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The role of liver biopsy in chronic HCV therapy
S116
Abstracts
363 Long-term survival after transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites and variceal bleed Le Roi A. Baez1, Eric M. Walser2, Rekha Pandula1 and Daryl T. Y. Lau1*. 1Gastroenterology & Hepatology, University of Texas Medical Branch, Galveston, Texas, United States; and 2Radiology, University of Texas Medical Branch, Galveston, Texas, United States. Purpose: To compare the survival after TIPS for refractory ascites and recurrent variceal bleed, and to identify the factors predictive of poor outcomes. Methods: Chart review on all patients underwent TIPS between 1993 and 2000 at UTMB was performed. Demographics, clinical plus biochemical features and liver related mortality after TIPS were systematically recorded. Every effort, including a search of death registries, was made to locate those lost to follow up. Statistical analysis: Kaplan-Meier analysis and Log-Rank test were used to compare the survival after TIPS for refractory ascites and variceal bleed. Cox proportional-hazards regression were applied to identify prognostic factors. Results: Analysis was performed on 164 patients which included 61 with refractory ascites (Group A) and 103 with variceal bleed (Group B). Both groups had similar age (48.2 vs. 48.9 yrs; p ⫽ 0.65) and consisted of predominantly white males. More than 75% had hepatitis C, alcoholic liver disease or both. By univariate analysis, Group A pts had significantly higher baseline serum creatinine (1.8 vs. 0.98 mg/ml; p ⬍ 0.00001) and BUN (32.3 vs. 18.0 mg/dl; p ⬍ 0.00001) compared to Group B pts. The serum bilirubin, albumin and INR were not significantly different between the 2 groups. The mortality rate after TIPS was significantly higher among the Group A pts (p ⫽ 0.0004). Cox regression identified Child-Pugh class as the most significant predictor of survival with hazard ratio (HR) ⫽ 2.4. The data was, therefore, further analyzed by a Child-Pugh score cut-off of ⱖ10 or ⬍10. By Kaplan Meier analysis, both Group A and B pts with Child-Pugh score ⱖ10 had poor outcomes with 50% mortality rates at 3 and 8 months after TIPS respectively (p ⫽ 0.27). In contrast, for ChildPugh Scores ⬍10, survival was significantly prolonged for Group B patients (5 year survival rate ⫽ 50%) compared to Group A pts (5 years survival rate ⫽ 25%) (p ⫽ 0.028). Cox regression identified that INR (HR ⫽ 3.4, p ⫽ 0.018) and creatinine (HR ⫽ 1.8, p ⫽ 0.006) were the 2 most important predictors of survival among those with Child-Pugh scores ⬍10. Conclusions: Patients with Child-Pugh Class C (score ⱖ10) have poor survival after TIPS regardless of the indication. For Child-Pugh score ⬍10, TIPS prolongs survival among those with recurrent variceal bleed. However, survival remains poor for patients with refractory ascites, especially those with creatinine or INR elevation.
364 A comparison of pre-treatment histopahology and ALT in African Americans and Caucasians patients with hepatitis C infection Husam A Barakat, MD1, Owen J Smith, MD2*, Wendell K Clarkston, MD3, Cecilla M Rosales, MD4, Dorothy D Wheeler, RN5 and Yong Zeng, PhD6. 1Gastroenteroloy, University of Missouri-Kansas City, Kansas City, MO, United States; 2Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, United States; 3 Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, United States; 4Pathology, University of Missouri-Kansas City, Kansas City, MO, United States; 5Nursing, University of MissouriKansas City, Kansas City, MO, United States; and 6Statistics, University of Missouri-Kansas City, Kansas City, MO, United States. Purpose: African Americans have been found to exhibit a poor response to combination therapy for HCV. Factors that may contribute to this poor response include viral genotype, serum ALT values, or the natural history of the infection, including differences in the degree of pre-treatment hepatic inflammation and fibrosis.
AJG – Vol. 96, No. 9, Suppl., 2001
Methods: We retrospectively reviewed demographic data, baseline liver biochemistry, viral genotype and histopathology in 197 consecutive patients referred for treatment for antiviral therapy for hepatitis C. Modified Knodell (HAI) scores were assigned by an independent pathologist. Results: One hundred ninety seven (103 Male (52.3%), 94 Female (47.7%)), mean age 44 years were evaluated. Average age was 46.9 for African-Americans and 43.1 for Caucasians. This included 138 (70%) Caucasians, 59 (30%) African-Americans. Mean serum ALT value was 104.6 for African-Americans and 120.4 for Caucasians. There were 138 (70%) with abnormal ALT and 59 (30%) with normal ALT. There were 44 (75%) African-Americans and 94 (68%) Caucasians with abnormal ALT. The data showed no significant difference in serum ALT values between African-Americans and Caucasians (p ⫽ 0.215). There were 133 (67.5%) with genotype 1 and 64 (32.5%) with non-type 1. There were 52 (88%) African-Americans and 77 (56%) Caucasians with genotype 1. AfricanAmericans demonstrated infection with genootype 1 in far greater numbers than Caucasians (p ⬍ 0.05). Data analysis failed to demonstrate a difference in Knodell score between the two races (p ⫽ 0.257). Conclusions: Baseline differences between Genotype 1 was noted between the racial groups, suggesting the need for prospective assessment of these factors in response to therapy. No differences in liver biochemistry or baseline histopathology, including the degree of fibrosis was seen, suggesting that the natural history of hepatitis C infection is similar in AfricanAmericans and Caucasians.
365 The role of liver biopsy in chronic HCV therapy Husam A Barakat, Wendell K Clarkston*, Owen J Smith, Stella G Quiason, Prashant K Pandya and Zahid A Afzal. 1Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, United States; 2 Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, United States; 3Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, United States; 4Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, United States; 5 Gastroenterology, Indiana University, Indianapolis, IN, United States; and 6Medicine, University of Missouri-Kansas City, Kansas City, MO, United States. Purpose: Most protocols recommend a liver biopsy before initiation of HCV therapy. This is traditionally done to identify co-existing liver disease, to evaluate the degree of inflammation and to exclude advanced cirrhosis. We proceeded to determine whether the performance of liver biopsy influenced the decision to treat patients with chronic HCV infection. Methods: A retrospective review of 258 consecutive patients with chronic HCV infection was performed. These patients were referred for antiviral therapy to an outpatient clinic over a 4 year period. The following data were collected: age, sex, race, serum ALT, serum AST, alkaline phosphatase, bilirubin, albumin, prothrombin time/INR, disease specific markers, quantitative HCV RNA and genotype. The histopathology of all liver biopsies were reviewed an independent blinded pathologist to determine the reason for not initiating treatment, and whether liver biopsy influenced that decision. Results: Two hundred fifty eight patients (138 Male (53.3%), 120 Female (46.5%)), mean age 44 years were evaluated. This number included 179 (69.4%) Caucasians, 71 (27.5%) African Americans and 8 (3.1%) others. There were 72 (27.9%) with normal ALT and 186 (72.1%) with abnormal ALT. One hundred thirty six (52.7%) were genotype 1 and 122 (47.3%) were non-type 1. Twenty six (10.1%) were excluded based on clinical criteria (10 decompensated liver disease, 8 severe psychiatric disorders, 6 active alcohol and drug use, 1 advanced HIV disease and 1 active rheumatoid arthritis). Two hundred thirty two (89.9%) underwent liver biopsy. Fourty (15.5%) were excluded after liver biopsy for the following reasons (26 refused therapy, 6 resumed alcohol and drug use, 4 elected to await new therapies). Four (1.6%) were excluded based on the histopathology of liver biopsy (3 advanced cirrhosis, 1 primary biliary cirrhosis).
AJG – September, Suppl., 2001
Conclusions: In a retrospective review, performance of liver biopsy influenced treatment decision in HCV infected patients in only 1.6%. Our data does not support the routine performance of liver biopsy prior to antiviral therapy of HCV infection.
366 Tenckhoff catheter placement for palliation of refractory ascites Gregory S Barnes, M.D.1, Devora E. Hathaway, BSN1, Daniel J Gagne, M.D.1 and Philip F Caushaj, M.D., FACG1*. 1Department of Surgery, Temple University School of Medicine, Clinical Campus, The Western Pennsyivania Hospital, Pittsburgh, Pennsylvania, United States. Purpose: Ascites, usually secondary to cirrhosis, but also secondary to cardiomyopathy and malignancy is routinely treated with Na restiction, aldosterone antagonists, and loop diuretics. This conservative medical treatment has a success rate of 90% in cirrhosis. In the remaining 10% of refractory ascites several treatment modalities have emerged. Large volume paracentesis, portosystemic shunts, transjugular intrahepatic portosystemic shunts and peritovenous shunts are all options. Large volume paracentesis (LVP) has been proven safe and is currently the treatment of choice, though treatment strategies are still being evaluated. Tenckhoff peritoneal dialysis catheters have been used for several years with a wealth of data regarding continuous ambulatory peritoneal dialysis (CAPD) but little has been documented regarding Teckhoff catheters for palliation and treatment of refractory ascites. Studies documenting the safety of LVP document a complication rate from infection from 0 – 4%. Studies of Tenckhoff catheters for CAPD are in place for multiple years and studies show exit site infections of up to 55% and 1.1 infections per patient year. A prior study of Tenckhoff catheters in the treatment of refractory ascites in mainly non-cirrhosis patients showed 0 complications in 6 months. Methods: We performed a retrospective chart review of patients who had undergone placement of a Tenckhoff catheter for treatment of refractory ascites. Results: Our own data in 5 patients with a treatment course of 6 months resulted in 1/5 infections necessitating catheter. Conclusions: Given the higher incidence of infection in Tenckhoff catheters in long-term use compared to LVP, the use of Tenkhoff catheters may be best served for short-term palliation from the mechanical effects of chronic ascites in uncorrectable cases such as malignancy and cardiomyopathy but may also be of use in patients requiring frequent drainage in cirrhosis.
367 The effect of milk thistle (Silymarin) on serum alanine aminotransferase and viral levels in patients with chronic hepatitis C Domenica Barritta1, Ira M Jacobson1, Stephen Esposito1 and Mark W Russo1*. 1Gastroenterology/Hepatology, Weill Medical College of Cornell University, New York, NY, United States. Purpose: Many patients with Chronic Hepatitis C(CHC) often resort to alternative medicines such as milk thistle(MT), whose efficacy is not well established. The purpose of this study was to determine the effect of milk thistle on serum alanine aminotransferase(ALT) and hepatitis C viral load in patients with CHC who had been on interferon based therapy. Methods: A retrospective review of 50 patients, 25 using milk thistle and 25 who were not on milk thistle. All 50 patients had been on interferon based therapy. The 25 patients in the milk thistle group were using milk thistle daily. Pre and post treatment serum ALT and viral levels were compared as well as the absolute change between the pre and post treatment ALT and viral levels.
Abstracts
S117
Results: The Results are shown in the Table.
Mean Age Male Interferon & Ribavirin PEG-IFN & Ribavirin Mean Duration of Therapy Stage of Fibrosis Genotype 1 ⬎106 copies/ml Pre-ALT Post-ALT Mean decrease in ALT Mean decrease in viral load
N ⴝ 25 Milk Thistle
N ⴝ 25 No Milk Thistle
49 ⫾ 7 19 (76%) 8 (32%) 17 (68%) 39 ⫾ 11 weeks 1.96 ⫾ 1.2 15 (60%) 17 (68%) 137 ⫾ 116 54 ⫾ 92 83 ⫾ 131 5 ⫻ 105 ⫾ 100,000
49 ⫾ 10 20 (80%) 12 (48%) 13 (52%) 39 ⫾ 13 weeks 1.68 ⫾ 0.85 19 (76%) 18 (72%) 110 ⫾ 93 38 ⫾ 29 72 ⫾ 96 3 ⫻ 105 ⫾ 90,000
None of the differences were statistically significant.
Conclusions: In our study group of patients on interferon based therapy, milk thistle did not result in lower ALT levels or viral level. Our sample size may have been too small to detect a difference. Larger studies need to be done in order to fully evaluate the potential effects of Milk Thistle.
368 Physician knowledge and management of chronic hepatitis B: A comparison between community hospitals in high and low endemic risk areas E J Burbige MD, G Fung MD, J L Takagi PharmD. Mt Diablo Medical Center, East Bay Clinical Trials Center, Concord, CA. Despite the large number of individuals infected with chronic hepatitis B virus (HBV) we recently reported that physicians practicing in a predominantly Caucasian community lacked knowledge about HBV and its treatment. The purpose of this study was to compare the understanding and management of HBV between physicians practicing in high and low endemic areas for HBV. Methods: Questionnaires were mailed to primary care physicians and selected specialists who were likely to be treating patients with hepatitis in two selected communities. Eighty-four questionnaires were mailed to physicians at Hospital A located in Chinatown in San Francisco. One hundred ninety four questionnaires were mailed to physicians at Hospital B, located approximately 35 miles from San Francisco in a predominantly Caucasian community. All physicians were asked to use their current database and not review any material regarding hepatitis before completing the questionnaire, which included questions about incidence, mortality, treatment options for HBV, and knowledge of YMDD variants. Physicians were also surveyed as to preferred educational venues. Results: Thirty-two (38%) physicians at Hospital A and forty-five (23%) at Hospital B responded to the survey. Knowledge of current incidence and mortality of HBV was low in both communities. Although respondents at Hospital A felt there was effective treatment for HBV (74%), only 61% listed interferon and 65% listed lamivudine. Only 48% of respondents at Hospital B felt there was effective treatment for HBV; 47% listed interferon and 33% lamivudine as treatment. At Hospital A 19% had either never heard of lamivudine or of its use in HBV whereas at Hospital B 69% were unaware of the use of lamivudine for HBV. At Hospital A 32% had used lamivudine for HBV, while at Hospital B 0% had used it. Awareness of YMDD mutants was higher at Hospital A (29%) than Hospital B (2%). Responses to the question of what can be done to help recognize and treat patients with HBV were similar at both hospitals. Conclusion: Physician interest and knowledge of treatment of HBV is greater in communities with higher risk, but physician knowledge of incidence, mortality, and treatment remains low. There is a need for further efforts in continuing medical education regarding HBV in both high and low risk areas.
Abstracts
363 Long-term survival after transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites and variceal bleed Le Roi A. Baez1, Eric M. Walser2, Rekha Pandula1 and Daryl T. Y. Lau1*. 1Gastroenterology & Hepatology, University of Texas Medical Branch, Galveston, Texas, United States; and 2Radiology, University of Texas Medical Branch, Galveston, Texas, United States. Purpose: To compare the survival after TIPS for refractory ascites and recurrent variceal bleed, and to identify the factors predictive of poor outcomes. Methods: Chart review on all patients underwent TIPS between 1993 and 2000 at UTMB was performed. Demographics, clinical plus biochemical features and liver related mortality after TIPS were systematically recorded. Every effort, including a search of death registries, was made to locate those lost to follow up. Statistical analysis: Kaplan-Meier analysis and Log-Rank test were used to compare the survival after TIPS for refractory ascites and variceal bleed. Cox proportional-hazards regression were applied to identify prognostic factors. Results: Analysis was performed on 164 patients which included 61 with refractory ascites (Group A) and 103 with variceal bleed (Group B). Both groups had similar age (48.2 vs. 48.9 yrs; p ⫽ 0.65) and consisted of predominantly white males. More than 75% had hepatitis C, alcoholic liver disease or both. By univariate analysis, Group A pts had significantly higher baseline serum creatinine (1.8 vs. 0.98 mg/ml; p ⬍ 0.00001) and BUN (32.3 vs. 18.0 mg/dl; p ⬍ 0.00001) compared to Group B pts. The serum bilirubin, albumin and INR were not significantly different between the 2 groups. The mortality rate after TIPS was significantly higher among the Group A pts (p ⫽ 0.0004). Cox regression identified Child-Pugh class as the most significant predictor of survival with hazard ratio (HR) ⫽ 2.4. The data was, therefore, further analyzed by a Child-Pugh score cut-off of ⱖ10 or ⬍10. By Kaplan Meier analysis, both Group A and B pts with Child-Pugh score ⱖ10 had poor outcomes with 50% mortality rates at 3 and 8 months after TIPS respectively (p ⫽ 0.27). In contrast, for ChildPugh Scores ⬍10, survival was significantly prolonged for Group B patients (5 year survival rate ⫽ 50%) compared to Group A pts (5 years survival rate ⫽ 25%) (p ⫽ 0.028). Cox regression identified that INR (HR ⫽ 3.4, p ⫽ 0.018) and creatinine (HR ⫽ 1.8, p ⫽ 0.006) were the 2 most important predictors of survival among those with Child-Pugh scores ⬍10. Conclusions: Patients with Child-Pugh Class C (score ⱖ10) have poor survival after TIPS regardless of the indication. For Child-Pugh score ⬍10, TIPS prolongs survival among those with recurrent variceal bleed. However, survival remains poor for patients with refractory ascites, especially those with creatinine or INR elevation.
364 A comparison of pre-treatment histopahology and ALT in African Americans and Caucasians patients with hepatitis C infection Husam A Barakat, MD1, Owen J Smith, MD2*, Wendell K Clarkston, MD3, Cecilla M Rosales, MD4, Dorothy D Wheeler, RN5 and Yong Zeng, PhD6. 1Gastroenteroloy, University of Missouri-Kansas City, Kansas City, MO, United States; 2Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, United States; 3 Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, United States; 4Pathology, University of Missouri-Kansas City, Kansas City, MO, United States; 5Nursing, University of MissouriKansas City, Kansas City, MO, United States; and 6Statistics, University of Missouri-Kansas City, Kansas City, MO, United States. Purpose: African Americans have been found to exhibit a poor response to combination therapy for HCV. Factors that may contribute to this poor response include viral genotype, serum ALT values, or the natural history of the infection, including differences in the degree of pre-treatment hepatic inflammation and fibrosis.
AJG – Vol. 96, No. 9, Suppl., 2001
Methods: We retrospectively reviewed demographic data, baseline liver biochemistry, viral genotype and histopathology in 197 consecutive patients referred for treatment for antiviral therapy for hepatitis C. Modified Knodell (HAI) scores were assigned by an independent pathologist. Results: One hundred ninety seven (103 Male (52.3%), 94 Female (47.7%)), mean age 44 years were evaluated. Average age was 46.9 for African-Americans and 43.1 for Caucasians. This included 138 (70%) Caucasians, 59 (30%) African-Americans. Mean serum ALT value was 104.6 for African-Americans and 120.4 for Caucasians. There were 138 (70%) with abnormal ALT and 59 (30%) with normal ALT. There were 44 (75%) African-Americans and 94 (68%) Caucasians with abnormal ALT. The data showed no significant difference in serum ALT values between African-Americans and Caucasians (p ⫽ 0.215). There were 133 (67.5%) with genotype 1 and 64 (32.5%) with non-type 1. There were 52 (88%) African-Americans and 77 (56%) Caucasians with genotype 1. AfricanAmericans demonstrated infection with genootype 1 in far greater numbers than Caucasians (p ⬍ 0.05). Data analysis failed to demonstrate a difference in Knodell score between the two races (p ⫽ 0.257). Conclusions: Baseline differences between Genotype 1 was noted between the racial groups, suggesting the need for prospective assessment of these factors in response to therapy. No differences in liver biochemistry or baseline histopathology, including the degree of fibrosis was seen, suggesting that the natural history of hepatitis C infection is similar in AfricanAmericans and Caucasians.
365 The role of liver biopsy in chronic HCV therapy Husam A Barakat, Wendell K Clarkston*, Owen J Smith, Stella G Quiason, Prashant K Pandya and Zahid A Afzal. 1Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, United States; 2 Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, United States; 3Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, United States; 4Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, United States; 5 Gastroenterology, Indiana University, Indianapolis, IN, United States; and 6Medicine, University of Missouri-Kansas City, Kansas City, MO, United States. Purpose: Most protocols recommend a liver biopsy before initiation of HCV therapy. This is traditionally done to identify co-existing liver disease, to evaluate the degree of inflammation and to exclude advanced cirrhosis. We proceeded to determine whether the performance of liver biopsy influenced the decision to treat patients with chronic HCV infection. Methods: A retrospective review of 258 consecutive patients with chronic HCV infection was performed. These patients were referred for antiviral therapy to an outpatient clinic over a 4 year period. The following data were collected: age, sex, race, serum ALT, serum AST, alkaline phosphatase, bilirubin, albumin, prothrombin time/INR, disease specific markers, quantitative HCV RNA and genotype. The histopathology of all liver biopsies were reviewed an independent blinded pathologist to determine the reason for not initiating treatment, and whether liver biopsy influenced that decision. Results: Two hundred fifty eight patients (138 Male (53.3%), 120 Female (46.5%)), mean age 44 years were evaluated. This number included 179 (69.4%) Caucasians, 71 (27.5%) African Americans and 8 (3.1%) others. There were 72 (27.9%) with normal ALT and 186 (72.1%) with abnormal ALT. One hundred thirty six (52.7%) were genotype 1 and 122 (47.3%) were non-type 1. Twenty six (10.1%) were excluded based on clinical criteria (10 decompensated liver disease, 8 severe psychiatric disorders, 6 active alcohol and drug use, 1 advanced HIV disease and 1 active rheumatoid arthritis). Two hundred thirty two (89.9%) underwent liver biopsy. Fourty (15.5%) were excluded after liver biopsy for the following reasons (26 refused therapy, 6 resumed alcohol and drug use, 4 elected to await new therapies). Four (1.6%) were excluded based on the histopathology of liver biopsy (3 advanced cirrhosis, 1 primary biliary cirrhosis).
AJG – September, Suppl., 2001
Conclusions: In a retrospective review, performance of liver biopsy influenced treatment decision in HCV infected patients in only 1.6%. Our data does not support the routine performance of liver biopsy prior to antiviral therapy of HCV infection.
366 Tenckhoff catheter placement for palliation of refractory ascites Gregory S Barnes, M.D.1, Devora E. Hathaway, BSN1, Daniel J Gagne, M.D.1 and Philip F Caushaj, M.D., FACG1*. 1Department of Surgery, Temple University School of Medicine, Clinical Campus, The Western Pennsyivania Hospital, Pittsburgh, Pennsylvania, United States. Purpose: Ascites, usually secondary to cirrhosis, but also secondary to cardiomyopathy and malignancy is routinely treated with Na restiction, aldosterone antagonists, and loop diuretics. This conservative medical treatment has a success rate of 90% in cirrhosis. In the remaining 10% of refractory ascites several treatment modalities have emerged. Large volume paracentesis, portosystemic shunts, transjugular intrahepatic portosystemic shunts and peritovenous shunts are all options. Large volume paracentesis (LVP) has been proven safe and is currently the treatment of choice, though treatment strategies are still being evaluated. Tenckhoff peritoneal dialysis catheters have been used for several years with a wealth of data regarding continuous ambulatory peritoneal dialysis (CAPD) but little has been documented regarding Teckhoff catheters for palliation and treatment of refractory ascites. Studies documenting the safety of LVP document a complication rate from infection from 0 – 4%. Studies of Tenckhoff catheters for CAPD are in place for multiple years and studies show exit site infections of up to 55% and 1.1 infections per patient year. A prior study of Tenckhoff catheters in the treatment of refractory ascites in mainly non-cirrhosis patients showed 0 complications in 6 months. Methods: We performed a retrospective chart review of patients who had undergone placement of a Tenckhoff catheter for treatment of refractory ascites. Results: Our own data in 5 patients with a treatment course of 6 months resulted in 1/5 infections necessitating catheter. Conclusions: Given the higher incidence of infection in Tenckhoff catheters in long-term use compared to LVP, the use of Tenkhoff catheters may be best served for short-term palliation from the mechanical effects of chronic ascites in uncorrectable cases such as malignancy and cardiomyopathy but may also be of use in patients requiring frequent drainage in cirrhosis.
367 The effect of milk thistle (Silymarin) on serum alanine aminotransferase and viral levels in patients with chronic hepatitis C Domenica Barritta1, Ira M Jacobson1, Stephen Esposito1 and Mark W Russo1*. 1Gastroenterology/Hepatology, Weill Medical College of Cornell University, New York, NY, United States. Purpose: Many patients with Chronic Hepatitis C(CHC) often resort to alternative medicines such as milk thistle(MT), whose efficacy is not well established. The purpose of this study was to determine the effect of milk thistle on serum alanine aminotransferase(ALT) and hepatitis C viral load in patients with CHC who had been on interferon based therapy. Methods: A retrospective review of 50 patients, 25 using milk thistle and 25 who were not on milk thistle. All 50 patients had been on interferon based therapy. The 25 patients in the milk thistle group were using milk thistle daily. Pre and post treatment serum ALT and viral levels were compared as well as the absolute change between the pre and post treatment ALT and viral levels.
Abstracts
S117
Results: The Results are shown in the Table.
Mean Age Male Interferon & Ribavirin PEG-IFN & Ribavirin Mean Duration of Therapy Stage of Fibrosis Genotype 1 ⬎106 copies/ml Pre-ALT Post-ALT Mean decrease in ALT Mean decrease in viral load
N ⴝ 25 Milk Thistle
N ⴝ 25 No Milk Thistle
49 ⫾ 7 19 (76%) 8 (32%) 17 (68%) 39 ⫾ 11 weeks 1.96 ⫾ 1.2 15 (60%) 17 (68%) 137 ⫾ 116 54 ⫾ 92 83 ⫾ 131 5 ⫻ 105 ⫾ 100,000
49 ⫾ 10 20 (80%) 12 (48%) 13 (52%) 39 ⫾ 13 weeks 1.68 ⫾ 0.85 19 (76%) 18 (72%) 110 ⫾ 93 38 ⫾ 29 72 ⫾ 96 3 ⫻ 105 ⫾ 90,000
None of the differences were statistically significant.
Conclusions: In our study group of patients on interferon based therapy, milk thistle did not result in lower ALT levels or viral level. Our sample size may have been too small to detect a difference. Larger studies need to be done in order to fully evaluate the potential effects of Milk Thistle.
368 Physician knowledge and management of chronic hepatitis B: A comparison between community hospitals in high and low endemic risk areas E J Burbige MD, G Fung MD, J L Takagi PharmD. Mt Diablo Medical Center, East Bay Clinical Trials Center, Concord, CA. Despite the large number of individuals infected with chronic hepatitis B virus (HBV) we recently reported that physicians practicing in a predominantly Caucasian community lacked knowledge about HBV and its treatment. The purpose of this study was to compare the understanding and management of HBV between physicians practicing in high and low endemic areas for HBV. Methods: Questionnaires were mailed to primary care physicians and selected specialists who were likely to be treating patients with hepatitis in two selected communities. Eighty-four questionnaires were mailed to physicians at Hospital A located in Chinatown in San Francisco. One hundred ninety four questionnaires were mailed to physicians at Hospital B, located approximately 35 miles from San Francisco in a predominantly Caucasian community. All physicians were asked to use their current database and not review any material regarding hepatitis before completing the questionnaire, which included questions about incidence, mortality, treatment options for HBV, and knowledge of YMDD variants. Physicians were also surveyed as to preferred educational venues. Results: Thirty-two (38%) physicians at Hospital A and forty-five (23%) at Hospital B responded to the survey. Knowledge of current incidence and mortality of HBV was low in both communities. Although respondents at Hospital A felt there was effective treatment for HBV (74%), only 61% listed interferon and 65% listed lamivudine. Only 48% of respondents at Hospital B felt there was effective treatment for HBV; 47% listed interferon and 33% lamivudine as treatment. At Hospital A 19% had either never heard of lamivudine or of its use in HBV whereas at Hospital B 69% were unaware of the use of lamivudine for HBV. At Hospital A 32% had used lamivudine for HBV, while at Hospital B 0% had used it. Awareness of YMDD mutants was higher at Hospital A (29%) than Hospital B (2%). Responses to the question of what can be done to help recognize and treat patients with HBV were similar at both hospitals. Conclusion: Physician interest and knowledge of treatment of HBV is greater in communities with higher risk, but physician knowledge of incidence, mortality, and treatment remains low. There is a need for further efforts in continuing medical education regarding HBV in both high and low risk areas.