Treatment journey of patients with hepatocellular carcinoma using real-world data in British Columbia, Canada

Aim

This study examined treatment patterns, survival outcomes and healthcare costs related to hepatocellular carcinoma (HCC) in British Columbia.

Methods

The study utilized data from two physician databases (HCC and MOTION) and the provincial British Columbia transplant database.

Results

The analysis revealed diverse treatment approaches and identified the varying treatment journeys of patients. Liver transplant and systemic therapies demonstrated improved survival rates. However, there was a scarcity of Canadian-specific cost data.

Conclusion

The research emphasizes the complexities of managing HCC and underscores the need for personalized treatment strategies to enhance patient outcomes. These findings contribute valuable insights into HCC management and provide a foundation for future studies and interventions aimed at optimizing care and resource allocation.

Exception points for liver transplantation: A Canadian review

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.

Comprehensive analysis (aerobic/anaerobic, molecular recognitions, band-position and degradation-mechanism) of undoped and Co-doped anatase-brookite - An experimental/theoretical evaluation of the less-studied TiO2 mixed phase

The molecular recognition (MRec) effect is required in the initial phase of organic reactions. The second stage involves molecular-orientations and molecular-orbitals energy-levels (MOrbE). The components of a reaction must be compatible in terms MRec and MOrbE. Therefore, the comprehension of photocatalytic systems applied in wastewater treatment will be improved if the MRec effect is also considered as an important factor. The purpose of this study is to provide a comprehensive understanding of the less studied anatase-brookite mixed-phase (doped and undoped). Anatase/brookite photocatalytic systems were evaluated utilizing experimental/theoretical approaches in H₂O (aerobic/anaerobic) environments with Vis-light and the organic pollutant (OrPo) methyl orange (MO). The compatibility of MRec and MOrbE of anatase-brookite mixed-phase (with the different reactive system components) confirmed this is the optimal combination for photocatalytic application. Using the sol-gel method, AM-TiO₂NP (amorphous), TiO₂NP (crystalline), and TiO₂NP-Co0.1 at% (crystalline Co-doped) anatase-brookite mixed-phase photocatalysts were obtained. The morphology and surface were characterized using XRD, BET, SEM, HR-TEM, FT-IR and XPS. Employing UV-vis DRS and PL, photo-response and electron-hole recombination were studied. LVS and Mott-Schottky plot were employed to determine photo-electrochemical activity. The results of TiO₂NP photocatalytic degradation in both aerobic and anaerobic environments are remarkable. The results of molecular dynamics (MD) simulation and Fukui Function (FF) based on density functional theory (DFT) validate the remarkable photocatalytic MO degradation.

A95 ASSESSMENT OF BIRTH COHORT SCREENING OF CHRONIC HEPATITIS C IN COLORECTAL CANCER SCREENING PATIENTS IN BRITISH COLUMBIA

Background

Birth cohort screening of chronic hepatitis C (CHC) is recommended in British Columbia since 2018 for baby boomers born between 1945 to 1964, with an estimated provincial prevalence of 2.31%. Though there remained a gap in care following anti-hepatitis C positivity, resulting in reflexive ribonucleic acid (RNA) testing provincially. Dual screening of CHC in patients referred to colorectal (CRC) screening programs can provide an opportunity to link patients with healthcare professionals to ensure appropriate follow-up.

Purpose

We aimed to assess the uptake of CHC screening amongst CRC screening patients after the release of British Columbia’s birth cohort guidelines, both pre and post-COVID-19 pandemic.

Method

A retrospective review of patients referred to a CRC screening program in Vancouver from October 1st to December 31st, 2019, and December 1st – 31st, 2021, was performed. Collected data included demographics, liver disease history, and co-infection rates with hepatitis B (HBV) or human immunodeficiency virus (HIV). Dates of first-time hepatitis C antibody, RNA and viral load testing were gathered. Descriptive statistics were used to identify the proportion of screening and prevalence of CHC.

Result(s)

A total of 553 patients were referred for colonoscopy to the CRC screening program, of whom 458 (82.8%) patients were born between 1945 to 1964, and 273 (n=49%) were female. Among the 250 (45.2%) patients screened for CHC, 4 (0.72%) had positive anti-hepatitis C, all of whom were baby boomers. In 2019, 44% (n=183) of patients were screened for CHC; 78.7% (n=144) were screened before colonoscopy referral. In 2020, 48.6% (n=67) of patients were screened for CHC; 100% of cases were screened before colonoscopy referral.

Conclusion(s)

Birth cohort screening of CHC is underutilized in British Columbia. Dual screening of CHC at the time of referral to CRC screening provides a practical approach to linking patients to healthcare.

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Disclosure of Interest

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COVID-19 infection immediately post-transplant in an unvaccinated patient: Clinical observations and ethical implications

We report the case of a 28-year-old woman who presented with acute liver failure from suspected drug-induced liver injury. She was not vaccinated against COVID-19 and expressed considerable reluctance to become vaccinated, prompting discussions within the transplant group regarding her candidacy. She received a liver transplant and acquired COVID-19 immediately post-operatively that was treated with sotrovimab. She recovered well and was discharged shortly following her transplant. This case suggests that unwillingness to receive COVID-19 vaccination pre-transplant should not represent an absolute contraindication to a life-saving liver transplantation.

Outcomes of liver transplant recipients with high MELD scores: an experience from a Canadian centre

BACKGROUND

The frequency with which patients with high Model for End-Stage Liver Disease (MELD) scores undergo liver transplantation has been increasing. Canadian literature regarding the outcomes of liver transplantation in recipients with high MELD scores is limited. The primary objective of this study was to assess patient and graft survival among recipients with high (> 35) and low (≤ 35) MELD scores. Secondary objectives were to potentially identify independent predictors of graft failure and patient mortality.

METHODS

We conducted a retrospective chart review of patients undergoing liver transplantation at a single Canadian centre from 2012 to 2017.

RESULTS

A total of 332 patients were included in the study: 280 patients had a MELD score of 35 or lower, and 52 had a MELD score above 35. Patients with high MELD scores had higher rates of pretransplant acute kidney injury and dialysis (p < 0.001), admission to the intensive care unit (ICU) or intubation (p < 0.001), intraoperative blood product transfusions (p < 0.001) and post-transplantation acute kidney injury and dialysis (p < 0.001), as well as longer ICU (p < 0.001) and hospital stays (p = 0.002). One- and 3-year patient survival in recipients with MELD scores of 35 or lower was 93.1% and 84.9% versus 85.0% and 80.0% in recipients with MELD scores above 35 (p = 0.37). One- and 3-year graft survival in recipients with MELD scores of 35 or lower was 91.7% and 90.9% versus 77.2% and 72.8% in recipients with MELD scores above 35 (p < 0.001). Prior liver transplant was an independent predictor of patient mortality, and no independent predictors of graft failure were identified. When MELD was replaced with D-MELD (donor age × recipient MELD), it predicted graft failure but not patient survival.

CONCLUSION

No difference in patient mortality was found between MELD groups. Graft survival was significantly lower in recipients with MELD scores above 35. D-MELD may potentially be used as an adjunct in determining risk of graft failure in recipients with high MELD scores.

Elevated serum ferritin in non-alcoholic fatty liver disease is not predictive of fibrosis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is common with widely ranging severity. Non-invasive risk scores for risk stratification are recommended but misclassify a significant proportion of patients. In situations where non-invasive risk scores do not provide guidance, referral is typically made to a Hepatologist for transient elastography or liver biopsy. Serum ferritin is elevated in many patients with NAFLD related to dysmetabolic and inflammatory hyperferritinemia. Ferritin is widely available and part of a standard workup for chronic liver disease.

METHODS

To explore the association of ferritin and risk of fibrosis in NAFLD, we reviewed patients diagnosed with NAFLD at the hepatology clinic of the Vancouver General Hospital between the years of 2015 and 2018. We collected data on 317 patients retrospectively assessing for a relationship between serum ferritin and elastography score.

RESULTS

Two hundred twenty-four patients were included in the final analysis. Median ferritin was 145 µg/L (IQR 62-311). Median liver stiffness was 5.2 kPa with 14.3% of patients having liver stiffness ≥8.7 kPa and 17.4% ≥ 8.0 kPa. ROC curve analysis using a liver stiffness ≥8.0 kPa as a cutoff for F2 fibrosis showed an AUROC of 0.54 for serum ferritin levels. At a cut-off of both 300 µg/L; and 450 µg/L median liver stiffness did not differ significantly in those with ferritin above the cutoff (ferritin ≥300 µg/L; p = 0.099, ferritin ≥450 µg/L; p = 0.12). Ferritin was significantly higher in male patients (198 versus 91 µg/L; p = 0.0001). There was a weak linear association between AST and ferritin levels.

CONCLUSION

In this cohort of 224 patients with NAFLD, serum ferritin was not predictive of significant liver fibrosis.

Non-alcoholic fatty liver disease (NAFLD) in Filipino North American patients: Results from a multi-ethnic cohort

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is more prevalent in certain ethnicities due to a combination of genetic, environmental, and metabolic factors. North American Filipino populations may have lifestyle and metabolic risk factors for NAFLD; however, the prevalence of NAFLD in this group is unknown. We sought to determine whether Filipino patients are over-represented in a multi-ethnic NAFLD cohort and describe their clinical presentation, primarily compared to other ethnicities in the same geographical region and secondarily compared to Manila-based Filipino patients.

METHODS

A cross-sectional study was conducted with patients with NAFLD who were followed at the Hepatology Clinic at Vancouver General Hospital, Canada, from January 2015 to August 2018. Data were extracted for clinicodemographic data, ethnicity, anthropometric measures, blood work, and transient elastography (TE). External comparison data was obtained online from the Metro Vancouver census and a NAFLD study conducted in Manila, Philippines.

RESULTS

Of 317 patients meeting inclusion criteria for the study, 224 patients had complete datasets. The mean age was 51.1 years, and 50% were female. There were 139 (62%) Caucasian and other ethnicity patients, 55 (25%) Asian patients, and 30 (13%) Filipino patients. Compared to other ethnic groups, the Filipino group had similar clinical characteristics, including NAFLD fibrosis scores and TE. Of included NAFLD patients, the proportion of Filipino patients (13.39%) was significantly greater than the proportion of Filipino residents in Metro Vancouver (5.52%, p <0.01). Our Filipino Canadians seemed to be younger, with fewer females and a lower proportion of diabetes mellitus, but a higher proportion of hypertension than the previously reported cohort from Manila.

CONCLUSIONS

While Filipino patients have not previously been examined in multi-ethnic NAFLD studies, they may represent a high-risk population. Further research is needed to clarify the prevalence and presentation of NAFLD in Filipino Canadian patients, as this appears to be a significant health issue in this community.

End stage liver disease etiology & transplantation referral outcomes of major ethnic groups in British Columbia, Canada: A cohort study

Liver disease etiology and transplantation outcomes may vary by ethnicity. We aimed to determine if disparities exist in our province.We reviewed the provincial database for liver transplant referrals. We stratified cohorts by ethnicity and analyzed disease etiology and outcomes.Four thousand nine hundred sixteen referrals included 220 South Asians, 413 Asians, 235 First Nations (Indigenous), and 2725 Caucasians. Predominant etiologies by ethnicity included alcohol (27.4%) and primary sclerosing cholangitis (PSC) (8.8%) in South Asians, hepatitis B (45.5%) and malignancy (13.9%) in Asians, primary biliary cholangitis (PBC) (33.2%) and autoimmune hepatitis (AIH) (10.8%) in First Nations, and hepatitis C (35.9%) in Caucasians. First Nations had lowest rate of transplantation (30.6%, P = .01) and highest rate of waitlist death (10.6%, P = .03). Median time from referral to transplantation (268 days) did not differ between ethnicities (P = .47). Likelihood of transplantation increased with lower body mass index (BMI) (hazard ratio [HR] 0.99, P = .03), higher model for end stage liver disease (MELD) (HR 1.02, P < .01), or fulminant liver failure (HR 9.47, P < .01). Median time from referral to ineligibility status was 170 days, and shorter time was associated with increased MELD (HR 1.01, P < .01), increased age (HR 1.01, P < .01), fulminant liver failure (HR 2.56, P < .01) or South Asian ethnicity (HR 2.54, P < .01). Competing risks analysis revealed no differences in time to transplant (P = .66) or time to ineligibility (P = .91) but confirmed increased waitlist death for First Nations (P = .04).We have noted emerging trends such as alcohol related liver disease and PSC in South Asians. First Nations have increased autoimmune liver disease, lower transplantation rates and higher waitlist deaths. These data have significance for designing ethnicity specific interventions.

Comparing the performance of Fibrosis-4 and Non-Alcoholic Fatty Liver Disease Fibrosis Score with transient elastography scores of people with non-alcoholic fatty liver disease

BACKGROUND: With the rate of non-alcoholic fatty liver disease (NAFLD) on the rise, the necessity of identifying patients at risk of cirrhosis and its complications is becoming ever more important. Liver biopsy remains the gold standard for assessing fibrosis, although costs, risks, and availability prohibit its widespread use with at-risk patients. Transient elastography has proven to be a non-invasive and accurate way of assessing fibrosis, although the availability of this modality is often limited in primary care settings. The Fibrosis-4 (FIB-4) and Non-Alcoholic Fatty Liver Disease Fibrosis Score (NFS) are scoring systems that incorporate commonly measured lab parameters and BMI to predict fibrosis. METHOD: In this study, we compared FIB-4 and NFS scores with transient elastography scores to assess the accuracy of these inexpensive and readily available scoring systems in detecting fibrosis. RESULTS: Using an NFS score cut-off of –1.455 and a FibroScan score cut-off of ≥8.7 kPa, the NFS score had a negative predictive value of 94.1%. Using a FibroScan score cut-off of ≥8.7 kPa, the FIB-4 score had a negative predictive value of 91.6%. CONCLUSION: The NFS and FIB-4 are non-invasive, inexpensive scoring systems that have high negative predictive value for fibrosis compared with transient elastography scores. These findings suggest that the NFS and FIB-4 can provide adequate reassurance to rule out fibrosis in patients with NAFLD and can be used with select patients to circumvent the need for transient elastography or liver biopsy.

Review article: comprehensive analysis of cirrhotic cardiomyopathy

BACKGROUND

Patients with cirrhosis are at risk of developing cirrhotic cardiomyopathy. This syndrome is unique to cirrhosis and is generally defined as subnormal cardiac function in the absence of prior heart disease. There is no systematic or comprehensive review of cirrhotic cardiomyopathy to date.

AIMS

To comprehensively review the literature on the definition, pathogenic mechanisms, diagnostic criteria, prevalence, management and influence on liver transplantation including reversibility of cirrhotic cardiomyopathy.

METHODS

Electronic searches of the EMBASE, MEDLINE, EBM Reviews-Cochrane Central Register of Controlled Trials, EBM Reviews-Cochrane Database of Systematic Reviews and Google Scholar databases were conducted. MeSH terms focused on cirrhosis, cardiomyopathy, medication classes and epidemiology. Literature up to August 2020 was reviewed.

RESULTS

New diagnostic criteria for the definition of cirrhotic cardiomyopathy have recently been published, consisting of systolic and diastolic dysfunction parameters as assessed by echocardiographic methods. The roles of electrocardiographic disturbances and biomarkers in the definition criteria remain unclear. Pathogenic mechanisms underlying cirrhotic cardiomyopathy are likely related to the inflammatory phenotype of cirrhosis. Prevalence rates of 26%-81% in cirrhotic patients are reported. Several medical therapies have been proposed, but none with clear evidence of efficacy. The presence of cirrhotic cardiomyopathy complicates the liver transplantation process with a higher risk of adverse cardiovascular events post-transplant. Complete reversibility of the syndrome after transplantation remains controversial but most studies suggest that it does not occur at least within the first post-operative year.

CONCLUSIONS

Cirrhotic cardiomyopathy is a clinically relevant syndrome that affects morbidity and mortality in patients with cirrhosis.

A208 PREDICTORS OF OUTCOMES IN PSC: RETROSPECTIVE ANALYSIS OF TWO TERTIARY CARE CENTERS IN BC

Background

Primary sclerosing cholangitis (PSC) is a chronic inflammatory disorder of the bile ducts. PSC can rapidly progress to cholangiocarcinoma and death. Many clinical features of PSC, as well as its relationship with diseases such as IBD, remain ill-defined. These features are important for disease modeling and clinical trial design.

Aims

To identify features of PSC that may aid in disease modeling and outcomes prediction.

Methods

Patients with a diagnosis of PSC with visits between 2012 and 2018 were identified and data were extracted. Survival analysis was performed, with time defined as time of PSC diagnosis to time at clinical endpoint. The clinical endpoint for survival analysis was defined as development of cholangiocarcinoma, liver transplantation or death. Univariate and multivariate Cox-regression was then performed.

Results

169 patients (99 male, 70 female) were identified. Of these, 102 (60.4%) had a diagnosis of IBD (84 UC). 138 were Caucasian, 9 East Asian, 9 South Asian and 13 Middle East. Mean age at PSC diagnosis was 39.3, IBD diagnosis 29.3 years. Mean time to next diagnosis in those with PSC-IBD was 7.7 years. Of those with PSC-IBD, IBD preceded the diagnosis of PSC in 69 (67.6%) patients. 22 (13.0%) had concurrent liver disease, including 14 AIH and 1 PBC overlap. In those with UC, disease was most often pancolitis (57.8%), with noticeable rate of backwash ileitis (23.3%). There were 26 patients with current or prior use of Infliximab, 14 with Humira, and 6 with Vedolizumab. 28 (16.6%) patients had a partial or total colectomy. 35 (20.7%) patients had diagnoses of cancer, including 16 cholangiocarcinoma, 2 gall bladder carcinoma, and 4 colorectal. 33 (19.5%) patients received liver transplant, and 31 (18.3%) died. Most frequent cause of death was cholangiocarcinoma (12, 38.7%). Univariate analysis identified increased age at PSC diagnosis, presence of IBD, increased age at IBD diagnosis, diagnosis of IBD prior to PSC, increased time from diagnosis of IBD to PSC, diagnosis of UC as opposed to Crohn’s, and lack of Infliximab use as significant predictors of our clinical endpoints (p&lt;0.05). Multivariate analysis only identified increased age at PSC diagnosis, presence of IBD, and diagnosis of IBD prior to PSC as predictors.

Conclusions

PSC affects persons of various ethnic backgrounds. Diagnosis of IBD appears to precede PSC in most PSC-IBD cases, and the temporal relationship may impact outcomes, possibly due to delayed diagnosis of PSC. UC has a worse disease course than Crohn’s. Cholangiocarcinoma still accounts for a large burden of overall death in PSC, and strategies for early diagnosis should be explored. More studies are required to delineate the relationship between biologic use and PSC outcomes. The major limitation of our study is the smaller sample size that may have limited statistical power.

Funding Agencies

NoneNone

Occult Hepatitis B Reactivation after Liver Transplant: The Role of a Novel Mutation in the Surface Antigen

Occult hepatitis B infection is characterized by loss of hepatitis B surface antigen (HBsAg) and persistence of low levels of hepatitis B virus (HBV) replication that may or may not be detectable in plasma/serum. We present a case of HBV reactivation in a male patient who underwent orthotopic liver transplant for hepatocellular carcinoma secondary to active hepatitis C (HCV) infection. Pre-transplant, he was HBsAg-negative and hepatitis B core antibody-positive, with an undetectable HBV viral load that was incidentally found to be positive at a very low HBV viral load on the day of transplant. Post-transplant, his HBsAg remained undetectable, with an undetectable HBV viral load, until eradication of his HCV infection with direct acting antiviral agents. After eradication of HCV, there was reactivation of HBV, with a high viral load and emergence of serum HBsAg. A deep sequencing genetic analysis of his HBV both pre- and post-transplant revealed the presence of a mutation in the "a" determinant of the HBV surface antigen. The role of HBV genotype 'a' determinant mutation in HBV reactivation post-transplant is unknown and needs further examination. Our experience suggests a possible role for antiviral prophylaxis in these patients or monitoring of HBV viral loads post-transplant.

Incidental alpha-1-antitrypsin deficiency found in post-transplant liver allografts: Report of two cases

Alpha-1 antitrypsin deficiency is an autosomal recessive disease most commonly caused by misfolding of the Alpha-1-antitrypsin protein, which prevents its release from hepatocytes into the systemic circulation. This results in increased lifetime risk of liver and lung disease. Due to its variable penetrance, presentation and natural history, patients with alpha-1 antitrypsin deficiency are often underdiagnosed. In this report, we present two cases of alpha-1 antitrypsin deficiency in deceased-donor liver transplant allografts diagnosed post-transplant. There is currently no known adverse outcome directly linked to alpha-1 antitrypsin deficiency in the immediate post-transplant follow-up period. Thus, these allografts should not be excluded from transplantation.

Biomarkers for hepatocellular cancer

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related deaths worldwide. If diagnosed early, curative treatment options such as surgical resection, loco-regional therapies, and liver transplantation are available to patients, increasing their chances of survival and improving their quality of life. Unfortunately, most patients are diagnosed with late stage HCC where only palliative treatment is available. Therefore, biomarkers which could detect HCC early with a high degree of sensitivity and specificity, may play a crucial role in the diagnosis and management of the disease. This review will aim to provide an overview of the different biomarkers of HCC comprising those used in the diagnosis of HCC in at risk populations, as well as others with potential for prognosis, risk predisposition and prediction of response to therapeutic intervention.

Ablative Transarterial Radioembolization Improves Survival in Patients with HCC and Portal Vein Tumor Thrombus

PURPOSE

Patients with hepatocellular carcinoma and portal vein tumor thrombus have a poor prognosis and limited therapeutic options. We sought to compare survival, tolerability, and safety in such patients treated with conventional yttrium-90 transarterial radioembolization dosimetric techniques or ablative transarterial radioembolization.

MATERIALS AND METHODS

This retrospective, single-center cohort study included patients with hepatocellular carcinoma and right, left, and/or main portal vein tumor thrombus, preserved liver function (Child-Pugh class ≤ B7), and good performance status (Eastern Cooperative Oncology Group score ≤ 1) treated with yttrium-90 microspheres from 2011 to 2018 with ablative intent transarterial radioembolization (A-TARE), or conventional technique (cTARE). Statistical models were used to compare overall survival, post-treatment survival, toxicities, and prognosticators of response.

RESULTS

Fifty-seven patients were included (21 [36.8%] ablative and 36 [63.2%] conventional intent). Median overall survival was 15.7 months. Compared to conventional treatment, ablative radioembolization was associated with longer median overall survival (45.3 vs 18.2 months; P = 0.003), longer post-treatment survival (19.1 vs 4.9 months; P = 0.005), a 70% lower risk of death (hazard ratio 0.30; 95% confidence interval, 0.13-0.70; P = 0.005), and improved 4-year survival (53.9% vs 11.2%). Overall survival did not differ significantly between treatment with resin and glass microspheres (27.5 vs 22.2 months; P = 0.62). Acceptable hepatic toxicities were observed after yttrium-90 administration, without statistical differences between the groups.

CONCLUSION

In patients with advanced hepatocellular carcinoma and portal vein tumor thrombus, A-TARE is associated with longer survival than cTARE. Neither modality is associated with deleterious effects on liver function.

HCC complicated by PVT: Outcome and the role of anticoagulation therapy

BACKGROUND

This retrospective study investigated the clinical impact of PVT on the course of patients with HCC who were and were not treated with anticoagulation (AC).

METHODS

We retrospectively evaluated a cohort of 60 patients diagnosed with HCC and PVT. Nine patients were excluded for lack of follow-up. HCC, PVT diagnosis, and imaging follow-up were performed using contrast-enhanced computed tomography or MRI. Of the 51 patients evaluated, 12 received AC and 39 did not.

RESULTS

Forty-two patients were male; mean age was 60.3 years. Mean survival after HCC diagnosis was 32.9 months; after PVT diagnosis, it was 18.4 months. No symptoms directly related to PVT development were reported. AC therapy was initiated for 12 patients and had to be discontinued for 3 patients because of complications. AC was not associated with a difference in PVT progression (49% in non-AC group vs. 50% in AC group). After adjusting for age, HCC type (single vs. multifocal), and Child-Pugh score, AC was associated with an improved survival after HCC diagnosis (adjusted hazard ratio [HR] = 0.37; 95% confidence interval [CI] 0.14 to 0.99) and after PVT diagnosis (HR = 0.34; 95% CI 0.13 to 0.88).

CONCLUSION

Patients with HCC complicated by PVT in both AC and non-AC groups had a similar rate of progression. Neither group had symptoms attributable to PVT. Possible AC-related complications need to be considered before proceeding with therapy in patients with HCC and PVT. AC may be associated with a survival advantage in patients with HCC and PVT.

Patients' Perspectives on Early Liver Transplantation in Alcohol-Related Liver Disease

Liver transplant programs in Canada require a period of 6 months of abstinence from alcohol before considering a patient with liver disease secondary to alcohol for transplantation. Although some studies have demonstrated good outcomes following a transplant in carefully selected patients before the 6‐month abstinence period has been met, there have been arguments against this, including the claim that the public has a general negative perception of those with alcohol dependence. We performed a multicenter cross‐sectional survey to determine the perception of people in British Columbia, Canada, toward liver transplantation in patients with liver disease due to alcohol who have not demonstrated the capacity to remain abstinent from alcohol for 6 months. A total of 304 patient questionnaires were completed, and 83.1% agreed with a period of abstinence of 6 months. In those patients who were unlikely to survive 6 months without a transplant, 34.1% of respondents agreed with, 44.1% did not agree with, and 21.4% were neutral about, early transplantation; 42.8% would have less trust in the process of transplantation if a period of abstinence was not maintained, but relaxing the requirement for an abstinence period would not have an impact on the majority's decision to donate organs. Only 30.5% would support abandoning the abstinence criteria. Conclusion: Among patients followed at general gastroenterology, medicine, or transplant clinics, there is a willingness to relax the criteria in selected patients unlikely to survive without a transplant, although a general consensus remains in support of the existing 6‐month alcohol abstinence rule. A larger scale survey of all provinces in Canada would be required to assess support for such a change in policy.

B-type peptides to predict post–liver transplant mortality: systematic review and meta-analysis

Background: Cirrhotic patients undergoing liver transplantation are at risk of cardiac complications. Brain natriuretic peptide (BNP) and amino terminal brain natriuretic peptide (NT-BNP) are used in cardiac risk stratification. Their significance in predicting mortality risk in cirrhotic patients during or after liver transplantation is unknown. We conducted a systematic review and meta-analysis to answer this question. Methods: An electronic search of EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews (2005–September 2016), Google Scholar, and study bibliographies was conducted. Study quality was determined, and demographic and outcome data were gathered. Random effects meta-analyses of mortality-based BNP and NT-BNP level or presence of post-transplant heart failure were conducted. Results: Seven studies including 2,010 patients were identified. Demographics were similar between patients with high or low BNP or NT-BNP levels. Hepatitis C was the most prevalent etiology of cirrhosis (38%). Meta-analysis revealed a pooled relative risk of 3.1 (95% CI 1.9% to 5.0%) for post-transplant mortality based on elevated BNP or NT-BNP level. Meta-analysis also revealed a pooled relative risk of 1.6 (95% CI 1.3% to 2.1%) for post-transplant mortality if patients had demonstrated post-transplant heart failure. Conclusions: Our analysis suggests that BNP or NT-BNP measurement may help in risk stratification and provides data on post-operative mortality in cirrhotic patients undergoing liver transplantation. Discriminatory thresholds are higher in cirrhotic patients relative to prior studies with non-cirrhotic patients. However, the number of analyzed studies is limited, and our findings should be validated further through larger, prospective studies.

In-hospital post-transplant acute hepatitis A viral (HAV) infection in a liver transplant recipient who was HAV seropositive pre-transplant

Acute hepatitis A viral (HAV) infection is rare in the liver transplant population due to recommended pre-transplant vaccinations. We report a case of acute hepatitis A infection in a liver transplant recipient. This individual had immunity to hepatitis A with protective IgG antibodies and presented with abnormal liver biochemistry in the post-transplant in-patient setting. Hepatitis A infection was confirmed by positive HAV IgM whereas other etiologies, including acute cellular rejection, were ruled out by laboratory tests and liver biopsies. He was treated conservatively with supportive care and liver enzymes recovered to normal baseline. Despite adequate pre-transplant immunity, in the post-transplant setting there may be loss of protective immunity due to profound immunosuppression and hence hepatitis A should remain an important differential diagnosis in the setting of acute hepatitis.

Assessing Maternity Care Providers' Knowledge of the Management of Hepatitis B in Pregnancy

OBJECTIVE

This study sought to evaluate maternity care providers' knowledge of the management of hepatitis B virus (HBV) in pregnancy.

METHODS

A total of 71 maternity care providers from obstetrics, family practice, and midwifery who were practicing at a tertiary women's hospital in Canada completed a survey assessing their demographics and knowledge of the management of HBV in pregnancy. Descriptive statistics were used to assess the survey responses.

RESULTS

Of 71 participants, 28% were obstetricians, 35% were family doctors, and 37% were midwives. Most participants (72%) had seen fewer than six pregnant patients with HBV in the last 2years. Correctly, 100% of participants indicated that all pregnant patients should be screened for HBV in pregnancy, and 99% indicated that infants should receive post-exposure prophylaxis. Incorrectly, 25.4% of participants indicated that pregnancy is a contraindication to HBV immunization, 90.1% indicated the recommended timeline for infant serological follow-up, and participants were largely divided on which investigations were needed for a pregnant patient with HBV. Only 23.9% of participants indicated the current recommended viral load for consideration of antiviral treatment in pregnancy.

CONCLUSION

Maternity care providers in our cohort had a strong understanding of the fundamentals of caring for pregnant patients with HBV. Continuing education should emphasize the safety of HBV vaccination in pregnancy, novel investigations in pregnancy, current evidence on the use of antivirals in pregnancy, and appropriate timelines for infant serological follow-up.

Colorectal Polyps in Childhood Cancer Survivors Treated with Radiation Therapy

BACKGROUND

Cancer survivors treated with abdominal or pelvic radiation therapy (RT) for childhood cancer have an increased risk of colorectal cancer. However, clinical guidelines are inconsistent on recommendations regarding the early initiation of screening in these patients due to the lack of supporting evidence that these patients pass through a pre-invasive phase, in which adenomatous polyps can be detected and removed.

AIMS

To determine the prevalence of adenomatous polyps in cancer survivors treated with RT for childhood cancer; the prevalence in average-risk patients aged 17-49; and the prevalence in average-risk patients aged 50-75.

METHODS

We conducted a retrospective study comparing the prevalence of adenomatous polyps among three patient groups: childhood cancer survivors aged 17-49 with prior RT who underwent colonoscopy screening from 2006 to 2017; age- and gender-matched patients in the average-risk population; and average-risk patients aged 50-75.

RESULTS

One hundred and forty-five patients were included in the study. The proportion of patients with adenomatous polyps in the cancer survivor group was significantly higher than that in the age- and gender-matched average-risk group (58.6 vs 17.2%, p = 0.00) and higher than the average-risk group aged 50-75 (58.6 vs 27.6%, p = 0.009). The prevalence of adenomas with high-risk features was higher in the survivor group compared to patients aged 50-75 (20.7 vs 3.5%, p = 0.015).

CONCLUSIONS

Cancer survivors treated with RT for childhood cancer have a higher prevalence of adenomatous polyps compared to the average-risk population. These findings support the early initiation of colonoscopy screening 10 years after radiation therapy, even in patients who have received RT doses below 30 Gy.

Effect of Treatment with Direct Acting Antiviral on Glycemic Control in Patients with Diabetes Mellitus and Chronic Hepatitis C

INTRODUCTION AND AIM

The effect of the new direct acting antiviral drugs (DAAs) for chronic hepatitis C (HCV) on glycemic control is unknown.

MATERIALS AND METHODS

We conducted a retrospective cohort study of patients who were treated for chronic HCV with direct-acting antiviral medications at a single academic institution between May 2013 and April 2016. Univariate analysis was performed comparing subjects pre- and post-treatment.

RESULTS

One hundred seventy-five consecutive adult patients were treated for chronic HCV and met enrollment criteria. The majority (80.8%) were genotype 1 and overall cohort sustained virologic response at week 12 (SVR12) was 97.8%. Thirty-one (18.5%) had diabetes mellitus (DM); twenty-six had pre- and post-treatment HbA1c values. Of these, 76.9% were male and 61.5% had cirrhosis. Ninety-six percent were prescribed sofosbuvir-based therapy and all but one (96.8%) achieved SVR12. Three patients were started on treatment despite meeting the definition for poorly controlled DM (HbA1c > 9 mg/dL). There was no significant difference when comparing pre-treatment (7.36 mg/dL, 95% CI 6.55-8.16) to post-treatment HbA1c (7.11 mg/dL, 95% CI 6.34-7.88, p = 0.268). Thirty-one percent of subjects required dose escalation or the initiation of insulin based therapy during treatment.

DISCUSSION

Although chronic HCV is associated with exacerbation of insulin resistance, our results showed HbA1c to be unaffected by eradication of chronic HCV with DAA in diabetic patients with and without cirrhosis. Paradoxically, almost 1/3 of patients required escalation of anti-diabetic therapy during treatment. Long-term studies are warranted to understand the relationship between HCV viral eradication and insulin metabolism.

Sensitivities of Biopsy Sites in the Endoscopic Evaluation of Graft-Versus-Host Disease: Retrospective Review from a Tertiary Center

BACKGROUND

Graft-versus-host disease (GVHD) is a complication of hematopoietic stem cell transplantation that frequently affects the gastrointestinal (GI) tract. The best biopsy sites to establish the diagnosis have not been clearly established.

AIMS

To determine the best sites for obtaining biopsies in evaluating GI GVHD.

METHODS

All cases of biopsy-proven GI GVHD (GVHD+) were isolated from a pathology database over a 2-year period at a single tertiary center (n = 46). Demographic, clinical, and endoscopic data were extracted. For comparison, 46 consecutive GVHD-negative cases (GVHD-) were obtained. Sensitivities in diagnosing GVHD in the upper and lower GI tract were calculated.

RESULTS

In the GVHD- group, they were commonly investigated with an esophagogastroduodenoscopy (EGD) (60 vs. 22 % in the GVHD+ group, p < 0.01), while a colonoscopy (CLN) was commonly performed in the GVHD+ group (33 vs. 12 %, p = 0.02). Among the GVHD + patients, for EGDs, the sensitivity was highest for duodenal biopsies at 89 %. For flexible sigmoidoscopies (FSs) and CLNs, the sensitivities among all sites were similar (85 % agreement, kappa 0.58, p = 0.01). There were no cases in which GVHD was diagnosed in the right side of the colon without a positive biopsy in the left side of the colon.

CONCLUSIONS

In this cohort of GI GVHD patients, duodenum biopsies produced the highest yield in diagnosing GVHD when compared to other sites of the upper GI tract. Sensitivities were similar among all sites on lower endoscopies, suggesting that a FS is sufficient for diagnosing GVHD in suspected patients with diarrhea.

Impact of cytolysis following transarterial chemoembolization for hepatocellular carcinoma

BACKGROUND AIMS

Transarterial chemoembolization (TACE) is increasingly used as a treatment of hepatocellular carcinoma. Cytolysis, which may occur within days following the procedure is due to either necrosis of the tumour or of the non-tumoral parenchyma. Therefore it may influence either tumour response or liver function or both. We evaluated the impact of cytolysis after TACE on tumour response, incidence of hepatobiliary complications and overall survival.

METHODS

We conducted a retrospective analysis of 157 patients with liver disease who underwent 271 treatments for hepatocellular carcinoma. Cytolysis was defined as an increase of AST value above 100 IU/L with at least doubling of the baseline value. The associations between cytolysis and radiologic tumor response two months following each treatment and adverse hepatobiliary events were estimated using generalized estimating equations models. Comparison of 18 months survival after a first treatment of chemoembolization between the groups with and without cytolysis was performed using the proportional hazards model.

RESULTS

Cytolysis occurred in 198 out of 271 cases and was associated with a favourable radiological response (OR 1.90, 1.03-3.54) at two months compared to non-cytolysis with no difference in the occurrence of adverse hepatobiliary events. The adjusted hazard ratio for overall survival was 1.33 times greater in the group with cytolysis compared to non-cytolysis (0.45-3.90).

CONCLUSIONS

The occurrence of cytolysis was associated with a favorable radiological response, but had no impact on short-term adverse events and on survival at 18 months.

Adolescents as victims of familial violence: a hospital based surveillance

Adolescent abuse is an important and understudied issue in society. The objective of this study was to examine the epidemiology of physical injuries due to maltreatment among adolescents aged 10-19 years. Subjects came from seven hospitals/trauma centres in Washington DC that were involved in the Washington DC Initiative to Reduce Infant Mortality and Prevention of Childhood Injuries Study. From 1996-1998, information was gathered about all injuries to adolescents aged 10-19 years that resulted in a visit to a participating emergency department. This paper focuses on the subset 178 adolescents aged 10-19 years who presented with physical injuries due to maltreatment. It was found that 55% of victims of abuse were female. Abuse victims were more likely to be female than those with unintentional injury. The most common injuries were contusions to the extremities (29%). Mothers were the most common perpetrators (48%). A total of 64% of victims were assaulted with an object/weapon and the most common object used was a belt. There are some similarities and some important differences between patterns of maltreatment in adolescents vs. younger children. Increased awareness of maltreatment among older children is a critical step in increasing and improving screening and prevention practices among health-care professionals.

Identification of intermediates and enzymes involved in the early steps of artemisinin biosynthesis in Artemisia annua

An important group of antimalarial drugs consists of the endoperoxide sesquiterpene lactone artemisinin and its derivatives. Only little is known about the biosynthesis of artemisinin in Artemisia annua L., particularly about the early enzymatic steps between amorpha-4,11-diene and dihydroartemisinic acid. Analyses of the terpenoids from A. annua leaves and gland secretory cells revealed the presence of the oxygenated amorpha-4,11-diene derivatives artemisinic alcohol, dihydroartemisinic alcohol, artemisinic aldehyde, dihydroartemisinic aldehyde and dihydroartemisinic acid. We also demonstrated the presence of a number of biosynthetic enzymes such as the amorpha-4,11-diene synthase and the--so far unknown--amorpha-4,11-diene hydroxylase as well as artemisinic alcohol and dihydroartemisinic aldehyde dehydrogenase activities in both leaves and glandular trichomes. From these results, we hypothesise that the early steps in artemisinin biosynthesis involve amorpha-4,11-diene hydroxylation to artemisinic alcohol, followed by oxidation to artemisinic aldehyde, reduction of the C11-C13 double bond to dihydroartemisinic aldehyde and oxidation to dihydroartemisinic acid.

Cyclopentenyl uracil: an effective inhibitor of uridine salvage in vivo

Cyclopentenyl uracil, a non-cytotoxic inhibitor of uridine kinase, was found to effectively block the salvage of circulating uridine by host and tumor tissues in the intact mouse. Dose-response characteristics of the inhibition were determined. Large doses (1 g/kg) of cyclopentenyl uracil were required, and the effect of a single dose fell rapidly over a 24-hr period. A sustained inhibition of uridine salvage of > 64-79% could be maintained by multiple doses of 1 g/kg given on an every 8-hr schedule. Mice given cyclopentenyl uracil (1 g/kg) every 8 hr for 5 days continued to gain weight and showed no signs of toxicity; however, the combination of cyclopentenyl uracil with a non-toxic dose of N-(phosphonacetyl)-L-aspartic acid (PALA; 200 mg/kg daily for 5 days) was lethal to mice, indicating that circulating uridine modifies the toxicity of agents that act on enzymes of the de novo pyrimidine pathway. Although the duration of action and potency of cyclopentenyl uracil are not ideal, this is the first demonstration of an effective inhibition of uridine salvage in the intact mouse with a non-cytotoxic agent. This makes possible the evaluation of concurrent inhibition of de novo and salvage routes to pyrimidine nucleotides as an approach to chemotherapy.

A simple method for the rapid determination of the stereospecificity of NAD-dependent dehydrogenases applied to mammalian IMP dehydrogenase and bacterial NADH peroxidase

The stereospecificity of IMP dehydrogenase (IMP:NAD+ oxidoreductase, EC 1.1.1.205) from two different sources was determined. The enzyme preparations were obtained from murine lymphoblasts and from Escherichia coli. Both enzymes transferred the 2-3H of IMP to the pro-S position of carbon atom C-4 of the nicotinamide ring in NAD. Thus, B-sided stereospecificity is common to the enzyme from two very different species. In addition, the studies described here demonstrate that alcohol dehydrogenase and NADH peroxidase, used as auxiliary enzymes, in combination with a microdistillation procedure, should permit rapid determination of the stereospecificity of any NAD-dependent dehydrogenase for which the appropriate tritiated substrate is available.