Eduardo B. da Silveira

The Stretta procedure versus proton pump inhibitors and laparoscopic Nissen fundoplication in the management of gastroesophageal reflux disease: A cost-effectiveness analysis

BACKGROUND The Stretta procedure is an endoscopic therapy for gastroesophageal reflux disease. OBJECTIVE To evaluate the cost-effectiveness of the Stretta procedure and that of competing strategies in the long-term management of gastroesophageal reflux disease. METHODS A Markov model was designed to estimate costs and health outcomes in Canadian patients with gastroesophageal reflux disease over five years, from a Ministry of Health perspective. Strategies included the use of daily proton pump inhibitors (PPIs), laparoscopic Nissen fundoplication (LNF) and the Stretta procedure. Probabilities and utilities were derived from the literature. Costs are expressed in 2006 Canadian dollars. Units of effectiveness were symptom-free months (SFMs) and quality-adjusted life years (QALYs), using a five-year time horizon. RESULTS In the analysis that used SFMs, the strategy using PPIs exhibited the lowest costs (

Mutations in HBV DNA Polymerase Associated With Nucleos(t)ide Resistance Are Rare in Treatment-naive Patients

40 per SFM) and the greatest number of SFMs, thus dominating both the LNF and Stretta systems. But the cost-effectiveness analysis using QALYs as the measure of effectiveness showed that PPIs presented the lowest cost-effectiveness ratio, while both the LNF and Stretta strategies were associated with very high incremental costs (approximately

High proportion of hepatitis C virus in community Asian American patients with non-liver-related complaints.

353,000 and

Self-Expanding Metal Stents Confer a Survival Advantage in the Palliation of Distal Malignant Biliary Obstruction

393,000, respectively) to achieve an additional QALY. However, the PPI strategy did not dominate the two other strategies, which were associated with better effectiveness. CONCLUSIONS If SFMs are used as the measure of effectiveness, PPIs dominate the Stretta and LNF strategies. However, if QALYs are used, the PPIs still present the lowest cost and LNF gives the best effectiveness. Regardless of the units of effectiveness or utility used in the present cost analysis, an approach of prescribing PPIs appears to be the preferred strategy.

Antibiotic prophylaxis in acute necrotizing pancreatitis

BACKGROUND & AIMS Prior studies have detected hepatitis B virus (HBV) DNA polymerase mutations in treatment-naive patients. However, most of these studies used either direct polymerase chain reaction sequencing, which detects these mutations with low levels of sensitivity, or patient cohorts that were not well-characterized. We investigated the prevalence of HBV mutations in DNA polymerase by using a line probe assay. METHODS In a prospective, cross-sectional study, we enrolled 198 treatment-naive patients with chronic hepatitis B (52.5% male; mean age, 41 years) from February 2009 to May 2011 from 3 gastroenterology and liver clinics in Northern California. Exclusion criteria included infection with hepatitis C or D viruses or human immunodeficiency virus. All patients completed a questionnaire (to determine demographics, history of liver disease, prior treatments, family medical history, drug and alcohol use, and environmental risk factors for hepatitis) that was administered by a research coordinator; mutations in HBV DNA polymerase were detected by using the INNO-LiPA HBV DR v.3 assay. RESULTS Most patients were Vietnamese (48.5%) or Chinese (36.4%) and were infected with HBV genotypes B (67.5%) or C (24.2%). Mutations in HBV DNA polymerase were found in 2 patients (1%), rtI233V (n = 1) and rtM250M/L (n = 1). CONCLUSIONS In a multicenter prospective study of treatment-naive patients with chronic hepatitis B, we detected mutations in HBV DNA polymerase in only 1%. Because of the low prevalence of these mutations and the uncertain clinical significance of such quasispecies, routine HBV DNA polymerase mutation analysis cannot be recommended before initiation of antiviral therapy for treatment-naive patients with chronic hepatitis B. The analysis requires further molecular and clinical studies.

Comparison Costs of ERCP and MRCP in Patients with Suspected Biliary Obstruction Based on a Randomized Trial.

Goals and Background: Besides United States population born between 1945 and 1965, screening for hepatitis C virus (HCV) is not recommended for the general US population. However, HCV may be more prevalent in certain subgroups and screening may be warranted. The goal of this study was to examine the proportion of HCV in a large sample of community Asian American patients presenting for non–liver-related complaints. Study: We conducted a cross-sectional study of 1246 patients tested for hepatitis C virus antibodies (anti-HCV) referred to 2 gastroenterology clinics for non–liver-related gastrointestinal reasons between January 2001 and February 2011. We determined HCV status and patient history via electronic medical record review. Results: Of the 1246 study patients tested for anti-HCV, the majority were Asian (81.4%) and 29 Asian patients (2.9%) had positive anti-HCV. HCV proportion in the remaining 232 non-Asians (non-Hispanic whites and Hispanics) was 1.7%. Asians with positive anti-HCV were more likely to have had blood transfusions (31.0% vs. 6.6%, P<0.0001) or acupuncture (10.3% vs. 1.5%, P<0.0001). Of the 976 Asian patients with hepatitis B surface antigen testing, 38 (3.9%) also had detectable hepatitis B surface antigen. Conclusions: Among patients seen at community gastroenterology clinics for non–liver-related reasons, HCV proportion was 1.7% for non-Asians and 2.9% for Asians. Screening for HCV should be offered to high-risk patients presenting to gastroenterology clinics with unrelated gastrointestinal complaints.

Significant Hepatic Fibrosis Among Treatment-Naive Chronic Hepatitis B Virus With Increased Hepatitis B Virus DNA and Normal Alanine Aminotransferase

Self-Expanding Metal Stents Confer a Survival Advantage in the Palliation of Distal Malignant Biliary Obstruction Kevin Waschke, Eduardo da Silveira, Youssef Toubouti, Elham Rahme, Alan Barkun Background: Plastic and self-expanding metal stents are used to palliate malignant biliary obstruction, yet can be complicated by occlusion. A previous set of meta-analyses by our group showed that no plastic stent design is superior and that adjuvant therapy does not improve stent patency or prolong patient survival. Objectives: To determine the effect of metal stent technologies compared with plastic stent insertion on duration of stent patency and patient survival in malignant biliary obstruction. Methods: Relevant English RCTs (1980-2004) were assessed by 2 reviewers for methodological quality using a validity assessment score created for this analysis. Data were abstracted regarding patient characteristics of stent insertion (ERCP vs. percutaneous) for distal malignant biliary obstruction, excluding hepatic metastases. Only trials with sufficient statistical information were included. The main outcomes were median stent occlusion and median patient survival. The difference of log-transformed median stent patency or survival ratio of the treatment stent vs. control was calculated for each study. Data were pooled using a random effect model and then re-transformed to the original scale to provide pooled estimates and 95% CI. Sensitivity analysis was done. SAS software (v 8.2) was used for statistical analysis. Results: A meta-analysis of 3 trials with 184 patients treated with plastic vs. self-expanding metal stent insertion showed a significant benefit for metal stents in terms of median patency (ratio 0.3, 95% CI 0.131 to 0.599 p Z 0.001). A survival advantage was also noted that favored metal stents (0.69, p Z 0.03, 95% CI 0.486 to 0.968). Conclusions: The use of metal stents results in a prolonged median patency when compared with plastic, which confirms results of individual trials. The use of SEMS was shown in this meta-analysis to provide a survival advantage when compared to plastic stents–this has never been shown in individual trials, probably due to insufficient statistical power but bears significant clinical implications. Additional high quality clinical data are required to assess this important finding. T1324 Case Finding for Celiac Disease Using Zoom Endoscopy Rawya Badreldin, Paul Barrett, John Mansfield, Yan Yiannakou Introduction: The detection of coeliac disease is often difficult as 20-50% of adult coeliac disease (CD) fails to present with malabsorptive symptoms and up to 5% have negative serology. Although coeliac disease fulfils the criteria for mass screening, the best epidemiological approach at present, is a case finding one. Using a zoom endoscope, a patients’ presentation for an endoscopy for any indication provides an opportunity to screen for villous atrophy. The role of zoom endoscopy in coeliac disease has been evaluated in only a few small studies. Aims: 1-To establish the efficacy of zoom endoscopy in detecting villous atrophy villous atrophy in a large case finding series. 2-Compare the detection of villous atrophy using conventional video and magnification endoscopy. Methods: 951 patients were prospectively recruited over a 22 month period. Patients with known coeliac disease were excluded. All endoscopies were performed by one endoscopist using the Olympus Q240Z endoscope. The duodenum was first examined for loss of folds, scalloping and a mosaic pattern. Then on full magnification of 115 normal, a score of Z1 to Z4 was allocated, with Z1 being normal villi and Z4 a flat mucosa. Results: Two patients were excluded; one with childhood coeliac disease and the other with duodenal Crohn’s disease. Of the patients referred, 147 had symptoms consistent with coeliac disease and 802 had non-suggestive symptoms. Twenty-three new cases of coeliac disease were found giving a prevalence rate of 2.42%. Seven of these patients had non-suggestive symptoms giving a prevalence rate of unsuspected CD of 0.74% in this population. Zoom endoscopy has a sensitivity of 95.65% and a specificity of 97.08% in detecting villous atrophy and a negative and positive predictive value of 99.88% and 44.89% respectively. Conclusions: Zoom endoscopy can be utilized successfully as a case finding tool for coeliac disease in patients presenting for endoscopy and is particularly useful when the diagnosis had not been considered.

Sa1003 High Prevalence of Hepatitis C Virus in Ethnically Diverse Community Patients With Non-Liver Related Gastrointestinal Complaints

To evaluate the role of prophylactic antibiotic therapy in the prevention of superimposed infection in acute necrotizing pancreatitis, Sharma and Howden conducted a meta-analysis that included the only three randomized, controlled trials published between 1996 and 2000. The selected studies compared supportive treatment plus antibiotic prophylaxis and supportive treatment alone in patients with clinical and radiographic evidence of acute necrotizing pancreatitis. The primary endpoints were occurrence of pancreatic infection, sepsis, and overall mortality. The pooled data consisted of 84 patients in the treatment group and 76 patients in the control group. Absolute and relative risk reduction as well as number needed to treat were calculated for each of the outcomes. Only one of the three trials demonstrated a significant benefit of antibiotic therapy in the prevention of sepsis and death. However, the analysis of the pooled data suggested that sepsis and death were less likely to occur in patients enrolled in the antibiotic arm. The numbers needed to treat to prevent one episode of sepsis and death were five and eight, respectively. Interestingly, the analysis failed to show a significant benefit of prophylactic antibiotics in preventing pancreatic infections. The authors concluded that antibiotics should be given to patients with sterile necrosis because both overall morbidity and mortality can be reduced.

Reye's syndrome in a 17-year-old male: Is this disease really disappearing?

BACKGROUND The optimal management of patients with suspected biliary obstruction remains unclear, and includes the possible performance of magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP). OBJECTIVES To complete a cost analysis based on a medical effectiveness randomized trial comparing an ERCP-first approach with an MRCP-first approach in patients with suspected bile duct obstruction. METHODS The management strategies were based on a medical effectiveness trial of 257 patients over a 12-month follow-up period. Direct and indirect costs were included, adopting a societal perspective. The cost values are expressed in 2012 Canadian dollars. RESULTS Total per-patient direct costs were Can

Diagnostic laparoscopy in radiation-induced liver disease

3547 for ERCP-first patients and Can