Third-generation cephalosporin-resistant spontaneous bacterial peritonitis: A single-centre experience and summary of existing studies

BACKGROUND:

Spontaneous bacterial peritonitis (SBP) is the most prevalent bacterial infection in patients with cirrhosis. Although studies from Europe have reported significant rates of resistance to third-generation cephalosporins, there are limited SBP-specific data from centres in North America.

OBJECTIVE:

To evaluate the prevalence of, predictors for and clinical impact of third-generation cephalosporin-resistant SBP at a Canadian tertiary care centre, and to summarize the data in the context of the existing literature.

METHODS:

SBP patients treated with both antibiotics and albumin therapy at a Canadian tertiary care hospital between 2003 and 2011 were retrospectively identified. Multivariate logistic regression was used to determine independent predictors of third-generation cephalosporin resistance and mortality.

RESULTS:

In 192 patients, 25% of infections were nosocomial. Forty per cent (77 of 192) of infections were culture positive; of these, 19% (15 of 77) were resistant to third-generation cephalosporins. The prevalence of cephalosporin resistance was 8% with community-acquired infections, 17% with health care-associated infections and 41% with nosocomial acquisition. Nosocomial acquisition of infection was the only predictor of resistance to third-generation cephalosporins (OR 4.0 [95% CI 1.04 to 15.2]). Thirty-day mortality censored for liver transplantation was 27% (50 of 184). In the 77 culture-positive patients, resistance to third-generation cephalosporins (OR 5.3 [1.3 to 22]) and the Model for End-stage Live Disease score (OR 1.14 [1.04 to 1.24]) were independent predictors of 30-day mortality.

CONCLUSIONS:

Third-generation cephalosporin-resistant SBP is a common diagnosis and has an effect on clinical outcomes. In an attempt to reduce the mortality associated with resistance to empirical therapy, high-risk subgroups should receive broader empirical antibiotic coverage.     

Predictors of a variceal source among patients presenting with upper gastrointestinal bleeding

BACKGROUND:

Patients with upper gastrointestinal bleeding (UGIB) require an early, tailored approach best guided by knowledge of the bleeding lesion, especially a variceal versus a nonvariceal source.

OBJECTIVE:

To identify, by investigating a large national registry, variables that would be predictive of a variceal origin of UGIB using clinical parameters before endoscopic evaluation.

METHODS:

A retrospective study was conducted in 21 Canadian hospitals during the period from January 2004 until the end of May 2005. Consecutive charts for hospitalized patients with a primary or secondary discharge diagnosis of UGIB were reviewed. Data regarding demographics, including historical, physical examination, initial laboratory investigations, endoscopic and pharmacological therapies administered, as well as clinical outcomes, were collected. Multivariable logistic regression modelling was performed to identify clinical predictors of a variceal source of bleeding.

RESULTS:

The patient population included 2020 patients (mean [± SD] age 66.3±16.4 years; 38.4% female). Overall, 215 (10.6%) were found to be bleeding from upper gastrointestinal varices. Among 26 patient characteristics, variables predicting a variceal source of bleeding included history of liver disease (OR 6.36 [95% CI 3.59 to 11.3]), excessive alcohol use (OR 2.28 [95% CI 1.37 to 3.77]), hematemesis (OR 2.65 [95% CI 1.61 to 4.36]), hematochezia (OR 3.02 [95% CI 1.46 to 6.22]) and stigmata of chronic liver disease (OR 2.49 [95% CI 1.46 to 4.25]). Patients treated with antithrombotic therapy were more likely to experience other causes of hemorrhage (OR 0.44 [95% CI 0.35 to 0.78]).

CONCLUSION:

Presenting historical and physical examination data, and initial laboratory tests carry significant predictive ability in discriminating variceal versus nonvariceal sources of bleeding.     

Noninvasive ventilation initiation in clinical practice: A six-year prospective, observational study

BACKGROUND:

Despite evidence supporting the role of noninvasive ventilation (NIV) in diverse populations, few publications describe how NIV is used in clinical practice.

OBJECTIVE:

To describe NIV initiation in a teaching hospital that has a guideline, and to characterize temporal changes in NIV initiation over time.

METHODS:

A prospective, observational study of continuous positive airway pressure ventilation (CPAP) or bilevel NIV initiation from January 2000 to December 2005 was conducted. Registered respiratory therapists completed a one-page data collection form at NIV initiation.

RESULTS:

Over a six-year period, NIV was initiated in 623 unique patients (531 bilevel NIV, 92 CPAP). Compared with bilevel NIV, CPAP was initiated more often using a nasal interface, with a machine owned by the patient, and for chronic conditions, especially obstructive sleep apnea. Whereas CPAP was frequently initiated and continued on the wards, bilevel NIV was most frequently initiated and continued in the emergency department, intensive care unit and the coronary care unit. Patients initiated on bilevel NIV were more likely to be female (OR 1.8, 95% CI 1.08 to 2.85; P=0.02) and to have an acute indication compared with CPAP initiations (OR 7.5, 95% CI 1.61 to 34.41; P=0.01). Bilevel NIV was initiated more often in the emergency department than in the intensive care unit (OR 5.8, 95% CI 0.89 to 38.17; P=0.07). Bilevel NIV initiation increased from 2000 to 2005.

CONCLUSIONS:

The present study illustrates how NIV is used in clinical practice and confirms that NIV initiation has increased over time.     

Prevalence of asthma and chronic obstructive pulmonary disease in Aboriginal and non-Aboriginal populations: A systematic review and meta-analysis of epidemiological studies

BACKGROUND:

Asthma and chronic obstructive pulmonary disease (COPD) have considerable potential for inequities in diagnosis and treatment, thereby affecting vulnerable groups.

OBJECTIVE:

To evaluate differences in asthma and COPD prevalence between adult Aboriginal and non-Aboriginal populations.

METHODS:

MEDLINE, EMBASE, specialized databases and the grey literature up to October 2011 were searched to identify epidemiological studies comparing asthma and COPD prevalence between Aboriginal and non-Aboriginal adult populations. Prevalence ORs (PORs) and 95% CIs were calculated in a random-effects meta-analysis.

RESULTS:

Of 132 studies, eight contained relevant data. Aboriginal populations included Native Americans, Canadian Aboriginals, Australian Aboriginals and New Zealand Maori. Overall, Aboriginals were more likely to report having asthma than non-Aboriginals (POR 1.41 [95% CI 1.23 to 1.60]), particularly among Canadian Aboriginals (POR 1.80 [95% CI 1.68 to 1.93]), Native Americans (POR 1.41 [95% CI 1.13 to 1.76]) and Maori (POR 1.64 [95% CI 1.40 to 1.91]). Australian Aboriginals were less likely to report asthma (POR 0.49 [95% CI 0.28 to 0.86]). Sex differences in asthma prevalence between Aboriginals and their non-Aboriginal counterparts were not identified. One study compared COPD prevalence between Native and non-Native Americans, with similar rates in both groups (POR 1.08 [95% CI 0.81 to 1.44]).

CONCLUSIONS:

Differences in asthma prevalence between Aboriginal and non-Aboriginal populations exist in a variety of countries. Studies comparing COPD prevalence between Aboriginal and non-Aboriginal populations are scarce. Further investigation is needed to identify and account for factors associated with respiratory health inequalities among Aboriginal peoples.     

Outcomes of chronic hepatitis C therapy in patients treated in community versus academic centres in Canada: final results of APPROACH (a prospective study of peginterferon alfa-2a and ribavirin at academic and community centres in Canada)

BACKGROUND:

In patients chronically infected with the hepatitis C virus (HCV), it is not established whether viral outcomes or health-related quality of life (HRQoL) differ between individuals treated at academic or community centres.

METHODS:

In the present observational study, adults with chronic HCV were treated with peginterferon alfa-2a 180 μg/week plus ribavirin at 45 Canadian centres (16 academic, 29 community). The primary efficacy end point was sustained virological response (SVR). Other outcome measures included HRQoL (assessed using the 36-item Short-Form Health Survey), heath resource use, and workplace productivity and absences within a 60-day interval.

RESULTS:

In treatment-naive patients infected with HCV genotype 1, significantly higher SVR rates were achieved in those treated at academic (n=54) compared with community (n=125) centres (52% versus 32% [P=0.01]), although rates of dosage reduction and treatment discontinuation were similar across settings. SVR rates among patients infected with genotype 2/3 were similar between academic (n=59) and community (n=100) centres (64% versus 67% [P=0.73]). Following antiviral therapy, patients with genotype 1 who achieved an SVR (n=67) had significantly higher mean scores on the physical (P=0.005) and mental components of the 36-item Short-Form Health Survey (P=0.043) compared with those without an SVR (n=111). In contrast, HRQoL scores were similar in HCV genotype 2/3 patients with and without an SVR. There were no differences in workplace productivity or absences between patients with and without an SVR. The most frequently used health care resources by all patients were visits and phone calls to hepatitis nurses, and general practice or walk-in clinics.

CONCLUSION:

Patients infected with HCV genotype 1 achieved higher SVR rates when treated at academic rather than community centres in Canada. The reasons for this difference require additional investigation.     

Hospital volume and other risk factors for in-hospital mortality among diverticulitis patients: A nationwide analysis

BACKGROUND:

Previous studies have found that a higher volume of colorectal surgery was associated with lower mortality rates. While diverticulitis is an increasingly common condition, the effect of hospital volume on outcomes among diverticulitis patients is unknown.

OBJECTIVE:

To evaluate the relationship between hospital volume and other factors on in-hospital mortality among patients admitted for diverticulitis.

METHODS:

Data from the Nationwide Inpatient Sample (years 1993 to 2008) were analyzed to identify 822,865 patients representing 4,108,726 admissions for diverticulitis. Hospitals were divided into quartiles based on the volume of diverticulitis cases admitted over the study period, adjusted for years contributed to the dataset. Mortality according to hospital volume was modelled using logistic regression adjusting for age, sex, race, comorbidities, health care insurance, admission type, calendar year, colectomy, disease severity and clustering. Risk estimates were expressed as adjusted ORs with 95% CIs.

RESULTS:

Patients at high-volume hospitals were more likely to be admitted emergently, undergo surgical treatment and have more severe disease. In-hospital mortality was higher among the lowest quartile of hospital volume compared with the highest volume (OR 1.13 [95% CI 1.05 to 1.21]). In-hospital mortality was increased among patients admitted emergently (OR 2.58 [95% CI 2.40 to 2.78]) as well as those receiving surgical treatment (OR 3.60 [95% CI 3.42 to 3.78]).

CONCLUSIONS:

Diverticulitis patients admitted to hospitals with a low volume of diverticulitis cases had an increased risk for death compared with those admitted to high-volume centres.     

Factors associated with the appropriate use of asthma drugs

BACKGROUND:

When used properly, asthma drugs can reduce asthma-related morbidity and mortality.

OBJECTIVE:

To assess the use of asthma drugs, and to identify factors associated with appropriateness of use among patients 12 to 45 years of age.

METHODS:

Asthmatic patients were interviewed about their asthma drug(s) use and the factors potentially associated with appropriateness of use according to the 2003 Canadian Asthma Consensus Conference guidelines. To determine the factors associated with the appropriate use of asthma drugs, a multivariate logistic regression model was built using a stepwise procedure, and ORs and associated 95% CIs were calculated.

RESULTS:

Of the 349 study participants, 43 (12.3%) reported appropriate use of their asthma drugs. Respondents who were more likely to report appropriate use were patients with sound knowledge of their asthma drugs (OR 2.61 [95% CI 1.29 to 5.29]), those in good, very good or excellent self-perceived health (OR 3.37 [95% CI 1.31 to 8.71]), those who had consulted a specialist during the preceding year (OR 2.28 [95% CI 1.05 to 4.97]) and those who declared themselves short of drugs due to a lack of money (OR 2.78 [95% CI 1.26 to 6.17]).

CONCLUSIONS:

Results of the present study suggested that recommendations in the current guidelines regarding the appropriate use of asthma medications are being poorly implemented. Educational interventions with the aim of improving quality of care and knowledge about asthma drugs should be offered.     

Adaptation to different noninvasive ventilation masks in critically ill patients

OBJECTIVE:

To identify which noninvasive ventilation (NIV) masks are most commonly used and the problems related to the adaptation to such masks in critically ill patients admitted to a hospital in the city of São Paulo, Brazil.

METHODS:

An observational study involving patients ≥ 18 years of age admitted to intensive care units and submitted to NIV. The reason for NIV use, type of mask, NIV regimen, adaptation to the mask, and reasons for non-adaptation to the mask were investigated.

RESULTS:

We evaluated 245 patients, with a median age of 82 years. Acute respiratory failure was the most common reason for NIV use (in 71.3%). Total face masks were the most commonly used (in 74.7%), followed by full face masks and near-total face masks (in 24.5% and 0.8%, respectively). Intermittent NIV was used in 82.4% of the patients. Adequate adaptation to the mask was found in 76% of the patients. Masks had to be replaced by another type of mask in 24% of the patients. Adequate adaptation to total face masks and full face masks was found in 75.5% and 80.0% of the patients, respectively. Non-adaptation occurred in the 2 patients using near-total facial masks. The most common reason for non-adaptation was the shape of the face, in 30.5% of the patients.

CONCLUSIONS:

In our sample, acute respiratory failure was the most common reason for NIV use, and total face masks were the most commonly used. The most common reason for non-adaptation to the mask was the shape of the face, which was resolved by changing the type of mask employed.     

Hepatitis C virus seroconversion among HIV-positive men who have sex with men with no history of injection drug use: Results from a clinical HIV cohort

BACKGROUND:

Internationally, there is a growing recognition that hepatitis C virus (HCV) may be sexually transmitted among HIV-positive men who have sex with men (MSM).

OBJECTIVE:

To report the first Canadian estimate of HCV seroincidence in 2000 to 2010 and its risk factors among HIV-positive MSM with no known history of injection drug use.

METHODS:

Data from the Ontario HIV Treatment Network Cohort Study, an ongoing cohort of individuals in HIV care in Ontario, were analyzed. Data were obtained from medical charts, interviews and record linkage with the provincial public health laboratories. The analysis was restricted to 1534 MSM who did not report injection drug use and had undergone ≥2 HCV antibody tests, of which the first was negative (median 6.1 person-years [PY] of follow-up; sum 9987 PY).

RESULTS:

In 2000 to 2010, 51 HCV seroconversions were observed, an overall incidence of 5.1 per 1000 PY (95% CI 3.9 to 6.7). Annual incidence varied from 1.6 to 8.9 per 1000 PY, with no statistical evidence of a temporal trend. Risk for seroconversion was elevated among men who had ever had syphilis (adjusted HR 2.5 [95% CI 1.1 to 5.5) and men who had acute syphilis infection in the previous 18 months (adjusted HR 2.8 [95% CI 1.0 to 7.9]). Risk was lower for men who had initiated antiretroviral treatment (adjusted HR 0.49 [95% CI 0.25 to 0.95]). There were no statistically significant effects of age, ethnicity, region, CD4 cell count or HIV viral load.

CONCLUSIONS:

These findings suggest that periodic HCV rescreening may be appropriate in Ontario among HIV-positive MSM. Future research should seek evidence whether syphilis is simply a marker for high-risk sexual behaviour or networks, or whether it potentiates sexual HCV transmission among individuals with HIV.     

The Prospective Antifungal Therapy Alliance? registry: A two-centre Canadian experience

BACKGROUND:

The Prospective Antifungal Therapy Alliance^® registry is a prospective surveillance study that collected data on the diagnosis, management and outcomes of invasive fungal infections (IFIs) from 25 centres in North America from 2004 to 2008.

OBJECTIVE:

To evaluate surveillance data on IFIs obtained from study centres located in Canada.

METHODS:

Patients with proven or probable IFIs at two Canadian medical centres were enrolled in the registry. Information regarding patient demographics, fungal species, infection sites, diagnosis techniques, therapy and survival were analyzed.

RESULTS:

A total of 347 patients from Canada with documented IFIs were enrolled in the Prospective Antifungal Therapy Alliance registry. Infections occurred most commonly in general medicine (71.8%), nontransplant surgery (32.6%) and patients with hematological malignancies (21.0%). There were 287 proven IFIs, including 248 Candida infections. Forty-six patients had invasive aspergillosis (IA); all of these were probable infections. Most cases of invasive candidiasis were confirmed using blood culture (90.5%), while IA was most frequently diagnosed using computed tomography scan (82.6%) and serological methods (82.6%). Fluconazole was the most common therapy used for Candida infections, followed by the echinocandins. Voriconazole therapy was most commonly prescribed for IA.

CONCLUSIONS:

The present study demonstrated that general medicine, surgery and hematological malignancy patients in Canada are susceptible to developing IFIs. In contrast to the United States, Candida albicans remains responsible for most IFIs in these Canadian centres. Surrogate serum markers are commonly being used for the diagnosis of IA, while therapy for both IFIs has shifted to broader-spectrum azoles and echinocandins.     

Antibiotic-resistant Escherichia coli in women with acute cystitis in Canada

BACKGROUND:

Trimethoprim-sulfamethoxazole (TMP-SMX) has been a traditional first-line antibiotic treatment for acute cystitis; however, guidelines do not recommend TMP-SMX in regions where Escherichia coli resistance exceeds 20%. While resistance is increasing, there are no recent Canadian estimates from a primary care setting to guide prescribing decisions.

METHODS:

A total of 330 family physicians assessed 752 women with suspected acute cystitis between 2009 and 2011. Physicians documented clinical features and collected urine for cultures for 430 (57.2%) women. The proportion of resistant isolates of E coli and exact binomial 95% CIs were estimated nationally, and compared regionally and demographically. These estimates were compared with those from a 2002 national study.

RESULTS:

The proportion of TMP-SMX-resistant E coli was 16.0% nationally (95% CI 11.3% to 21.8%). This was not statistically higher than 2002 (10.9% [P=0.14]). TMP-SMX resistance was increased in women ≤50 years of age (21.4%) compared with older women (10.7% [P=0.037]). In women with no antibiotic exposure in the previous three months, TMP-SMX-resistant E coli remained more prevalent in younger women (21.8%) compared with older women (4.4% [P=0.003]). The proportion of ciprofloxacin-resistant E coli was 5.5% nationally (95% CI 2.7% to 9.9%), and was increased compared with 2002 (1.1% [P=0.036]). Ciprofloxacin resistance was highest in British Columbia (17.7%) compared with other regions (2.7% [P=0.003]), and was increased compared with 2002 levels in this province (0.0% [P=0.025]). Nitrofurantoin-resistant E coli levels were low (0.5% [95% CI 0.01% to 2.7%).

DISCUSSION:

The proportion of TMP-SMX-resistant E coli causing acute cystitis in women in Canada remains below 20% nationally, but may exceed this level in premenopausal women. Ciprofloxacin resistance has increased, notably in British Columbia. Nitrofurantoin resistance levels are low across the country. These observations indicate that TMP-SMX and nitrofurantoin remain appropriate empirical antibiotic agents for treating cystitis in primary care settings in Canada.     

Use of fecal occult blood test in hospitalized patients: Survey of physicians practicing in a large central Canadian health region and Canadian gastroenterologists

BACKGROUND:

Although the fecal occult blood test (FOBT) was developed for colorectal cancer screening in the outpatient setting, it continues to be used among hospitalized patients. No previous study has evaluated the knowledge, beliefs and attitudes of practicing physicians on the use of FOBT among hospitalized patients and compared practices among physicians with different medical specialty training.

OBJECTIVE:

To survey physicians in the Winnipeg Regional Health Authority (WRHA) and Canadian gastroenterologists (GIs) on the use of FOBT in hospitals.

METHODS:

A survey was distributed by e-mail to internists (n=198), emergency medicine (EM) physicians (n=118), general surgeons (n=47) and family medicine (FM) physicians with admitting privileges (n=29) in the WRHA. Canadian GIs were surveyed through the membership database of the Canadian Association of Gastroenterology (CAG) (n=449). The survey included items regarding demographics of the respondents and their current use of FOBT in hospitals.

RESULTS:

Response rates ranged from 18% among CAG members to 69% among FM physicians in the WRHA. General internal medicine, general surgeon and GI respondents were less likely to order a FOBT and less likely to believe that an FOBT was useful in assessing emergency room or hospitalized patients when compared with FM and EM respondents (P<0.001). The most common indications for ordering a FOBT were black stools and anemia with and without iron deficiency. Two-thirds of EM physicians preferred point-of-care testing rather than laboratory reporting of FOBT.

CONCLUSIONS:

The present survey suggests that FOBTs are commonly used in hospitals by EM and FM physicians for indications such as anemia and black stools.     

Cost analysis of monitoring asthma treatment using sputum cell counts

BACKGROUND:

In a four-centre trial, the use of sputum cell counts (sputum strategy [SS]) to guide treatment had resulted in fewer and less severe exacerbations without the need for a higher corticosteroid dose, compared with the use of symptoms and spirometry (clinical strategy [CS]).

OBJECTIVE:

To compare the cost of the SS with the CS in the treatment of patients with moderate to severe asthma.

METHODS:

In 39 patients (19 in the SS, 20 in the CS) from one of the centres, the cost (third-party payer) of the two treatment strategies was compared. Resource use data were collected using a structured questionnaire. Corresponding unit costs in 2006 Canadian dollars were obtained.

RESULTS:

The clinical characteristics of the patients were similar to the study population at the four centres. In the SS, the number of visits to a family physician for health disorders indirectly related to asthma (P=0.003) and the amount of inhaled long-acting beta-agonists (P=0.007) were less than that of the CS. While the total estimated median cost per patient for spirometry ($393; range $299 to $487) was less than that for sputum induction ($1,008; range $907 to $1,411), the total cost of the SS ($2,265; range $1,466 to $4,347) was less than that of the CS ($3369; range $2208 to $3927) (P=0.216). This cost difference was due to lower costs of physician and hospital visits and services (P=0.078), of inhaled short-acting bronchodilators (P=0.067), of long-acting beta-agonists (P=0.002) and of inhaled corticosteroids (P=0.064) in the SS.

CONCLUSION:

In patients with moderate to severe asthma, the use of sputum cell counts to guide treatment is more effective and is likely to be less costly than management using symptoms and spirometry.     

Adherence to guidelines: A national audit of the management of acute upper gastrointestinal bleeding. The REASON registry

OBJECTIVES:

To assess process of care in nonvariceal upper gastrointestinal bleeding (NVUGIB) using a national cohort, and to identify predictors of adherence to ‘best practice’ standards.

METHODS:

Consecutive charts of patients hospitalized for acute upper gastrointestinal bleeding across 21 Canadian hospitals were reviewed. Data regarding initial presentation, endoscopic management and outcomes were collected. Results were compared with ‘best practice’ using established guidelines on NVUGIB. Adherence was quantified and independent predictors were evaluated using multivariable analysis.

RESULTS:

Overall, 2020 patients (89.4% NVUGIB, variceal in 10.6%) were included (mean [± SD] age 66.3±16.4 years; 38.4% female). Endoscopy was performed in 1612 patients: 1533 with NVUGIB had endoscopic lesions (63.1% ulcers; high-risk stigmata in 47.8%). Early endoscopy was performed in 65.6% and an assistant was present in 83.5%. Only 64.5% of patients with high-risk stigmata received endoscopic hemostasis; 9.8% of patients exhibiting low-risk stigmata also did. Intravenous proton pump inhibitor was administered after endoscopic hemostasis in 95.7%. Rebleeding and mortality rates were 10.5% and 9.4%, respectively. Multivariable analysis revealed that low American Society of Anesthesiologists score patients had fewer assistants present during endoscopy (OR 0.63 [95% CI 0.48 to 0.83), a hemoglobin level <70 g/L predicted inappropriate high-dose intravenous proton pump inhibitor use in patients with low-risk stigmata, and endoscopies performed during regular hours were associated with longer delays from presentation (OR 0.33 [95% CI 0.24 to 0.47]).

CONCLUSION:

There was variability between the process of care and ‘best practice’ in NVUGIB. Certain patient and situational characteristics may influence guideline adherence. Dissemination initiatives must identify and focus on such considerations to improve quality of care.     

Invasive cardiac procedure use and mortality among South Asian and Chinese Canadians with coronary artery disease

BACKGROUND:

Previous studies evaluated cardiac procedure use and outcome over the short term, with relatively few Asian patients included.

OBJECTIVES:

To determine the likelihood of undergoing percutaneous coronary intervention and coronary artery bypass grafting, and survival during 10.5 years of follow-up after coronary angiography among South Asian, Chinese and other Canadian patients.

METHODS:

Using prospective cohort study data from two large Canadian provinces, 3061 South Asian, 1473 Chinese and 77,314 other Canadian patients with angiographically proven coronary artery disease from 1995 to 2004 were assessed, and their revascularization and mortality rates during 10.5 years of follow-up were determined.

RESULTS:

Compared with other Canadian patients, South Asian and Chinese patients were slightly less likely to undergo revascularization (risk-adjusted HR 0.94, 95% CI 0.90 to 0.98 for South Asian patients; and HR 0.94, 95% CI 0.88 to 1.00 for Chinese patients). However, South Asian patients underwent coronary artery bypass grafting (HR 1.00, 95% CI 0.94 to 1.07) and Chinese patients underwent percutaneous coronary intervention (HR 0.96, 95% CI 0.89 to 1.04) as frequently as other Canadian patients. Although the 30-day mortality rate was similar across the three ethnic groups, the mortality rate in the follow-up period was significantly lower for South Asian patients (HR 0.76, 95% CI 0.61 to 0.95) and marginally lower for Chinese patients (HR 0.80, 95% CI 0.60 to 1.07) compared with other Canadian patients.

CONCLUSIONS:

South Asian and Chinese patients used revascularization slightly less but had better survival outcomes than other Canadian patients. The factors underlying the better outcomes for South Asian and Chinese patients warrant further study.     

Can the presence of endoscopic high-risk stigmata be predicted before endoscopy? A multivariable analysis using the RUGBE database

BACKGROUND:

Many aspects in the management of acute upper gastrointestinal bleeding rely on pre-esophagogastroduodenoscopy (EGD) stratification of patients likely to exhibit high-risk stigmata (HRS); however, data predicting the presence of HRS are lacking.

OBJECTIVE:

To determine clinical and laboratory predictors of HRS at the index EGD in patients presenting with acute upper gastrointestinal bleeding using retrospective data from a validated national database – the Canadian Registry in Upper Gastrointestinal Bleeding and Endoscopy registry.

METHODS:

Relevant clinical and laboratory parameters were evaluated. HRS was defined as spurting, oozing, nonbleeding visible vessel or adherent clot after vigorous irrigation. Multivariable modelling was used to identify predictors of HRS including age, sex, hematemesis, use of antiplatelet agents, American Society of Anesthesiologists (ASA) classification, nasogastric tube aspirate, hemoglobin level and elapsed time from the onset of bleeding to EGD.

RESULTS:

Of the 1677 patients (mean [± SD] age 66.2±16.8 years; 38.3% female), 28.7% had hematemesis, 57.8% had an ASA score of 3 to 5, and the mean hemoglobin level was 96.8±27.3 g/L. The mean time from presentation to endoscopy was 22.2±37.5 h. The best fitting multivariable model included the following significant predictors: ASA score 3 to 5 (OR 2.16 [95% CI 1.71 to 2.74]), a shorter time to endoscopy (OR 0.99 [95% CI 0.98 to 0.99]) and a lower initial hemoglobin level (OR 0.99 [95% CI 0.99 to 0.99]).

CONCLUSION:

A higher ASA score, a shorter time to endoscopy and lower initial hemoglobin level all significantly predicted the presence of endoscopic HRS. These criteria could be used to improve the optimal selection of patients requiring more urgent endoscopy.     

Minimising cold ischaemic time is essential in cardiac death donor-associated liver transplantation

Background

An important issue in the transplantation of livers procured from cardiac death donors (CDDs) concerns why some centres report equivalent outcomes and others report inferior outcomes in transplantations using CDD organs compared with standard criteria donor (SCD) organs. Resolving this discrepancy may increase the number of usable organs.

Objectives

This study aimed to test whether differences in cold ischaemic time (CIT) are critical during CDD organ transplantation and whether such differences might explain the disparate outcomes.

Methods

Results of CDD liver transplants in our own centre were compared retrospectively with results in a matched cohort of SCD liver recipients. Endpoints of primary non-function (PNF) and ischaemic cholangiopathy (IC) were used because these outcomes are clearly associated with CDD organ use.

Results

In 22 CDD organ transplants, CIT was a strong predictor of PNF or IC (P = 0.021). Minimising CIT in CDD organ transplants produced outcomes similar to those in a matched SCD organ transplant cohort at our centre and in SCD organ transplant results nationally (1- and 3-year graft and patient survival rates: 90.9% and 73.3% vs. 77.6% and 69.2% in CDD and SCD grafts, respectively. A review of the published literature demonstrated that centres with higher CITs tend to have higher rates of PNF or IC (correlation coefficient: 0.41).

Conclusions

These findings suggest that a targeted effort to minimise CIT might improve outcomes and allow the safer use of CDD organs.     

Surgical management of hepatic hemangiomas: a multi-institutional experience

Background

The management of hepatic hemangiomas remains ill defined. This study sought to investigate the indications, surgical management and outcomes of patients who underwent a resection for hepatic hemangiomas.

Methods

A retrospective review from six major liver centres in the United States identifying patients who underwent surgery for hepatic hemangiomas was performed. Clinico-pathological, treatment and peri-operative data were evaluated.

Results

Of the 241patients who underwent a resection, the median age was 46 years [interquartile range (IQR): 39–53] and 85.5% were female. The median hemangioma size was 8.5 cm (IQR: 6–12.1). Surgery was performed for abdominal symptoms (85%), increasing hemangioma size (11.3%) and patient anxiety (3.7%). Life-threatening complications necessitating a hemangioma resection occurred in three patients (1.2%). Clavien Grade 3 or higher complications occurred in 14 patients (5.7%). The 30- and 90-day mortality was 0.8% (n = 2). Of patients with abdominal symptoms, 63.2% reported improvement of symptoms post-operatively.

Conclusion

A hemangioma resection can be safely performed at high-volume institutions. The primary indication for surgery remains for intractable symptoms. The development of severe complications associated with non-operative management remains a rare event, ultimately challenging the necessity of additional surgical indications for a hemangioma resection.     

Temporal trends in liver transplant centre volume in the USA

Background:

Although prior studies have suggested an inverse association between liver transplant centre volume and postoperative patient mortality, more recent analyses have failed to confirm this association. To date, all studies of the relationship between centre volume and outcomes in liver transplantation have been cross-sectional in design.

Objective:

The objective of our study was to examine temporal trends in the volume–outcomes relationship for liver transplantation.

Methods:

We used information obtained from the Scientific Registry of Transplant Recipients (SRTR) programme-specific data reports to examine the outcomes of adult liver transplant recipients stratified by annual centre volume. This relationship between centre volume and patient outcomes was assessed over three consecutive time periods from 2000 through 2007.

Results:

The overall 25% increase in adult liver transplant volume in the USA from 2000 to 2007 appeared to be distributed fairly equally among existing transplant centres. In the earliest time period of our analysis, high-volume centres achieved superior risk-adjusted 1-year patient outcomes compared with low-volume centres. By the third and most recent time period of the analysis, this discrepancy between the outcomes of high- and low-volume centres was no longer statistically apparent.

Conclusions:

The relationship between centre volume and patient outcomes for liver transplantation in the USA has become less pronounced over time, suggesting that the use of procedure volume as a marker of liver transplant centre quality cannot be justified. The performance-based review process currently utilized in the USA may have contributed to this diminishing influence of centre volume on liver transplant recipient outcomes. This type of review process should be considered as a potential alternative to the volume-based referral initiatives that have been developed for other non-transplant, complex surgical procedures.