Acute esophageal variceal bleeding (EVB) is a major cause of morbidity and mortality in patients with liver cirrhosis. Guidelines have been published in 1997; however, variability in the acute management and prevention of EVB rebleeding may occur.
Gastroenterologists in the provinces of British Columbia, Alberta, Manitoba and Saskatchewan were sent a self-reporting questionnaire.
The response rate was 70.4% (86 of 122). Intravenous octreotide was recommended by 93% for EVB patients but the duration was variable. The preferred timing for endoscopy in suspected acute EVB was within 12 h in 75.6% of respondents and within 24 h in 24.6% of respondents. Most (52.3%) gastroenterologists do not routinely use antibiotic prophylaxis in acute EVB patients. The preferred duration of antibiotic therapy was less than three days (35.7%), three to seven days (44.6%), seven to 10 days (10.7%) and throughout hospitalization (8.9%). Methods of secondary prophylaxis included repeat endoscopic therapy (93%) and beta-blocker therapy (84.9%). Most gastroenterologists (80.2%) routinely attempted to titrate beta-blockers to a heart rate of 55 beats/min or a 25% reduction from baseline. The most common form of secondary prophylaxis was a combination of endoscopic and pharmacological therapy (70.9%).
Variability exists in some areas of EVB treatment, especially in areas for which evidence was lacking at the time of the last guideline publication. Gastroenterologists varied in the use of prophylactic antibiotics for acute EVB. More gastroenterologists used combination secondary prophylaxis in the form of band ligation eradication and beta-blocker therapy rather than either treatment alone. Future guidelines may be needed to address these practice differences.
The epidemiology of primary sclerosing cholangitis (PSC) has been incompletely assessed by population-based studies. We therefore conducted a population-based study to determine: (a) incidence rates of large and small duct PSC in adults and children, (b) the risk of inflammatory bowel disease on developing PSC, and (c) patterns of clinical presentation with the advent of magnetic resonance cholangiopancreatography (MRCP).
All residents of the Calgary Health Region diagnosed with PSC between 2000 and 2005 were identified by medical records, endoscopic, diagnostic imaging, and pathology databases. Demographic and clinical information were obtained. Incidence rates were determined and risks associated with PSC were reported as rate ratios (RR) with 95% confidence intervals (CI).
Forty-nine PSC patients were identified for an age- and gender-adjusted annual incidence rate of 0.92 cases per 100,000 person-years. The incidence of small duct PSC was 0.15/100,000. In children the incidence rate was 0.23/100,000 compared with 1.11/100,000 in adults. PSC risk was similar in Crohn's disease (CD; RR 220.0, 95% CI 132.4-343.7) and ulcerative colitis (UC; RR 212.4, 95% CI 116.1-356.5). Autoimmune hepatitis overlap was noted in 10% of cases. MRCP diagnosed large duct PSC in one-third of cases. Delay in diagnosis was common (median 8.4 months). A minority had complications at diagnosis: cholangitis (6.1%), pancreatitis (4.1%), and cirrhosis (4.1%).
Pediatric cases and small duct PSC are less common than adult large duct PSC. Surprisingly, the risk of developing PSC in UC and CD was similar. Autoimmune hepatitis overlap was noted in a significant minority of cases.
To characterize the socioeconomic and health status, disease symptoms of anti-HCV-positive and negative transfusion recipients.
A cross-sectional interviewer-administered survey of subjects identified through the British Columbia Blood Recipient Program. Study subjects were 18 years and over and had to have had a transfusion between August 1, 1986 and June 30, 1990 and completed an interview of satisfactory quality. Anti-HCV-positive subjects were those seeking monetary compensation from the provincial and Canadian governments and the comparison group was randomly selected from a pool of anti-HCV-negative subjects. The study was designed to detect an assumed difference of 20% in signs and symptoms between the two groups. Statistical comparisons were conducted using bivariate and multivariate logistic regression analyses.
A total of 241 and 222 anti-HCV-positive and negative subjects were respectively interviewed and met the study's eligibility criteria. Results from the multivariate analysis indicated that anti-HCV-positive recipients were more likely to have two or more clinical symptoms (OR = 3.53; 95% CI: 1.44, 8.70), to be in worse health status as compared to ten years previous (OR = 1.60; 95% CI: 1.30, 1.96), to have a higher illness intrusiveness rating (OR = 1.35; 95% CI: 1.25, 1.46), and to be younger (OR = 0.97; 95% CI: 0.95, 0.98).
Our results show that persons exposed to HCV were more likely to have had two or more clinical symptoms, be male, have worse health status as compared to ten years previous, have a higher illness intrusiveness rating, and be younger in age.
We examined birth cohort and calendar period trends in hepatocellular carcinoma (HCC) incidence in Canada (1976-2000). We also projected HCC incidence rates through 2015.
Data were obtained from the Canadian Cancer Registry on all cases of HCC diagnosed among persons aged 20 years and older in Canada from 1976 to 2000 and was used to describe trends in HCC incidence rates.
We found that age-adjusted HCC incidence rates increased faster in males compared with females, 3.4% per year [95% confidence interval (CI): 3.0-3.8%] vs 2.2% per year (95% CI: 1.5-2.8%). An increasing birth cohort trend accelerated among males around the 1940 birth cohort and decelerated among females around the 1935 birth cohort. For calendar period trends, the increasing HCC risk was relatively constant over time among males whereas there was an acceleration in HCC risk around 1988 among females. Age-adjusted HCC incidence rates were projected to increase 73% in males and 28% in females from 1996 to 2015.
Our results suggest that HCC incidence rates will continue to increase in Canada during the next decade as persons born in more recent birth cohorts, who face a relatively greater risk for HCC, age.
Surveys originating from universities appear to have higher response rates than those from commercial sources. In light of the growing scrutiny placed on physician-industry relations, the present study aimed to determine the impact of the pharmaceutical industry versus university sponsorship on response to a postal survey completed by Canadian hepatitis C virus (HCV) care providers.
In the present controlled trial, 229 physicians and nurses involved in HCV treatment were randomly assigned to receive a survey with sponsorship from a pharmaceutical company or university. The primary outcome was the proportion of completed surveys returned. The secondary outcomes included the response rate after the first mailing and the number of days taken to respond.
One hundred fifteen participants were randomly assigned to receive the pharmaceutical industry survey and 114 were assigned to receive the university survey. The final response rate was 72.9% (167 of 229), which did not differ between the industry and university groups (RR=0.91; 95% CI 0.78 to 1.07). Nurses (OR=2.20; 95% CI 1.08 to 4.48) and participants from an academic centre (OR=3.14; 95% CI 1.64 to 6.00) were more likely to respond. The response rate after the first mailing (RR=0.85; 95% CI 0.68 to 1.07) and the median number of days taken to respond (21 days in both groups; P=0.20) did not differ between the industry and university groups.
Pharmaceutical industry sponsorship does not appear to negatively impact response rates to a postal survey completed by Canadian HCV care providers.
Cites: Fam Pract. 2002 Feb;19(1):105-1111818359
Cites: Can J Gastroenterol. 2006 Apr;20(4):281-416609758
Cites: Can J Gastroenterol. 2002 Feb;16(2):87-9311875592
Cites: BMJ. 2002 May 18;324(7347):118312016181
Cites: Can J Gastroenterol. 2002 Jun;16(6):369-7412096300
Cites: Ann Intern Med. 2002 Sep 17;137(6):511-2012230353
Cites: Can J Gastroenterol. 2002 Nov;16(11):801-512464974
Cites: Can J Gastroenterol. 2003 Jan;17(1):25-912560851
Cites: Can J Gastroenterol. 2003 Mar;17(3):183-612677268
Cites: Can J Gastroenterol. 2003 May;17(5):313-712772005
Cites: N Engl J Med. 2004 Oct 28;351(18):1891-90015509824
Cites: BMJ. 1997 Nov 1;315(7116):11369374887
Cites: Can J Gastroenterol. 2005 Sep;19(9):553-816151547
Conventional treatment of autoimmune hepatitis consists of either prednisone alone or in combination with azathioprine. Ten to 20% of patients do not respond to or are intolerant of this treatment. Novel drug treatments include immunosuppressive drugs such as tacrolimus (TAC), mycophenolate mofetil (MMF), methotrexate and cyclosporine. We describe a multi-centre Canadian experience with MMF and TAC.
To study a multi-centre patient population who had failed conventional therapy and were treated with non-conventional medical therapy for autoimmune hepatitis and document response.
Members of the Canadian Association for the Study of Liver (CASL) obtained MMF from Hoffmann-La Roche Ltd, as part of a compassionate release program, were contacted for standardized data on patients with AIH who received MMF or TAC. Response definitions based on aminotransferase changes were: Complete response (CR)-sustained normalization, partial response (PR)-improvement by greater than 50%, non-response (NR)-less than 50% improvement and relapse (RP)-initial CR or PR followed by an increase in aminotransferases.
A total of 16 patients were identified: six in Ontario, one in Quebec, five in Alberta and four in British Columbia. Three were treated with TAC, eleven with MMF and two with combination MMF and TAC. CR was observed in 50%, PR in 12.5%, RP in 25% and NR occurred in 12.5%. The CR for MMF without TAC was approximately 64%.
MMF is effective and well tolerated by patients with autoimmune hepatitis who do not respond to, or are intolerant of, conventional immunosuppressive agents.