.75). Additionally, there was no significant difference in mortality between sexes before (10.4% in females, 11.5% in males, p = 0.22) and after the pandemic (9.2% in females, 9.9% in males, p = 0.67). Conclusions Hospitalizations for AH rose during the pandemic and occurred at younger ages. There was no significant difference in disease severity or mortality before and during the pandemic. Overall, females have more severe AH than males. Public health efforts should continue to be made to educate about the harms of alcohol excess and offer community support. Future studies will expand the trend through multiple pandemic waves. ![]()
Funding Agencies None
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Affiliation(s)
- A Frolkis
- University of Calgary, Calgary, AB, Canada
| | - M Borman
- Division of Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - M D Sadler
- University of Calgary, Calgary, AB, Canada
| | - S E Congly
- Liver Unit, Division of Gastroenterology, Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - H H Nguyen
- Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - S Lee
- University of Calgary, Calgary, AB, Canada
| | - L Stinton
- University of Calgary, Calgary, AB, Canada
| | - M Swain
- University of Calgary, Calgary, AB, Canada
| | - C S Coffin
- Medicine, University of Calgary, Calgary, AB, Canada
| | - A Aspinall
- University of Calgary, Calgary, AB, Canada
| | - K W Burak
- Liver Unit, Univ Calgary, Calgary, AB, Canada
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Smith MK, Chan Y, Suo AE, Shaheen AA, Congly SE, Tandon P, Bhanji RA, Wells MM, Cheng T, Ma C. Clinical Course and Treatment Implications of Combination Immune Checkpoint Inhibitor-Mediated Hepatitis: A Multicentre Cohort. J Can Assoc Gastroenterol 2021; 5:39-47. [PMID: 35118226 PMCID: PMC8806044 DOI: 10.1093/jcag/gwab019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 12/31/2020] [Accepted: 07/06/2021] [Indexed: 12/18/2022] Open
Abstract
Background Immune-related adverse events can occur after treatment with immune checkpoint inhibitors (ICI), limiting treatment persistence. We aimed to evaluate the clinical course of ICI-mediated hepatitis (IMH) associated with combination ipilimumab and nivolumab treatment. Methods A retrospective cohort study including consecutive patients with metastatic melanoma treated with ipilimumab and nivolumab between 2013 and 2018 was conducted at two tertiary care centres. IMH was defined by the Common Terminology Criteria for Adverse Events (CTCAE). We determined the proportion of patients developing IMH, and compared the duration, treatment patterns and outcomes, stratified by hepatitis severity. Kaplan–Meier survival analysis was used to evaluate time to hepatitis resolution, and a linear mixed-effects model was used to compare longitudinal outcomes by treatment. Results A total of 63 patients were included. Thirty-two patients (51%) developed IMH (34% Grade 1–2, 66% Grade 3–4), at a median of 34 days (IQR 20 to 43.5 days) after the first dose. Baseline FIB4 index ≥1.45 was associated with IMH (OR 3.71 [95% CI: 1.03 to 13.38], P = 0.04). Ninety-four per cent (30/32) of patients had liver enzyme normalization after a median duration of 43 days (IQR 26 to 70 days). Corticosteroid use was not associated with faster IMH resolution or less ICI discontinuation. A total of 24 patients died during the study; no deaths were attributable to hepatitis-related complications. Fifty-three per cent (17/32) of patients resumed anti-PD-1 monotherapy and three patients developed IMH recurrence. Conclusions Approximately half of the patients treated with combination ipilimumab and nivolumab developed IMH in this cohort. However, most patients experienced uncomplicated IMH resolution.
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Affiliation(s)
- Matthew K Smith
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Yin Chan
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Aleksi E Suo
- British Columbia Cancer Agency, University of British Columbia, Abbotsford, British Columbia, Canada
| | - Abdel Aziz Shaheen
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Puneeta Tandon
- Division of Gastroenterology and Hepatology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Rahima A Bhanji
- Division of Gastroenterology and Hepatology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Malcolm M Wells
- Division of Gastroenterology and Hepatology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Tina Cheng
- Division of Medical Oncology, Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Sachar Y, Brahmania M, Dhanasekaran R, Congly SE. Screening for Hepatocellular Carcinoma in Patients with Hepatitis B. Viruses 2021; 13:1318. [PMID: 34372524 PMCID: PMC8310362 DOI: 10.3390/v13071318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/05/2021] [Accepted: 07/05/2021] [Indexed: 12/18/2022] Open
Abstract
Chronic hepatitis B (CHB) infection is a significant risk factor for developing hepatocellular carcinoma (HCC). As HCC is associated with significant morbidity and mortality, screening patients with CHB at a high risk for HCC is recommended in an attempt to improve these outcomes. However, the screening recommendations on who to screen and how often are not uniform. Identifying patients at the highest risk of HCC would allow for the best use of health resources. In this review, we evaluate the literature on screening patients with CHB for HCC, strategies for optimizing adherence to screening, and potential risk stratification tools to identify patients with CHB at a high risk of developing HCC.
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Affiliation(s)
- Yashasavi Sachar
- London Health Sciences Center, Department of Medicine, Division of Gastroenterology, Western University, London, ON N6A 5A5, Canada; (Y.S.); (M.B.)
| | - Mayur Brahmania
- London Health Sciences Center, Department of Medicine, Division of Gastroenterology, Western University, London, ON N6A 5A5, Canada; (Y.S.); (M.B.)
- Centre for Quality, Innovation and Safety, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 5W9, Canada
| | - Renumathy Dhanasekaran
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA 94305, USA;
| | - Stephen E. Congly
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, AB T2N 4Z6, Canada
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21
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Congly SE, Shaheen AA, Swain MG. Modelling the cost effectiveness of non-alcoholic fatty liver disease risk stratification strategies in the community setting. PLoS One 2021; 16:e0251741. [PMID: 34019560 PMCID: PMC8139490 DOI: 10.1371/journal.pone.0251741] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/01/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is highly prevalent worldwide. Identifying high-risk patients is critical to best utilize limited health care resources. We established a community-based care pathway using 2D ultrasound shear wave elastography (SWE) to identify high risk patients with NAFLD. Our objective was to assess the cost-effectiveness of various non-invasive strategies to correctly identify high-risk patients. METHODS A decision-analytic model was created using a payer's perspective for a hypothetical patient with NAFLD. FIB-4 [≥1.3], NAFLD fibrosis score (NFS) [≥-1.455], SWE [≥8 kPa], transient elastography (TE) [≥8 kPa], and sequential strategies with FIB-4 or NFS followed by either SWE or TE were compared to identify patients with either significant (≥F2) or advanced fibrosis (≥F3). Model inputs were obtained from local data and published literature. The cost/correct diagnosis of advanced NAFLD was obtained and univariate sensitivity analysis was performed. RESULTS For ≥F2 fibrosis, FIB-4/SWE cost $148.75/correct diagnosis while SWE cost $276.42/correct diagnosis, identifying 84% of patients correctly. For ≥F3 fibrosis, using FIB-4/SWE correctly identified 92% of diagnoses and dominated all other strategies. The ranking of strategies was unchanged when stratified by normal or abnormal ALT. For ≥F3 fibrosis, the cost/correct diagnosis was less in the normal ALT group. CONCLUSIONS SWE based strategies were the most cost effective for diagnosing ≥F2 fibrosis. For ≥F3 fibrosis, FIB-4 followed by SWE was the most effective and least costly strategy. Further evaluation of the timing of repeating non-invasive strategies are required to enhance the cost-effective management of NAFLD.
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Affiliation(s)
- Stephen E. Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary Alberta, Canada
- * E-mail:
| | - Abdel Aziz Shaheen
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary Alberta, Canada
| | - Mark G. Swain
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary Alberta, Canada
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22
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Jeyalingam T, Woo M, Congly SE, David J, Belletrutti PJ, Gupta M. A139 IMPROVED QUALITY OF LIFE AFTER ENDOSCOPIC THERAPY FOR BARRETT’S ESOPHAGUS AND EARLY ESOPHAGEAL CANCER IN SOUTHERN ALBERTA. J Can Assoc Gastroenterol 2021. [DOI: 10.1093/jcag/gwab002.137] [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: 11/13/2022] Open
Abstract
Abstract
Background
In patients with Barrett’s esophagus (BE), endoscopic therapy reduces the risk of progression to invasive esophageal adenocarcinoma (EAC). Data on the impact of endoscopic therapy on patient quality of life (QoL) is limited.
Aims
We aimed to assess: (1) change in QoL during the course of endoscopic therapy for BE, (2) factors which predict this change, (3) whether achieving complete remission of dysplasia (CRD) or intestinal metaplasia (CRIM) affect the degree of change.
Methods
We conducted a retrospective observational study using a prospectively maintained database of BE patients treated in Calgary, Alberta from 2013–2020 containing data on demographics, BE disease characteristics and therapeutics, QoL, and follow-up. QoL was determined prior to initiation of therapy and after each treatment session using a validated questionnaire. Descriptive statistics were calculated and change in QoL was compared using a Wilcoxon signed ranks test. Backwards multiple linear regression analysis was performed to determine predictors of change in QoL.
Results
Of 130 BE patients, 112 (86.1%) were male and 104 (80%) had dysplastic histology or intramucosal carcinoma on index endoscopy. Mean (SD) age was 65.6 (12.0) years. At time of analysis, 76 patients (58.5%) had completed endoscopic therapy, of whom 69 (90.8%) achieved CRIM; 54 patients (41.5%) were still undergoing treatment. There was significant improvement in all QoL measures during the treatment course except for “depression” (Table 1). Patients with CRIM or CRD had reductions in “sleep difficulty” and “negative impact on life” to a significantly greater degree vs patients not achieving CRIM (Δ sleep -0.45 vs 0.0, P=0.002; Δ negative impact -0.4 vs -0.05, P=0.014) or CRD (Δ sleep -0.40 vs +0.60, P=0.002; Δ negative impact -0.40 vs +0.20, P=0.04). Multiple linear regression revealed older age (B=-0.03, P=0.008) and fewer number of EMR sessions (B=0.254, P=0.008) were correlated with greater improvement in QoL.
Conclusions
Endoscopic therapy improves QoL in BE patients, especially in those achieving CRIM/CRD. Older age and fewer EMRs are correlated with greater improvement in QoL. These results further reinforce the role of endoscopic therapy as the first line treatment of BE and early EAC.
Funding Agencies
None
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Affiliation(s)
- T Jeyalingam
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - M Woo
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - S E Congly
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - J David
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - P J Belletrutti
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - M Gupta
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
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Stach J, Zhao I, Frolkis A, Haylock-Jacobs S, Israelson H, Pinto J, Williams S, Swain M, Stinton L, Aspinall A, Borman M, Sadler MD, Burak KW, Congly SE, Lee S, Coffin CS. A210 DECLINE IN HEPATITIS B QUANTITATIVE SURFACE ANTIGEN LEVELS IN CHRONIC HEPATITIS B PATIENTS ON TREATMENT WITH NUCLEOS(T)IDE ANALOGUES. J Can Assoc Gastroenterol 2021. [DOI: 10.1093/jcag/gwab002.208] [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: 11/12/2022] Open
Abstract
Abstract
Background
The Hepatitis B virus (HBV) affects over 250 million people worldwide and can lead to cirrhosis and hepatocellular carcinoma. HBV surface antigen (HBsAg) quantification is increasingly used to predict disease activity and treatment response. As there is no virologic cure, clinicians are seeking a “functional cure”, or HBsAg loss, as a guide to safely stopping nucleos(t)ide analogue therapy. Tenofovir Disoproxil Fumarate (TDF) and Entecavir (ETV) are first line therapy but require prolonged treatment to achieve HBsAg clearance.
Aims
To assess the association between nucleos(t)ide therapy and decline in quantitative HBsAg (qHBsAg) in patients with HBV from Calgary, Alberta.
Methods
A retrospective review of adult patients with chronic HBV, followed at the University of Calgary Liver Clinic, was conducted between January 2012 and October 2020. Patients were excluded if treatment was discontinued or changed, only had a single qHBsAg measurement, or were co-infected with hepatitis C virus, hepatitis delta virus, or HIV. Patients were stratified according to therapy with TDF, ETV, or no treatment. To identify associations between mean changes in qHBsAg by medication exposure, one-way ANOVAs and t-tests were performed. Results were reported as means and 95% confidence intervals (CI). The median time from initial qHBsAg to most-recent was calculated.
Results
187 patients were included in the final analysis (Table 1). 77 were excluded for being on more than one medication over the study period, 10 were excluded due to discontinuation of treatment, and 195 were excluded for single qHBsAg measurements. The mean qHBsAg decline was -750.04 IU/mL (95% CI -1311.58, -188.50) in the TDF group (n=45) and -309.20 IU/mL (95% CI -600.90, -17.50) in the ETV group (n=35) (p=0.20). In the no treatment group (n=107), the mean qHBsAg increased by 711.29 IU/mL (95% CI -600.78, 2023.80)(Figure 1). The median time from initial qHBsAg to most-recent was 980 days.
Conclusions
Quantitative HBsAg levels declined in patients on TDF and ETV, but increased in untreated patients. Although HBsAg levels showed a trend for greater decline in TDF-treated patients, results failed to reach statistical significance, and may be affected by overall treatment duration. Future studies will explore medication use as a time-varying covariate to identify how change in treatment influences changes in HBsAg over time.
Funding Agencies
None
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Affiliation(s)
- J Stach
- Gastroenterology, University of Calgary, Medicine Hat, AB, Canada
| | - I Zhao
- McMaster University, Hamilton, ON, Canada
| | - A Frolkis
- University of Calgary, Calgary, AB, Canada
| | - S Haylock-Jacobs
- Gastroenterology, University of Calgary, Medicine Hat, AB, Canada
| | - H Israelson
- Gastroenterology, University of Calgary, Medicine Hat, AB, Canada
| | - J Pinto
- Gastroenterology, University of Calgary, Medicine Hat, AB, Canada
| | - S Williams
- Gastroenterology, University of Calgary, Medicine Hat, AB, Canada
| | - M Swain
- University of Calgary, Calgary, AB, Canada
| | - L Stinton
- University of Calgary, Calgary, AB, Canada
| | - A Aspinall
- Gastroenterology, University of Calgary, Medicine Hat, AB, Canada
| | - M Borman
- Gastroenterology, University of Calgary, Medicine Hat, AB, Canada
| | - M D Sadler
- University of Calgary, Calgary, AB, Canada
| | - K W Burak
- Liver Unit, Univ Calgary, Calgary, AB, Canada
| | - S E Congly
- Liver Unit, Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - S Lee
- University of Calgary, Calgary, AB, Canada
| | - C S Coffin
- Medicine, University of Calgary, Calgary, AB, Canada
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24
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Carbonneau M, Davyduke T, Congly SE, Ma MM, Newnham K, Den Heyer V, Tandon P, Abraldes JG. Impact of specialized multidisciplinary care on cirrhosis outcomes and acute care utilization. Can Liver J 2021; 4:38-50. [PMID: 35991472 PMCID: PMC9203164 DOI: 10.3138/canlivj-2020-0017] [Citation(s) in RCA: 3] [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: 06/16/2020] [Accepted: 09/27/2020] [Indexed: 09/15/2023]
Abstract
BACKGROUND Multidisciplinary care has the potential to improve outcomes among patients with cirrhosis, yet its impact on this population remains unclear, with existing studies demonstrating discrepant results. Using data from the multidisciplinary outpatient Cirrhosis Care Clinic (CCC) at the University of Alberta Hospital, we aimed to evaluate acute care utilization and survival outcomes of patients followed by the CCC compared with those receiving standard care (SC). METHODS We performed a retrospective chart review of 212 patients with cirrhosis admitted to University of Alberta Hospital between 2014 and 2015. CCC patients (n = 36) were followed through the CCC before index admission. SC patients (n = 176) were managed outside of the CCC. Readmission time in hospital was collected until 1 year, death, or liver transplant. RESULTS CCC patients had more advanced liver disease (higher prevalence of ascites, encephalopathy, and varices). Despite this, acute care utilization was significantly lower among CCC patients (adjusted length of stay lower by 3 days, p = 0.03, and adjusted survival days spent in hospital lower by 9%, p = 0.02). CCC patients also had improved 1-year transplant-free survival, with an adjusted 1-year relative risk reduction of 53% (p = 0.03). Total mean cost of care was lower in the CCC group by $2,280 per patient-month of life. DISCUSSION For patients admitted with cirrhosis, specialized post-discharge multidisciplinary outpatient care is associated with decreased acute care utilization, improved 1-year transplant-free survival probability, and the potential for cost savings to the system.
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Affiliation(s)
| | - Tracy Davyduke
- Hepatology Department, Alberta Health Services, Edmonton, Alberta, Canada
| | - Stephen E Congly
- Liver Unit, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Mang M Ma
- Liver Unit, Division of Gastroenterology, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta, Canada
| | - Kim Newnham
- Hepatology Department, Alberta Health Services, Edmonton, Alberta, Canada
| | - Vanessa Den Heyer
- Hepatology Department, Alberta Health Services, Edmonton, Alberta, Canada
| | - Puneeta Tandon
- Liver Unit, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
- Liver Unit, Division of Gastroenterology, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta, Canada
| | - Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
- Liver Unit, Division of Gastroenterology, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta, Canada
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25
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Ma C, Congly SE, Novak KL, Belletrutti PJ, Raman M, Woo M, Andrews CN, Nasser Y. Epidemiologic Burden and Treatment of Chronic Symptomatic Functional Bowel Disorders in the United States: A Nationwide Analysis. Gastroenterology 2021; 160:88-98.e4. [PMID: 33010247 PMCID: PMC7527275 DOI: 10.1053/j.gastro.2020.09.041] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/10/2020] [Accepted: 09/24/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Functional bowel disorders (FBDs) are the most common gastrointestinal problems managed by physicians. We aimed to assess the burden of chronic symptomatic FBDs on ambulatory care delivery in the United States and evaluate patterns of treatment. METHODS Data from the National Ambulatory Medical Care Survey were used to estimate annual rates and associated costs of ambulatory visits for symptomatic irritable bowel syndrome, chronic functional abdominal pain, constipation, or diarrhea. The weighted proportion of visits associated with pharmacologic and nonpharmacologic (stress/mental health, exercise, diet counseling) interventions were calculated, and predictors of treatment strategy were evaluated in multivariable multinomial logistic regression. RESULTS From 2007-2015, approximately 36.9 million (95% CI, 31.4-42.4) weighted visits in patients of non-federally employed physicians for chronic symptomatic FBDs were sampled. There was an annual weighted average of 2.7 million (95% CI, 2.3-3.2) visits for symptomatic irritable bowel syndrome/chronic abdominal pain, 1.0 million (95% CI, 0.8-1.2) visits for chronic constipation, and 0.7 million (95% CI, 0.5-0.8) visits for chronic diarrhea. Pharmacologic therapies were prescribed in 49.7% (95% CI, 44.7-54.8) of visits compared to nonpharmacologic interventions in 19.8% (95% CI, 16.0-24.2) of visits (P < .001). Combination treatment strategies were more likely to be implemented by primary care physicians and in patients with depression or obesity. The direct annual cost of ambulatory clinic visits alone for chronic symptomatic FBDs is approximately US$358 million (95% CI, 233-482 million). CONCLUSIONS The management of chronic symptomatic FBDs is associated with considerable health care resource use and cost. There may be an opportunity to improve comprehensive FBD management because fewer than 1 in 5 ambulatory visits include nonpharmacologic treatment strategies.
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Affiliation(s)
- Christopher Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul J Belletrutti
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maitreyi Raman
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Woo
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher N Andrews
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yasmin Nasser
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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26
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Samadi Kochaksaraei G, Castillo E, Sadler MD, Seow CHT, Barkema HW, Martin SR, Israelson H, Pinto J, Williams S, Aspinall AII, Stinton LM, Borman MA, Burak KW, Swain MG, Congly SE, Lee SS, Shaheen AA, Coffin CS. Real-world clinical and virological outcomes in a retrospective multiethnic cohort study of 341 untreated and tenofovir disoproxil fumarate-treated chronic hepatitis B pregnant patients in North America. Aliment Pharmacol Ther 2020; 52:1707-1716. [PMID: 33111382 DOI: 10.1111/apt.16123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/31/2020] [Accepted: 10/06/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND There are limited long-term data on outcomes of chronic hepatitis B (CHB) in untreated and tenofovir disoproxil fumarate (TDF)-treated women during pregnancy. AIMS To assess clinical outcomes in a multiethnic cohort of patients during pregnancy and post-partum in a low HBV endemic region. METHODS Retrospective real-world study of women with CHB (treated or untreated with TDF) from 2011 to 2019; data including ALT, HBV DNA, HBeAg and liver stiffness measurement were collected during pregnancy and post-partum. RESULTS In 341 women (446 pregnancies) followed for a median of 33 months (IQR: 26.7-39.5) post-partum, 19% (65/341) received TDF (11 initiated pre-pregnancy, 53 for mother-to-child transmission (MTCT) prevention). During follow-up, 72/341 had subsequent pregnancy, including 18/53 on TDF for MTCT risk, of whom 7/18 were re-treated. In all TDF-treated women, HBV DNA declined but rebounded after TDF withdrawal (median baseline, near birth and early follow-up levels were 7.2, 3.0 and 5.5 log IU/mL respectively [P < 0.01]). In HBeAg+ patients (65/341) ALT flares were more common (P = 0.03), especially for those who stopped TDF post-partum, requiring re-treatment in 21% (11/53). In comparison, 54% (116/215) of untreated women had a post-partum ALT flare; one with fulminant hepatitis underwent transplant 13 months post-partum. HBsAg clearance occurred in 2.6% (9/341, 3/9 HBeAg+, 2/9 TDF treated) at median 30 months (IQR: 23-40) and 37% (24/65) of HBeAg+ patients had HBeAg loss at median 17 months (IQR: 12-26) post-partum. CONCLUSIONS Post-partum ALT flares were common, especially after TDF withdrawal. Overall, 37% achieved HBeAg clearance and 2.9% had HBsAg loss during long-term follow-up.
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Affiliation(s)
- Golasa Samadi Kochaksaraei
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eliana Castillo
- Medical Disorders in Pregnancy, Division of Internal Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Matthew D Sadler
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cynthia H-T Seow
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Herman W Barkema
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Production Animal Health, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Steven R Martin
- Department of Paediatrics, Alberta Children's Hospital, Calgary, AB, Canada
| | - Heidi Israelson
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jacqueline Pinto
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Sarah Williams
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - AIexander I Aspinall
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Laura M Stinton
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Meredith A Borman
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kelly W Burak
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mark G Swain
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Samuel S Lee
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Abdel Aziz Shaheen
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Carla S Coffin
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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27
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Syed A, Sadler MD, Borman MA, Burak KW, Congly SE. Assessment of Canadian policies regarding liver transplant candidacy of people who use alcohol, tobacco, cannabis, and opiates. Can Liver J 2020; 3:372-380. [PMID: 35990508 PMCID: PMC9202737 DOI: 10.3138/canlivj.2020-0005] [Citation(s) in RCA: 4] [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: 03/04/2020] [Accepted: 03/18/2020] [Indexed: 07/29/2023]
Abstract
BACKGROUND When last assessed in 2013, all Canadian liver transplant programs required 6 months of abstinence from alcohol. New studies have questioned the validity of this policy. Moreover, with recreational cannabis now legal in Canada, more transplant candidates may use cannabis. Given these changes, our objective was to obtain an understanding of current Canadian practices regarding liver transplantation and candidates with addiction or alcohol, tobacco, cannabis, or opiate use. METHODS Electronic surveys were distributed to the medical directors of all seven adult liver transplant programs in Canada. Questions were based on either a Likert-scale ranking or free response. The complete data set was aggregated to provide a national perspective on this topic and ensure each individual program remained anonymous. RESULTS All seven programs responded to the survey. Of these programs, 43% always require 6-month abstinence from alcohol, 29% usually require it, and 14% sometimes require it. Formal alcohol rehabilitation is mandatory in two programs. The majority (57%) of programs never or rarely consider transplant for patients with acute alcoholic hepatitis; 29% require smoking cessation before consideration for transplant; and 71% felt that cannabis use is rarely or never a contraindication to liver transplantation. CONCLUSIONS Significantly more Canadian programs now perform liver transplant for patients who have less than 6 months abstinence from alcohol, and alcoholic hepatitis is no longer an absolute contraindication in Canada. Policies on smoking and opiates are quite variable. Further study and discussion are critical for development of national policies to obtain equitable access to liver transplant for all.
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Affiliation(s)
- Ahsan Syed
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew D Sadler
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meredith A Borman
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly W Burak
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
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28
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Charette JH, Burak KW, Coffin CS, Congly SE, Lee SS, Israelson H, Williams S, Sadler M, Borman MA, Aspinall AI, Swain MG, Shaheen AA. Evaluating the role of transient elastography post chronic hepatitis C treatment to predict hepatocellular carcinoma. J Hepatol 2020; 73:1287-1289. [PMID: 32883554 DOI: 10.1016/j.jhep.2020.07.005] [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: 06/12/2020] [Revised: 07/03/2020] [Accepted: 07/09/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Jacob H Charette
- Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly W Burak
- Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Carla S Coffin
- Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E Congly
- Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Samuel S Lee
- Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Heidi Israelson
- Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sarah Williams
- Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Sadler
- Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meredith A Borman
- Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alexander I Aspinall
- Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mark G Swain
- Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Abdel-Aziz Shaheen
- Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Congly SE, Sadler MD, Abraldes JG, Tandon P, Lee SS, Burak KW. Practical management of esophageal varices in the context of SARS-CoV-2 (COVID-19): the Alberta protocol. Can Liver J 2020; 3:300-303. [PMID: 35992531 PMCID: PMC9202704 DOI: 10.3138/canlivj-2020-0007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 04/14/2020] [Accepted: 04/22/2020] [Indexed: 08/10/2023]
Abstract
The challenges of managing varices during the COVID-19 pandemic are reviewed, and a treatment algorithm is presented to best manage patients with advanced liver disease during periods of limited access to endoscopy.
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Affiliation(s)
- Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew D Sadler
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, Edmonton, Alberta, Canada
| | - Puneeta Tandon
- Division of Gastroenterology (Liver Unit), University of Alberta, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, Edmonton, Alberta, Canada
| | - Samuel S Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly W Burak
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Carbonneau M, Eboreime EA, Hyde A, Campbell-Scherer D, Faris P, Gramlich L, Tsuyuki RT, Congly SE, Shaheen AA, Sadler M, Zeman M, Spiers J, Abraldes JG, Sugars B, Sia W, Green L, Abdellatif D, Schaefer JP, Selvarajah V, Marr K, Ryan D, Westra Y, Bakshi N, Varghese JC, Tandon P. The cirrhosis care Alberta (CCAB) protocol: implementing an evidence-based best practice order set for the management of liver cirrhosis - a hybrid type I effectiveness-implementation trial. BMC Health Serv Res 2020; 20:558. [PMID: 32552833 PMCID: PMC7301349 DOI: 10.1186/s12913-020-05427-8] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/12/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Liver cirrhosis is a leading cause of morbidity, premature mortality and acute care utilization in patients with digestive disease. In the province of Alberta, hospital readmission rates for patients with cirrhosis are estimated at 44% at 90 days. For hospitalized patients, multiple care gaps exist, the most notable stemming from i) the lack of a structured approach to best practice care for cirrhosis complications, ii) the lack of a structured approach to broader health needs and iii) suboptimal preparation for transition of care into the community. Cirrhosis Care Alberta (CCAB) is a 4-year multi-component pragmatic trial which aims to address these gaps. The proposed intervention is initiated at the time of hospitalization through implementation of a clinical information system embedded electronic order set for delivering evidence-based best practices under real-world conditions. The overarching objective of the CCAB trial is to demonstrate effectiveness and implementation feasibility for use of the order set in routine patient care within eight hospital sites in Alberta. METHODS A mixed methods hybrid type I effectiveness-implementation design will be used to evaluate the effectiveness of the order set intervention. The primary outcome is a reduction in 90-day cumulative length of stay. Implementation outcomes such as reach, adoption, fidelity and maintenance will also be evaluated alongside other patient and service outcomes such as readmission rates, quality of care and cost-effectiveness. This theory-based trial will be guided by Normalization Process Theory, Consolidated Framework on Implementation Research (CFIR) and the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) Framework. DISCUSSION The CCAB project is unique in its breadth, both in the comprehensiveness of the multi-component order set and also for the breadth of its roll-out. Lessons learned will ultimately inform the feasibility and effectiveness of this approach in "real-world" conditions as well as adoption and adaptation of these best practices within the rest of Alberta, other provinces in Canada, and beyond. TRIAL REGISTRATION ClinicalTrials.gov: NCT04149223, November 4, 2019.
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Affiliation(s)
- Michelle Carbonneau
- Alberta Health Services, Edmonton & Calgary, AB, Canada
- Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, AB, T6G2X8, Canada
| | - Ejemai Amaize Eboreime
- Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, AB, T6G2X8, Canada
| | - Ashley Hyde
- Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, AB, T6G2X8, Canada
| | - Denise Campbell-Scherer
- Department of Family Medicine, University of Alberta, Edmonton, AB, Canada
- Office of Lifelong Learning and the Physician Learning Program, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Peter Faris
- Alberta Health Services, Edmonton & Calgary, AB, Canada
| | - Leah Gramlich
- Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, AB, T6G2X8, Canada
| | - Ross T Tsuyuki
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, AB, Canada
- Department of Pharmacology, University of Alberta, Edmonton, AB, Canada
| | - Stephen E Congly
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada
| | - Abdel Aziz Shaheen
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada
| | - Matthew Sadler
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Marilyn Zeman
- Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, AB, T6G2X8, Canada
| | - Jude Spiers
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Juan G Abraldes
- Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, AB, T6G2X8, Canada
- Centre of Excellence for Gastrointestinal Inflammation and Immunity Research (CEGIIR), University of Alberta, Edmonton, AB, T6G2X8, Canada
| | - Benjamin Sugars
- Department of Medicine, Division of General Internal Medicine, University of Alberta, Edmonton, AB, Canada
| | - Winnie Sia
- Department of Medicine, Division of General Internal Medicine, University of Alberta, Edmonton, AB, Canada
| | - Lee Green
- Department of Family Medicine, University of Alberta, Edmonton, AB, Canada
| | - Dalia Abdellatif
- Department of Family Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jeffrey P Schaefer
- Department of Medicine, Division of General Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - Vijeyakumar Selvarajah
- Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, AB, T6G2X8, Canada
| | - Kaleb Marr
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - David Ryan
- Central Alberta Digestive Disease Specialists, Red Deer, AB, Canada
| | - Yolande Westra
- Department of Medicine, Division of General Internal Medicine, University of Alberta, Edmonton, AB, Canada
| | - Neeja Bakshi
- Department of Medicine, Division of General Internal Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jayant C Varghese
- Department of Medicine, Division of General Internal Medicine, University of Alberta, Edmonton, AB, Canada
| | - Puneeta Tandon
- Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, AB, T6G2X8, Canada.
- Centre of Excellence for Gastrointestinal Inflammation and Immunity Research (CEGIIR), University of Alberta, Edmonton, AB, T6G2X8, Canada.
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Syed A, Sadler MD, Borman MA, Burak KW, Congly SE. Assessment of Canadian policies regarding liver transplant candidacy of people who use alcohol, tobacco, cannabis, and opiates. CanLivJ 2020. [DOI: 10.3138/canlivj-2020-0005] [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] [Indexed: 11/20/2022]
Affiliation(s)
- Ahsan Syed
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew D Sadler
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meredith A Borman
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly W Burak
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
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Ma C, Shaheen AA, Congly SE, Andrews CN, Moayyedi P, Forbes N. Interpreting Reported Risks Associated With Use of Proton Pump Inhibitors: Residual Confounding in a 10-Year Analysis of National Ambulatory Data. Gastroenterology 2020; 158:780-782.e3. [PMID: 31678304 DOI: 10.1053/j.gastro.2019.10.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/13/2019] [Accepted: 10/18/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Christopher Ma
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada; Robarts Clinical Trials, Inc, London, Ontario, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Abdel Aziz Shaheen
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E Congly
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Christopher N Andrews
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Paul Moayyedi
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada; Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
| | - Nauzer Forbes
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
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Brahmania M, Marquez V, Kneteman NM, Bhat M, Marleau D, Wong P, Peletekian KM, Burak KW, Congly SE. Canadian liver transplant allocation for hepatocellular carcinoma. J Hepatol 2019; 71:1058-1060. [PMID: 31495534 DOI: 10.1016/j.jhep.2019.07.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 12/04/2022]
Affiliation(s)
- Mayur Brahmania
- Division of Gastroenterology, Department of Medicine, and Multi Organ Transplant Unit, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Vladimir Marquez
- Division of Gastroenterology, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Norman M Kneteman
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Mamatha Bhat
- Department of Medicine, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Canada
| | - Denis Marleau
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Philip Wong
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Royal Victoria Hospital, Montréal, Quebec, Canada
| | - Kevork M Peletekian
- Division of Digestive Care & Endoscopy, Dalhousie University and Atlantic Multi-Organ Transplantation Program, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Kelly W Burak
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Coffin CS, Ramji A, Cooper CL, Miles D, Doucette KE, Wong P, Tam E, Wong DK, Wong A, Ukabam S, Bailey RJ, Tsoi K, Conway B, Barrett L, Michalak TI, Congly SE, Minuk G, Kaita K, Kelly E, Ko HH, Janssen HLA, Uhanova J, Lethebe BC, Haylock-Jacobs S, Ma MM, Osiowy C, Fung SK. Epidemiologic and clinical features of chronic hepatitis B virus infection in 8 Canadian provinces: a descriptive study by the Canadian HBV Network. CMAJ Open 2019; 7:E610-E617. [PMID: 31641059 PMCID: PMC6813030 DOI: 10.9778/cmajo.20190103] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 12/15/2022] Open
Abstract
BACKGROUND Published Canadian epidemiologic data on hepatitis B virus (HBV) infection include single-centre studies or are focused on Indigenous populations. We performed a study to characterize the demographic and clinical features, liver disease status and treatment of people with chronic hepatitis B in Canada. METHODS In this descriptive, opportunistic, cross-sectional study, available data for people known to be monoinfected with HBV were collected by the Canadian HBV Network from existing clinical databases, with support from the National Microbiology Laboratory, Public Health Agency of Canada. Data were collected in all provinces with the exception of New Brunswick and Newfoundland and Labrador. We analyzed the data using parametric and nonparametric statistical methods, with a significance level of p < 0.05. RESULTS In the 9380 unique patient records reviewed, the median age was 48 years, and 5193 patients (55.4%) were male. Ethnicity information was available for 7858 patients, of whom 5803 (73.8%) were Asian, 916 (11.6%) were black and 914 (11.6%) were white. Most of those tested (5556/6796 [81.8%]) were negative for HBV e-antigen, and most of those with fibrosis data (3481/4260 [81.7%]) had minimal liver fibrosis, with more advanced fibrosis noted in older people (> 40 yr). Of the 980 patients with genotype data, 521 (53.2%) had genotype B or C infection. Most of the 9241 patients with known confirmed treatment status received tenofovir disoproxil fumarate (1655 [17.9%]), lamivudine (1434 [15.5%]) or entecavir (548 [5.9%]). INTERPRETATION Based on available data, Canadian patients with chronic hepatitis B are predominantly Asian and negative for HBV e-antigen, and have genotype B or C infection. Interprovincial variations were noted in antiviral treatment regimen. This multicentre nationwide study provides data regarding patients with chronic hepatitis B and may inform future studies on the epidemiologic features of HBV infection in Canada.
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Affiliation(s)
- Carla S Coffin
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man.
| | - Alnoor Ramji
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Curtis L Cooper
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - David Miles
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Karen E Doucette
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Philip Wong
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Edward Tam
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - David K Wong
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Alexander Wong
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Sylvester Ukabam
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Robert J Bailey
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Keith Tsoi
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Brian Conway
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Lisa Barrett
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Tomasz I Michalak
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Stephen E Congly
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Gerald Minuk
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Kelly Kaita
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Erin Kelly
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Hin Hin Ko
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Harry L A Janssen
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Julia Uhanova
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Brendan C Lethebe
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Sarah Haylock-Jacobs
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Mang M Ma
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Carla Osiowy
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
| | - Scott K Fung
- Cumming School of Medicine (Coffin, Lethebe, Congly, Haylock-Jacobs), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji, Ko), Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC; Division of Infectious Diseases (Cooper), University of Ottawa, Ottawa Hospital Research Institute; Division of Gastroenterology (Kelly), Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Doucette, Ma), University of Alberta, Edmonton, Alta.; Division of Gastroenterology (P. Wong), Department of Medicine, McGill University, Royal Victoria Hospital, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Department of Medicine (D. Wong, Janssen, Fung), University of Toronto, Toronto Centre for Liver Disease, Toronto, Ont.; Department of Medicine (A. Wong), University of Saskatchewan; Regina General Hospital (Ukabam), Regina, Sask.; Bailey Health Clinic (Bailey), Edmonton, Alta.; Department of Medicine (Tsoi), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.; Vancouver Infectious Diseases Centre (Conway), Vancouver, BC; Division of Infectious Diseases (Barrett), Dalhousie University, Halifax, NS; Faculty of Medicine (Michalak), Memorial University of Newfoundland, St. John's, Nfld.; Department of Internal Medicine (Minuk, Uhanova, Miles, Kaita), University of Manitoba; National Microbiology Laboratory (Osiowy), Public Health Agency of Canada, Winnipeg, Man
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Neong SF, Billington EO, Congly SE. Sexual Dysfunction and Sex Hormone Abnormalities in Patients With Cirrhosis: Review of Pathogenesis and Management. Hepatology 2019; 69:2683-2695. [PMID: 30468515 DOI: 10.1002/hep.30359] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 05/29/2018] [Accepted: 11/06/2018] [Indexed: 02/06/2023]
Abstract
Healthy sexual function is important to maintain a good quality of life but is frequently impaired in patients with cirrhosis. The degree of sexual dysfunction appears to be linked with the degree of hepatic dysfunction. In men, sexual dysfunction can be related to the hyperestrogenism of portal hypertension and/or to decreased testosterone resulting from testicular dysfunction. In women, suppression of the hypothalamic-pituitary-gonadal axis appears to be a principal contributor, with no significant effect of portal hypertension. There is also a huge psychological barrier to break through as there is a component of depression in many patients with cirrhosis. Sexual dysfunction is often underdiagnosed in the cohort with cirrhosis. Management of sexual disorders in patients with cirrhosis can be challenging as they are often multifactorial. A multidisciplinary approach is key in managing these patients. We review the current literature on the pathogenesis of sexual dysfunction in patients with cirrhosis and propose a stepwise algorithm to better manage these patients.
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Affiliation(s)
- Shuet Fong Neong
- Multiorgan Transplant, University Health Network, Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Emma O Billington
- Division of Endocrinology & Metabolism, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
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Shaheen AA, Nguyen HH, Congly SE, Kaplan GG, Swain MG. Nationwide estimates and risk factors of hospital readmission in patients with cirrhosis in the United States. Liver Int 2019; 39:878-884. [PMID: 30688401 DOI: 10.1111/liv.14054] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [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: 07/18/2018] [Revised: 12/06/2018] [Accepted: 01/22/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND The burden of cirrhosis on the healthcare system is substantial and growing. Our objectives were to estimate the readmission rates and hospitalization costs as well as to identify risk factors for 90-day readmission in patients with cirrhosis. METHODS We conducted a weighted analysis of the 2014 Nationwide Readmission Database to identify adult patients with cirrhosis-related complications in the United States and assessed readmission rates at 30, 60 and 90 days post-index hospitalization. Predictors of 90-day readmissions were identified using weighted regression models adjusting for patient and hospital characteristics; the national estimate of hospitalization costs was also calculated. RESULTS Of the 58 954 patients admitted with cirrhosis-related complications in 2014, 14 910 (25%) were readmitted within 90 days because of cirrhosis-related complications. The main causes of readmission were ascites (56%), hepatic encephalopathy (47%) and bleeding oesophageal varices (9%). Independent predictors of 90-day readmissions were male sex (adjusted OR [aOR]: 1.08, 95% CI, 1.04-1.13), age <60 (aOR: 1.27, 95% CI, 1.22-1.32), privately insured (aOR: 0.74, 95% CI, 0.70-0.77), having ≥3 comorbid conditions (aOR: 1.27, 95% CI, 1.14-1.42) and being discharged against medical advice (aOR: 1.41, 95% CI, 1.25-1.59). The weighted cumulative national cost estimate of the index admission was $1.8 billion, compared to $0.5 billion for readmission. CONCLUSIONS A quarter of patients admitted with cirrhosis-related complications were readmitted within 90 days, representing a significant economic burden related to readmission of this population. Interventions and resource allocations to reduce readmission rates among cirrhotic patients is critical.
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Affiliation(s)
- Abdel-Aziz Shaheen
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Henry H Nguyen
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mark G Swain
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Abstract
BACKGROUND Antiviral treatment for chronic hepatitis B is costly, which presents challenges for universal drug coverage for the estimated 480 000 people with the disease in Canada. We appraised criteria for reimbursement of chronic hepatitis B antivirals by public drug plans in Canada. METHODS In this descriptive study, we reviewed the reimbursement criteria for lamivudine, adefovir, tenofovir, entecavir, telbivudine, pegylated or standard interferon, and emtricitabine-tenofovir in the 10 provinces and the Yukon Territory as well as 3 federal programs: Correctional Services Canada, Veterans' Affairs and the Non-Insured Health Benefits Program. We extracted data from publicly available formularies. The primary outcomes extracted were prescriber details, reimbursement regulations and published list price. RESULTS All public drug insurance plans limit access to antiviral treatment in patients with chronic hepatitis B based on viral characteristics, fibrosis stage and/or specialist approval. Lamivudine use is restricted only in British Columbia and Ontario. Six plans (43%) cover entecavir or tenofovir with no restriction, and 8 plans (57%) cover these agents if patients have advanced fibrosis/cirrhosis. Nine plans (64%) provide coverage of interferon, although 4 of these programs reimburse only nonpegylated interferon, which is not currently recommended for chronic hepatitis B treatment. INTERPRETATION We found substantial variability among jurisdictions in reimbursement criteria for the treatment of chronic hepatitis B in Canada. The findings can inform health policy and support the development and adoption of a national chronic hepatitis B strategy to ensure equitable and timely access to treatment no matter where patients reside in Canada.
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Affiliation(s)
- Stephen E Congly
- University of Calgary Liver Unit (Congly), Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alta.; Division of Gastroenterology, Department of Medicine, and Multi Organ Transplant Unit (Brahmania), London Health Sciences Centre, Western University, London, Ont
| | - Mayur Brahmania
- University of Calgary Liver Unit (Congly), Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alta.; Division of Gastroenterology, Department of Medicine, and Multi Organ Transplant Unit (Brahmania), London Health Sciences Centre, Western University, London, Ont.
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Andrews CN, Devlin SM, Le Foll B, Fischer B, Tse F, Storr M, Congly SE. Canadian Association of Gastroenterology Position Statement: Use of Cannabis in Gastroenterological and Hepatic Disorders. J Can Assoc Gastroenterol 2018; 2:37-43. [PMID: 31294362 PMCID: PMC6507278 DOI: 10.1093/jcag/gwy064] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/17/2018] [Indexed: 12/19/2022] Open
Affiliation(s)
- Christopher N Andrews
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Correspondence: Christopher N Andrews, MD, MSc, FRCPC, Clinical Professor, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, 6th Floor, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, Canada. E-mail
| | - Shane M Devlin
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bernard Le Foll
- Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Acute Care Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Departments of Family and Community Medicine, Pharmacology and Toxicology, Psychiatry, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Benedikt Fischer
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Frances Tse
- Department of Gastroenterology and Hepatology, McMaster University, Hamilton, Ontario, Canada
| | - Martin Storr
- Department of Medicine, University of Munich and Center of Endoscopy, Starnberg, Germany
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Abstract
BACKGROUND Hepatic encephalopathy, a form of brain dysfunction seen in the setting of liver insufficiency, negatively affects driving performance and so is both a patient and public safety issue. We aimed to review the motor vehicle codes in each Canadian province and territory relating to the reporting of patients with hepatic encephalopathy and to search a Canadian legal database for cases of motor vehicle collisions involving patients with hepatic encephalopathy. METHODS In this descriptive analysis, the transportation agencies of each Canadian province and territory were contacted via telephone and/or email between April and August 2017. Requirements of physicians to report medical conditions (including liver disease and hepatic encephalopathy) affecting a patient's fitness to drive were assessed. WestlawNext Canada was searched for any Canadian cases on hepatic encephalopathy and driving-related lawsuits from inception to Dec. 31, 2017. RESULTS Reporting of medically unfit drivers is a requirement in all Canadian provinces and territories except Alberta, Quebec and Nova Scotia. Hepatic encephalopathy, cirrhosis and advanced liver disease were not specifically identified as reportable medical conditions in any province or territory. Our search did not identify any lawsuits involving a motor vehicle collision in Canada that were made either against physicians caring for patients with hepatic encephalopathy or against such patients themselves. INTERPRETATION Although hepatic encephalopathy has a substantial impact on driving performance, it is not specifically identified as a reportable medical condition in Canada. Increasing awareness of the potential impact of hepatic encephalopathy on safe driving for health care providers and the public is critical.
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Affiliation(s)
- Henry H Nguyen
- University of Calgary Liver Unit, Department of Medicine (Nguyen, Swain, Congly), Division of Gastroenterology and Hepatology, Calgary, Alta.; McGill University Health Centre (Wong), Royal Victoria Hospital, Montréal, Que
| | - Mark G Swain
- University of Calgary Liver Unit, Department of Medicine (Nguyen, Swain, Congly), Division of Gastroenterology and Hepatology, Calgary, Alta.; McGill University Health Centre (Wong), Royal Victoria Hospital, Montréal, Que
| | - Philip Wong
- University of Calgary Liver Unit, Department of Medicine (Nguyen, Swain, Congly), Division of Gastroenterology and Hepatology, Calgary, Alta.; McGill University Health Centre (Wong), Royal Victoria Hospital, Montréal, Que
| | - Stephen E Congly
- University of Calgary Liver Unit, Department of Medicine (Nguyen, Swain, Congly), Division of Gastroenterology and Hepatology, Calgary, Alta.; McGill University Health Centre (Wong), Royal Victoria Hospital, Montréal, Que.
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Faisal N, Bilodeau M, Aljudaibi B, Hirch G, Yoshida EM, Hussaini T, Ghali MP, Congly SE, Ma MM, Lilly LB. Impact of Sofosbuvir-Based Regimens for the Treatment of Hepatitis C After Liver Transplant on Renal Function: Results of a Canadian National Retrospective Study. EXP CLIN TRANSPLANT 2018; 17:59-63. [PMID: 29619910 DOI: 10.6002/ect.2017.0201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES We assessed the impact of sofosbuvir-based regimens on renal function in liver transplant recipients with recurrent hepatitis C virus and the role of renal function on the efficacy and safety of these regimens. MATERIALS AND METHODS In an expanded pan-Canadian cohort, 180 liver transplant recipients were treated with sofosbuvir-based regimens for hepatitis C virus recurrence from January 2014 to May 2015. Mean age was 58 ± 6.85 years, and 50% had F3/4 fibrosis. Patients were stratified into 4 groups based on baseline estimated glomerular filtration rate (calculated by the Modification of Diet in Renal Disease formula): < 30, 30 to 45, 46 to 60, and > 60 mL/min/173 m2. The primary outcome was posttreatment changes in renal function from baseline. Secondary outcomes included sustained virologic response at 12 weeks posttreatment and anemia-related and serious adverse events. RESULTS Posttreatment renal function was improved in most patients (58%). Renal function declined in 22% of patients, which was more marked in those with estimated glomerular filtration rate < 30 mL/min/173 m2, advanced cirrhosis (P = .05), and aggressive hepatitis C virus/fibrosing cholestatic hepatitis (P < .05). High rates (80%-88%) of sustained virologic response at 12 weeks posttreatment were seen across all renal function strata. Cirrhotic patients with glomerular filtration rates < 30 mL/min/173 m2 had sustained virologic response rates at 12 weeks posttreatment comparable to the overall patient group. Rates of anemia-related adverse events and transfusion requirements increased across decreasing estimated glomerular filtration rate groups, with notably more occurrences with ribavirin-based regimens. CONCLUSIONS Sofosbuvir-based regimens improved overall renal function in liver transplant recipients, with sustained virologic response, suggesting an association of subclinical hepatitis C virus-related renal disease. Sustained virologic response rates at 12 weeks posttreatment (80%-88%) were comparable regardless of baseline renal function but lower in cirrhosis.
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Affiliation(s)
- Nabiha Faisal
- From the Organ Transplant and Hepatobiliary Department, King Abdulaziz Medical City/National Guard Health Sciences, Riyadh, Saudi Arabia
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Affiliation(s)
- Stephen E Congly
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary Liver Unit, Calgary, Alberta, Canada
| | - Samuel S Lee
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary Liver Unit, Calgary, Alberta, Canada
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O'Neil CR, Congly SE, Rose MS, Lee SS, Borman MA, Charlton CL, Osiowy C, Swain MG, Burak KW, Coffin CS. Long-Term Follow-up and Quantitative Hepatitis B Surface Antigen Monitoring in North American Chronic HBV Carriers. Ann Hepatol 2018; 17:232-241. [PMID: 31097238 DOI: 10.5604/01.3001.0010.8640] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 04/10/2017] [Accepted: 07/03/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Quantitative hepatitis B surface antigen (qHBsAg) combined with HBV DNA may be useful for predicting chronic hepatitis B (CHB) activity and nucleoside analogue (NA) response. MATERIAL AND METHODS In this retrospective cohort study we evaluated qHBsAg levels according to CHB disease phase and among patients on treatment. Random effect logistic regression analysis was used to analyze qHBsAg change with time in the NA-treated cohort. RESULTS 545 CHB carriers [56% M, median age 48 y (IQR 38-59), 73% Asian] had qHBsAg testing. In the untreated group (44%), 8% were classified as immune tolerant, 10% immune clearance, 40% inactive, and 43% had HBeAg- CHB and the median HBsAg levels were 4.6 (IQR 3.4-4.9), 4.0 (IQR 3.4-4.5), 2.9 (IQR 1.4-3.8), and 3.2 log IU/mL (IQR 2.6-4.0), respectively; p < 0.001. In the NA-treated group (28% entecavir, 68% tenofovir, 4% lamivudine), no significant change in qHBsAg levels occured with time. However, 19% of patients on long-term NA had sustained qHBsAg < 2 log10 IU/mL. CONCLUSION qHBsAg titers were associated with CHB phase and remained stable in those on long-term NA. A significant number of treated patients had low-level qHBsAg, of which some may be eligible for treatment discontinuation without risk of flare.
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Affiliation(s)
- Conar R O'Neil
- Division of Infectious Disease, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada; Department of Internal Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Stephen E Congly
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - M Sarah Rose
- Research Facilitation, Alberta Health Services, Calgary, Alberta, Canada
| | - Samuel S Lee
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Meredith A Borman
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Carmen L Charlton
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada, Provincial Laboratory for Public Health, Edmonton, Alberta, Canada
| | - Carla Osiowy
- National Microbiology Laboratory, Winnipeg, Manitoba, Canada
| | - Mark G Swain
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Kelly W Burak
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Carla S Coffin
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada; Department of Microbiology, Immunology and Infectious Diseases, University of Calgary Cumming School of Medicine, Calgary, Canada.
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Chan Y, Maclennan S, Douglas L, Congly SE, Coffin CS, Dixon E, Wong J, Burak KW. A264 ADHERENCE TO ENHANCED POST-TREATMENT SURVEILLANCE IS ASSOCIATED WITH INCREASED DETECTION OF EARLY STAGE RECURRENCE AFTER RADIOFREQUENCY ABLATION BUT NOT SURGICAL MANAGEMENT OF HEPATOCELLULAR CARCINOMA. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy009.264] [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: 11/13/2022] Open
Affiliation(s)
- Y Chan
- University of Calgary, Calgary, AB, Canada
| | | | - L Douglas
- University of Calgary, Calgary, AB, Canada
| | - S E Congly
- University of Calgary, Calgary, AB, Canada
| | - C S Coffin
- University of Calgary, Calgary, AB, Canada
| | - E Dixon
- University of Calgary, Calgary, AB, Canada
| | - J Wong
- University of Calgary, Calgary, AB, Canada
| | - K W Burak
- University of Calgary, Calgary, AB, Canada
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Shaheen AA, Al-Mattooq M, Yazdanfar S, Burak KW, Swain MG, Congly SE, Borman MA, Lee SS, Myers RP, Coffin CS. Letter: lipid-lowering effect of tenofovir disoproxil fumarate in chronic hepatitis B-more evidence is needed. Authors' reply. Aliment Pharmacol Ther 2017; 46:770-771. [PMID: 28901569 DOI: 10.1111/apt.14282] [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: 12/08/2022]
Affiliation(s)
- A A Shaheen
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - M Al-Mattooq
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - S Yazdanfar
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - K W Burak
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - M G Swain
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - S E Congly
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - M A Borman
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - S S Lee
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - R P Myers
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - C S Coffin
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Shaheen AA, AlMattooq M, Yazdanfar S, Burak KW, Swain MG, Congly SE, Borman MA, Lee SS, Myers RP, Coffin CS. Tenofovir disoproxil fumarate significantly decreases serum lipoprotein levels compared with entecavir nucleos(t)ide analogue therapy in chronic hepatitis B carriers. Aliment Pharmacol Ther 2017; 46:599-604. [PMID: 28707319 DOI: 10.1111/apt.14218] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [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: 04/18/2017] [Revised: 05/25/2017] [Accepted: 06/20/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Tenofovir disoproxil fumarate (TDF) and entecavir (ETV) are first-line treatments for chronic hepatitis B (CHB). Studies suggest lipid lowering effect of TDF in human immunodeficiency virus positive (HIV+) individuals, but the effect on lipids and cardiovascular disease (CVD) risk in CHB is unknown. AIM To compare TDF vs ETV effects on lipid levels in CHB. METHODS In this retrospective cohort study, data on serum lipids and CVD risk factors at baseline and ~1 year on TDF or ETV were collected from CHB carriers. We used propensity score matched models to assess the effect on total cholesterol (TC), LDL-C, HDL and triglycerides (TGL). RESULTS In 348 patients, median age was 57 (IQR: 47-65 years), 63% were male, 77% were Asian, 19% were cirrhotic, 25% were HBeAg positive at baseline, and 72% received TDF vs 28% ETV. ETV-treated patients were older (median age: 60 vs 55, P<.01), had similar smoking and hypertension rates, but diabetes and dyslipidemia were more prevalent (19% vs 9%, P=.01; 14% vs 6%, P=.05, respectively). In propensity score matched models for age, gender, usage of lipid lowering agents, dyslipidemia and diabetes, TDF-treated patients were more likely to show a 20% decrease in TC (95% CI: 3%-25%), LDL-C (95% CI: 1%-25%) and HDL-C (CI: 10%-30%) levels compared with those on ETV. No change in TGL was observed in either group. CONCLUSIONS A greater decline in TC, LDL-C and HDL was observed in CHB carriers receiving TDF compared with ETV. These data may influence anti-viral choice in CHB carriers at risk for CVD.
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Affiliation(s)
- A A Shaheen
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - M AlMattooq
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - S Yazdanfar
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - K W Burak
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - M G Swain
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - S E Congly
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - M A Borman
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - S S Lee
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - R P Myers
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - C S Coffin
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Lau KCK, Shaheen AA, Aspinall AA, Ricento Ba T, Qureshi Mba K, Congly SE, Borman MA, Jayakumar S, Eksteen B, Lee SS, Stinton L, Swain MG, Burak KW, Coffin CS. Hepatitis B virus testing and linkage to care in a Canadian urban tertiary referral centre: a retrospective cohort study. CMAJ Open 2017; 5:E431-E436. [PMID: 28596186 PMCID: PMC5498308 DOI: 10.9778/cmajo.20170002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 12/21/2022] Open
Abstract
BACKGROUND Despite universal vaccination, chronic hepatitis B virus (HBV) infection remains a public health concern in North America owing to immigration. We aimed to characterize the number of people with a positive result of testing for HBV surface antigen (HBsAg) in Calgary, a large urban Canadian health care region, and to assess whether recommended laboratory tests and specialist consultation were done for those identified as HBsAg-positive. METHODS Based on laboratory and Alberta Health Services administrative data, we identified all adults (age > 18 yr) with a positive HBsAg test result from Jan. 1 to Dec. 31, 2014 within the Calgary Zone. Demographic and relevant laboratory data were extracted within 6 months of a positive HBsAg test result, and referral to hepatology (2011-2014) was identified from data on referral to a centralized clinic. Parametric and nonparametric statistical methods were used for analyses. RESULTS We identified 1214 HBsAg-positive people (584 women [48.1%]; median age 44 [interquartile range (IQR) 36-55] yr). A total of 1192 people (98.2%) had alanine aminotransferase testing (median level 23 [IQR 16-34] U/L; 117 [9.8%] with elevated levels), 682 (56.2%) had testing for HBV DNA (median level 2.8 [IQR 2.1-3.8] logIU/mL), 630 (51.9%) had HBV e antigen testing (negative result in 548 [87.0%]), and 145 (11.9%) had HBV e antibody testing (positive result in 111 [76.6%]). Overall, 144 people (11.9%) received anti-HBV treatment, and 390 (32.1%) were referred to a hepatologist. INTERPRETATION Many HBsAg-positive people in Calgary did not receive the recommended laboratory assessments. The results highlight the necessity of continual public health efforts to screen for chronic HBV infection in Canada and to ensure adequate follow-up in order to reach the World Health Organization's goal of viral hepatitis elimination by 2030.
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Affiliation(s)
- Keith C K Lau
- Affiliations: Calgary Liver Unit (Lau, Shaheen, Aspinall, Congly, Borman, Jayakumar, Eksteen, Lee, Stinton, Swain, Burak, Coffin), Division of Gastroenterology and Hepatology, Department of Medicine; Department of Microbiology, Immunology and Infectious Diseases (Lau, Coffin), Cumming School of Medicine, University of Calgary; Alberta Health Services (Ricento, Qureshi), Calgary, Alta
| | - Abdel Aziz Shaheen
- Affiliations: Calgary Liver Unit (Lau, Shaheen, Aspinall, Congly, Borman, Jayakumar, Eksteen, Lee, Stinton, Swain, Burak, Coffin), Division of Gastroenterology and Hepatology, Department of Medicine; Department of Microbiology, Immunology and Infectious Diseases (Lau, Coffin), Cumming School of Medicine, University of Calgary; Alberta Health Services (Ricento, Qureshi), Calgary, Alta
| | - Alexander A Aspinall
- Affiliations: Calgary Liver Unit (Lau, Shaheen, Aspinall, Congly, Borman, Jayakumar, Eksteen, Lee, Stinton, Swain, Burak, Coffin), Division of Gastroenterology and Hepatology, Department of Medicine; Department of Microbiology, Immunology and Infectious Diseases (Lau, Coffin), Cumming School of Medicine, University of Calgary; Alberta Health Services (Ricento, Qureshi), Calgary, Alta
| | - Tazuko Ricento Ba
- Affiliations: Calgary Liver Unit (Lau, Shaheen, Aspinall, Congly, Borman, Jayakumar, Eksteen, Lee, Stinton, Swain, Burak, Coffin), Division of Gastroenterology and Hepatology, Department of Medicine; Department of Microbiology, Immunology and Infectious Diseases (Lau, Coffin), Cumming School of Medicine, University of Calgary; Alberta Health Services (Ricento, Qureshi), Calgary, Alta
| | - Kamran Qureshi Mba
- Affiliations: Calgary Liver Unit (Lau, Shaheen, Aspinall, Congly, Borman, Jayakumar, Eksteen, Lee, Stinton, Swain, Burak, Coffin), Division of Gastroenterology and Hepatology, Department of Medicine; Department of Microbiology, Immunology and Infectious Diseases (Lau, Coffin), Cumming School of Medicine, University of Calgary; Alberta Health Services (Ricento, Qureshi), Calgary, Alta
| | - Stephen E Congly
- Affiliations: Calgary Liver Unit (Lau, Shaheen, Aspinall, Congly, Borman, Jayakumar, Eksteen, Lee, Stinton, Swain, Burak, Coffin), Division of Gastroenterology and Hepatology, Department of Medicine; Department of Microbiology, Immunology and Infectious Diseases (Lau, Coffin), Cumming School of Medicine, University of Calgary; Alberta Health Services (Ricento, Qureshi), Calgary, Alta
| | - Meredith A Borman
- Affiliations: Calgary Liver Unit (Lau, Shaheen, Aspinall, Congly, Borman, Jayakumar, Eksteen, Lee, Stinton, Swain, Burak, Coffin), Division of Gastroenterology and Hepatology, Department of Medicine; Department of Microbiology, Immunology and Infectious Diseases (Lau, Coffin), Cumming School of Medicine, University of Calgary; Alberta Health Services (Ricento, Qureshi), Calgary, Alta
| | - Saumya Jayakumar
- Affiliations: Calgary Liver Unit (Lau, Shaheen, Aspinall, Congly, Borman, Jayakumar, Eksteen, Lee, Stinton, Swain, Burak, Coffin), Division of Gastroenterology and Hepatology, Department of Medicine; Department of Microbiology, Immunology and Infectious Diseases (Lau, Coffin), Cumming School of Medicine, University of Calgary; Alberta Health Services (Ricento, Qureshi), Calgary, Alta
| | - Bertus Eksteen
- Affiliations: Calgary Liver Unit (Lau, Shaheen, Aspinall, Congly, Borman, Jayakumar, Eksteen, Lee, Stinton, Swain, Burak, Coffin), Division of Gastroenterology and Hepatology, Department of Medicine; Department of Microbiology, Immunology and Infectious Diseases (Lau, Coffin), Cumming School of Medicine, University of Calgary; Alberta Health Services (Ricento, Qureshi), Calgary, Alta
| | - Samuel S Lee
- Affiliations: Calgary Liver Unit (Lau, Shaheen, Aspinall, Congly, Borman, Jayakumar, Eksteen, Lee, Stinton, Swain, Burak, Coffin), Division of Gastroenterology and Hepatology, Department of Medicine; Department of Microbiology, Immunology and Infectious Diseases (Lau, Coffin), Cumming School of Medicine, University of Calgary; Alberta Health Services (Ricento, Qureshi), Calgary, Alta
| | - Laura Stinton
- Affiliations: Calgary Liver Unit (Lau, Shaheen, Aspinall, Congly, Borman, Jayakumar, Eksteen, Lee, Stinton, Swain, Burak, Coffin), Division of Gastroenterology and Hepatology, Department of Medicine; Department of Microbiology, Immunology and Infectious Diseases (Lau, Coffin), Cumming School of Medicine, University of Calgary; Alberta Health Services (Ricento, Qureshi), Calgary, Alta
| | - Mark G Swain
- Affiliations: Calgary Liver Unit (Lau, Shaheen, Aspinall, Congly, Borman, Jayakumar, Eksteen, Lee, Stinton, Swain, Burak, Coffin), Division of Gastroenterology and Hepatology, Department of Medicine; Department of Microbiology, Immunology and Infectious Diseases (Lau, Coffin), Cumming School of Medicine, University of Calgary; Alberta Health Services (Ricento, Qureshi), Calgary, Alta
| | - Kelly W Burak
- Affiliations: Calgary Liver Unit (Lau, Shaheen, Aspinall, Congly, Borman, Jayakumar, Eksteen, Lee, Stinton, Swain, Burak, Coffin), Division of Gastroenterology and Hepatology, Department of Medicine; Department of Microbiology, Immunology and Infectious Diseases (Lau, Coffin), Cumming School of Medicine, University of Calgary; Alberta Health Services (Ricento, Qureshi), Calgary, Alta
| | - Carla S Coffin
- Affiliations: Calgary Liver Unit (Lau, Shaheen, Aspinall, Congly, Borman, Jayakumar, Eksteen, Lee, Stinton, Swain, Burak, Coffin), Division of Gastroenterology and Hepatology, Department of Medicine; Department of Microbiology, Immunology and Infectious Diseases (Lau, Coffin), Cumming School of Medicine, University of Calgary; Alberta Health Services (Ricento, Qureshi), Calgary, Alta
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Samadi Kochaksaraei G, Congly SE, Matwiy T, Castillo E, Martin SR, Charlton CL, Coffin CS. Cost-effectiveness of quantitative hepatitis B virus surface antigen testing in pregnancy in predicting vertical transmission risk. Liver Int 2016; 36:1604-1610. [PMID: 27059287 DOI: 10.1111/liv.13139] [Citation(s) in RCA: 16] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 03/26/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Vertical transmission of hepatitis B virus (HBV) can occur despite immunoprophylaxis in mothers with high HBV DNA levels (>5-7 log10 IU/ml). Quantitative hepatitis B surface antigen (qHBsAg) testing could be used as a surrogate marker to identify high viral load carriers, but there is limited data in pregnancy. We conducted a prospective observational study to determine the cost-effectiveness and utility of qHBsAg as a valid surrogate marker of HBV DNA. METHODS Pregnant patients with chronic hepatitis B were recruited from a tertiary referral centre. HBV DNA levels and qHBsAg were assessed in the second to third trimester. Statistical analysis was performed by Spearman's rank correlation and student's t-test. The cost-effectiveness of qHBsAg as compared to HBV DNA testing was calculated. RESULTS Ninety nine women with 103 pregnancies, median age 32 years, 65% Asian, 23% African and 12% other [Hispanic, Caucasian] were enrolled. Overall, 23% (23/99) were HBV e Ag (HBeAg)-positive. A significant correlation between qHBsAg and HBV DNA levels was noted in HBeAg-positive patients (r = 0.79, P < 0.05) but not in HBeAg-negative patients (r = 0.17, P = 0.06). In receiver operating characteristic analysis, the optimal qHBsAg cut-off values for predicting maternal viraemia associated with immunoprophylaxis failure (i.e., HBV DNA ≥7 log10 IU/ml) was 4.3 log10 IU/ml (accuracy 98.7%, sensitivity 94.7%, specificity 94.4%) (95% CI, 97-100%, P < 0.05). Use of HBV DNA as compared to qHBsAg costs approximately $20 000 more per infection prevented. CONCLUSION In resource poor regions, qHBsAg could be used as a more cost-effective marker for high maternal viraemia, and indicate when anti-HBV nucleos/tide analogue therapy should be used to prevent HBV immunoprophylaxis failure.
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Affiliation(s)
| | - Stephen E Congly
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Trudy Matwiy
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eliana Castillo
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Steven R Martin
- Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Carmen L Charlton
- Provincial Laboratory for Public Health (ProvLab), University of Alberta Hospital, Edmonton, AB, Canada.,Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Carla S Coffin
- Department of Medicine, University of Calgary, Calgary, AB, Canada.
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Lynn AM, Singh S, Congly SE, Khemani D, Johnson DH, Wiesner RH, Kamath PS, Andrews JC, Leise MD. Embolization of portosystemic shunts for treatment of medically refractory hepatic encephalopathy. Liver Transpl 2016; 22:723-31. [PMID: 26970243 PMCID: PMC4917293 DOI: 10.1002/lt.24440] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [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: 11/17/2015] [Revised: 01/28/2016] [Accepted: 02/06/2016] [Indexed: 01/13/2023]
Abstract
Treatment options for refractory hepatic encephalopathy (HE) are limited. Patients who fail medical management may harbor large portosystemic shunts (PSSs) which are possible therapeutic targets. This study aims to describe patient selection, effectiveness, and safety of percutaneous PSS embolization in those with medically refractory HE. A retrospective evaluation of consecutive adult patients with medically refractory HE referred for PSS embolization at a tertiary center was performed (2003-2015). Patient data collected included the type of HE, medications, Model for End-Stage Liver Disease (MELD) score, shunt type, embolization approach, and materials used. Outcomes of interest were immediate (7 days), intermediate (1-4 months), and longer-term (6-12 months) effectiveness and periprocedural safety. Effectiveness was determined based on changes in hospitalization frequency, HE medications, and symptoms. Twenty-five patients with large PSS were evaluated for shunt embolization. Five were excluded due to high MELD scores (n = 1), comorbid conditions (n = 1), or technical considerations (n = 3). Of 20 patients who underwent embolization, 13 had persistent and 7 had recurrent HE; 100% (20/20) achieved immediate improvement. Durable benefit was achieved in 100% (18/18) and 92% (11/12) at 1-4 and 6-12 months, respectively. The majority (67%; 8/12) were free from HE-related hospitalizations over 1 year; 10% developed procedural complications, and all resolved. Six developed new or worsening ascites. In conclusion, PSS embolization is a safe and effective treatment strategy that should be considered for select patients with medically refractory HE. Liver Transplantation 22 723-731 2016 AASLD.
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Affiliation(s)
- Amanda M. Lynn
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Siddharth Singh
- Division of Gastroenterology, University of California, San Diego, La Jolla, CA
| | - Stephen E. Congly
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Disha Khemani
- Department of Gastroenterology and Hepatology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - David H. Johnson
- Department of Gastroenterology and Hepatology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Russell H. Wiesner
- Department of Gastroenterology and Hepatology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Patrick S. Kamath
- Department of Gastroenterology and Hepatology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - James C. Andrews
- Department of Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN
| | - Michael D. Leise
- Department of Gastroenterology and Hepatology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
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Congly SE, Lee SS. Editorial: can we afford the new direct-acting antivirals for treatment of genotype 1 hepatitis C? Aliment Pharmacol Ther 2014; 40:983-4. [PMID: 25229813 DOI: 10.1111/apt.12927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 07/29/2014] [Accepted: 07/30/2014] [Indexed: 12/13/2022]
Affiliation(s)
- S E Congly
- Liver Unit, Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, AB, Canada
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Congly SE, Leise MD. Rifaximin for episodic, overt hepatic encephalopathy: the data are catching up to clinical practice, but questions remain. Am J Gastroenterol 2014; 109:598. [PMID: 24698864 DOI: 10.1038/ajg.2013.480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 12/11/2022]
Affiliation(s)
- Stephen E Congly
- Liver Unit, Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Leise
- Department of Gastroenterology and Hepatology, Mayo Clinic and Foundation, Rochester, Minnesota, USA
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