BACKGROUND:Waitlist volumes for hepatology referrals in Calgary, Alberta, have increased with population growth and rising chronic liver disease [alcohol-related, metabolic dysfunction-associated steatotic liver disease, hepatitis B virus (HBV) infection, and cirrhosis complications]. Prolonged waits threaten timely surveillance, diagnosis, and treatment. We conducted a QI (quality improvement) project in the Calgary Liver Unit at the University of Calgary Medical Clinic (UCMC), a tertiary clinic using a central access and triage (CAT) system serving ~2 million residents. METHODS:Our aim was to cut the median wait for routine referrals from 78.4 to 39 weeks (50%) between October 2023 and August 2025. Six Plan-Do-Study-Act cycles targeted referral coding (ICD-10 groupings), a dedicated HBV clinic, clearer triage acuity criteria, standardized waitlist management, redirecting benign liver neoplasms to primary care with guidance, and recruiting 2 additional hepatologists to expand capacity. The primary outcome was median routine wait time; secondary outcomes included urgent and emergent wait times and total waitlist size. Net waitlist accrual (accepted referrals minus new patients seen per month) tracked the flow. Data from CAT and scheduling systems were analyzed using statistical process control (SPC) charts. RESULTS:By August 2025, the median routine wait fell to 8.4 weeks, the urgent wait fell from 28.3 to 6.6 weeks, and the emergent wait remained near the 2-week target (2.4 to ~2.7 weeks). The waitlist decreased from 1426 to 158 patients, and net accrual shifted from persistently positive to sustained negative values, reflecting backlog reduction. Routine-wait SPC charts showed special-cause variation and a sustained performance shift after key interventions. CONCLUSION:This multi-component, data-driven strategy within a CAT model improved access for routine referrals while protecting timely care for higher-acuity patients and may translate to other subspecialty clinics facing similar constraints.

Background: Ketamine-related cholangiopathy is increasingly being described in America, Europe, and Asia, paralleling increases in ketamine use globally. However, ketamine-related cholangiopathy has not been described in Canada previously. We report three cases of ketamine-related cholangiopathy in Calgary, Alberta.Results: Between May 2024 and April 2025, three patients were assessed by the University of Calgary Liver Unit in Calgary, Alberta, Canada. Case 1 was a 28-year-old female referred for elevated liver enzymes and features concerning for sclerosing cholangitis identified on magnetic resonance cholangiopancreatography. Case 2 was a 40-year-old male referred due to features of sclerosing cholangitis identified on magnetic resonance cholangiopancreatography. Case 3 was a 33-year-old female referred for elevated liver enzymes with biliary dilation on abdominal CT scan. In all cases, a history of chronic ketamine use and a negative comprehensive workup for other etiologies strongly suggested ketamine as the cause of their presentations. Case 1 had normalization of liver enzymes and marked improvement of radiographic biliary changes at 3-month follow-up after complete cessation of ketamine. Case 2 reduced ketamine use by 50% and experienced similar clinical improvement at 3-month follow-up. Case 3 continued using ketamine, resulting in worsening liver enzyme elevations and persistent biliary tree imaging abnormalities.Conclusions: Chronic ketamine use should be considered in patients presenting with liver enzyme elevation and/or imaging evidence of biliary dilation. Increased awareness in Canada is essential to ensuring health care providers consider ketamine-related cholangiopathy in patients presenting with these clinical findings, as with ketamine cessation liver injury and biliary abnormalities are potentially reversible.

Background/Objectives: Caregivers play a critical role in patient care across the pre- and post-transplant periods. However, the demands of caregiving can negatively impact caregivers’ own physical and psychosocial well-being. The Transplant Wellness Program (TWP) is a behavior change intervention that provides exercise support for pre- and post-kidney, pre- and post-liver, and post-lung transplant patients but has not yet included transplant caregivers. Thus, the purpose of this study was to explore the experiences and needs of organ transplant caregivers to inform the development of caregiver-specific support resources for the TWP. Methods: Semi-structured interviews with family caregivers of patients receiving kidney or liver transplant in the TWP were conducted and recorded via Zoom. Interview recordings were transcribed verbatim and analyzed using conventional content analysis. Results: Eight interviews were conducted, with caregivers in both the pre- (n = 4) and post-transplant (n = 4) periods. Four categories resulted from the data: caregiver strain, life changes, individual wellness needs, and caregiving needs. Nine sub-categories further described caregivers’ experiences and opportunities for wellness support. Conclusions: The caregiving experience was characterized by feelings of overwhelm, stress, and uncertainty. This study highlights the need for comprehensive services such as exercise classes, peer support programs, and tangible aide to support transplant caregivers’ well-being. Three caregiver resources were built out of this study and integrated into the TWP.

INTRODUCTION:Patient, clinician, and system-related barriers may affect adherence to hepatocellular carcinoma (HCC) surveillance programmes. The impact of a dedicated automated recall HCC surveillance programme on retention rates in patients eligible for screening is unknown. We aimed to describe and evaluate a large HCC surveillance programme in a publicly funded healthcare system. METHODS:Data were collected from January 1, 2013, to December 31, 2022, from a retrospective cohort of subjects enrolled in a publicly funded automated recall semi-annual surveillance programme as per the American Association for the Study of Liver Disease HCC guidance in the Calgary Health Zone (~1.6 million), Canada. Patients were excluded if there was incomplete data or did not meet indications for surveillance. Cox regression was used to identify predictors of non-retention to surveillance. RESULTS:A total of 7269 patients were included. The median was age 55.5 years (IQR: 45.5-63.8), 60% were male, 46% were of Asian descent, 51% had HBV infection, and 36% had cirrhosis (35% alcohol-related). Median follow-up was 4.9 years (IQR: 1.5-7.2). Overall, 52% (n = 3768) of patients were retained in the surveillance programme, while 8.3% (n = 603) left for potential medical reasons, and 40% (n = 2898) were lost in follow-up. The median time in the programme for those lost in follow-up was 0.81 years (IQR: 0.0-2.8) compared to 6.75 years if retained (IQR: 5.6-8.6; p < 0.001). In multivariable Cox regression analysis, HCV aetiology (HR 1.41; CI 1.23-1.62, p < 0.01), African ethnicity (HR 1.20, CI 1.02-1.42, p = 0.03), and cirrhosis (HR 1.16, CI 1.05-1.28, p < 0.01) increased risk of dropout. On interaction analysis, Hepatitis B amongst cirrhotic patients also increased risk of dropout (HR 1.48, CI 1.05-2.07, p = 0.02). CONCLUSION:A dedicated automated recall HCC surveillance programme has a high retention rate in a large multi-ethnic cohort of patients while identifying certain marginalised patient populations, such as those with viral liver disease, cirrhosis, or African ethnicity, as particularly vulnerable to loss to follow-up.

ABSTRACTChronic hepatitis B (CHB) is the leading cause of hepatocellular carcinoma (HCC) globally. We described and evaluated the outcomes of patients with CHB‐HCC in Canada. In this retrospective cross‐sectional cohort study, data were analysed from CHB mono‐infected subjects seen between 1 January 2012 and 31 December 2022, and entered the Canadian Hepatitis B Network Registry. Descriptive analysis and chi‐squared modelling were used to compare cohorts, followed by multivariable survival analysis regarding survival post‐diagnosis. Statistical analyses were completed in R version 2.2. Of the 6711 patients with CHB who met inclusion criteria, 232 (3.5%) developed HCC. Compared with the CHB cohort, the majority of CHB‐HCC cohort were male, SEA and HBeAg negative and born in endemic area (80% vs. 56%, 73% vs. 55%, 84% vs. 54%, 64% vs. 40% and all p < 0001). Overall, median HBV DNA level was log 2.54 (IQR: 0–4.04). Advanced liver disease, defined as minimum Fibrosis stage F3, was seen in 9.4% of overall cohort, but 92% of HCC cohort. At diagnosis, median tumour size was 2.5 cm (IQR: 1.7–4.0) and mean tumour number was 1.33 (SD: 1.33), with 81% of patients BCLC 0‐A. Fifty‐three per cent of patients were diagnosed with HCC as part of surveillance protocols. The survival rate after HCC diagnosis was 78.7%, during the median follow‐up of 52.9 months (IQR: 17–90). In multivariable analysis, survival was significantly correlated with diagnosis through the screening programme. In this large cohort of patients with CHB‐HCC, the majority of patients were detected with early‐stage HCC and received treatment with curative intent, resulting in strong survival rates.

Background: Exercise prehabilitation is an evidence-based, safe, and effective method to increase quality of life, physical fitness and function, and post-surgical outcomes in solid organ transplant (SOT) patients. However, few prehabilitation programs for SOT patients exist in practice. Furthermore, there is a lack of multimodal prehabilitation programs that include behavior change support. To address this need, the Transplant Wellness Program (TWP) was designed. Objectives: The objective of the TWP is to assess both the effectiveness and implementation of a comprehensive and multimodal exercise and wellness behavior change intervention for patients undergoing kidney or liver transplant. Design: The TWP is a hybrid effectiveness-implementation trial consisting of exercise and wellness behavior change support. Patients: Individuals who are in evaluation or listed for kidney or liver transplant in Southern Alberta, Canada. Measurements: The primary outcomes of self-reported exercise and quality of life are assessed at intake, post-exercise intervention, 6 months post-intake, 12 weeks post-transplant, and annually for 5 years after program completion. Functional fitness measures will be assessed at intake, post-exercise intervention, 12 weeks post-transplant, 6 months post-intake, and 1-year post-intake. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework is used to determine the impact of TWP at the individual and health care system level. Methods: Recruitment began in November 2023 and will continue until November 2028. Participants take part in a 12-week exercise intervention and are offered individualized and group behavior change support. Continued exercise support is offered through maintenance classes after the completion of the 12-week intervention. Limitations: The design of the hybrid effectiveness-implementation trial with a single experimental group will not allow for comparisons to a control or usual care group, potentially impacting internal validity. Differences in number of participants between organ groups (kidney vs liver) and cohorts (pre-transplant vs post-transplant) will likely be uneven, requiring consideration when running and interpreting analyses. Conclusions: The TWP aims to support patients throughout the transplant journey through a multimodal and comprehensive exercise and wellness behavior change program. Results from this study will determine the effectiveness of the program and inform future scale-up and sustainability. Trial registry number: NCT06367244.

The IMbrave150 trial established atezolizumab with bevacizumab (A+B) as standard care for hepatocellular carcinoma (HCC), recommending an esophagogastroduodenoscopy (EGD) within 6 months of treatment initiation to prevent bleeding from esophagogastric varices. The necessity of mandatory EGD for all patients remains unclear. We retrospectively analyzed 112 HCC patients treated with A+B at five Canadian cancer centers from 1 July 2020 to 31 August 2022. A+B was the first-line therapy for 90% of patients, with median overall survival at 20.3 months and progression-free survival at 9.6 months. There was no survival difference between patients with bleeding and those without. Before A+B, 71% (n = 79) of patients underwent an EGD within 6 months, revealing varices in 41% (n = 32) and requiring intervention in 19% (n = 15). The overall bleeding rate was 15% (n = 17), with GI-specific bleeding occurring in 5% (n = 17). In the EGD group, GI-specific bleeding was 6% (n = 5) while in the non-EGD group, it was 3% (n = 1). Non-GI bleeding was observed in 10% (n = 11) of patients. Outcomes for HCC patients treated with A+B in Canada were comparable to IMbrave150. There was no increase in GI bleeding in patients without pre-treatment EGD, possibly supporting a selective EGD approach.

INTRODUCTION:Biopsy of hepatocellular carcinoma (HCC) may help with selecting appropriate chemotherapy with inconclusive imaging; concern about potential seeding may limit its use. METHODS:A systematic review was conducted to assess the risk of tumor seeding with biopsy of HCC excluding nonliver cancers or seeding after interventions. RESULTS:A total of 2,339 unique abstracts were identified; 37 studies were included in the final analysis. The rate of tumor seeding was 0.62% (range 0%-7.77%) in 13,959 biopsies performed. The average reported median lengths of follow-up was 35.8 months (range 10.5-60 months). DISCUSSION:Overall, the risk of tumor seeding with biopsy of HCC is low.

ObjectivesFollowing positive surveillance ultrasound (US), magnetic resonance imaging (MRI) is recommended for further characterization. We propose contrast-enhanced ultrasound (CEUS) shows equivalent efficacy. MethodsThis prospective institutional review board approved study recruited 195 consecutive at-risk patients with a positive surveillance US. All had CEUS and MRI. Biopsy (n = 44) and follow-up are gold standard. MRI and CEUS results are classified according to liver imaging reporting and data system (LI-RADS) and patient outcome. ResultsAs an US-based modality, CEUS is superior in confirming findings from surveillance US, correlation in 189/195 (97%) on CEUS compared to 153/195 (79%) on MRI. Within these negative MRI examinations, there are 2 hepatocellular carcinoma (HCC) and 1 cholangiocarcinoma (iCCA) diagnosed on CEUS and proven by biopsy. From 195 patients, there are 71 malignant diagnoses from all sources, including 58 LR-5 (45 on MRI and 54 on CEUS) and 13 others, including HCC outside of LR-5 category, and LR-M with biopsy proven iCCA (3 on MRI and 6 on CEUS). CEUS and MRI show concordant results in the majority of patients (146/195, 75%), including 57/146 malignant and 89/146 benign diagnoses. There are 41/57 concordant LR-5 and 6/57 concordant LR-M. When CEUS and MRI are discordant, CEUS upgraded 20 (10 biopsy-proven) from MRI LR-3/4 to CEUS LR-5 or LR-M by showing washout (WO) that MRI failed to show. Additionally, CEUS characterized time and intensity of WO and diagnosed 13/20 LR-5 by showing late and weak WO and 7 LR-M by showing fast and marked WO. CEUS is 81% sensitive and 92% specific in diagnosing malignancy. MRI is 64% sensitive and 93% specific. ConclusionsCEUS performance is at least equivalent if not superior to MRI for initial evaluation of lesions from surveillance US.

Background:Frailty is a clinical state of increased vulnerability and is common in patients with cirrhosis. The liver frailty index (LFI) is a validated tool to evaluate frailty in cirrhosis, comprising of grip strength, chair stands, and balance tests. The chair-stand test is an easy to conduct frailty subcomponent that does not require specialized equipment and may be valuable to predict adverse clinical outcomes in cirrhosis. The objective of this study was to determine if the chair-stand test is an independent predictor of mortality and hospitalization in cirrhosis. Methods:A retrospective review of 787 patients with cirrhosis was conducted. Chair-stand times were collected at baseline in person and divided into three groups: <10 seconds (n = 276), 10-15 seconds (n = 290), and >15 seconds (n = 221). Fine-Gray proportional hazards regression models were used to evaluate the association between chair-stand times and the outcomes of mortality and non-elective hospitalization. Results:The hazard of mortality (HR 3.21, 95% CI 2.16%-4.78%, p <0.001) and non-elective hospitalization (HR 2.24, 95% CI 1.73%-2.91%, p <0.001) was increased in group 3 in comparison to group 1. A chair-stand test time >15 seconds had increased all-cause mortality (HR 2.78, 95% CI 2.01%-3.83%, p <0.001) and non-elective hospitalizations (HR 1.84, 95% CI 1.48%-2.29%, p <0.001) compared to <15 seconds. Conclusions:A chair-stand test time of >15 seconds is independently associated with mortality and non-elective hospitalizations. This test holds promise as a rapid prognostication tool in cirrhosis. Future work will include external validation and virtual assessment in this population.

Journal of Ultrasound in MedicineVolume 42, Issue 6 p. 1175-1180 Editorial Comparing Magnetic Resonance Imaging and Contrast-Enhanced Ultrasound (CEUS) for the Characterization of Nodules Found on Hepatocellular Carcinoma Surveillance CEUS is Our Clear Choice Kelly W. Burak MD, FRCPC, MSc (Epid), Corresponding Author Kelly W. Burak MD, FRCPC, MSc (Epid) [email protected] Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Division of Transplant Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Division of Medical Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Address correspondence to Kelly W. Burak, Calgary Liver Unit, Division of Gastroenterology and Hepatology, Division of Transplant Medicine, Departments of Medicine and Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. E-mail: [email protected]Search for more papers by this authorLisa Douglas RN, NP, Lisa Douglas RN, NP Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, CanadaSearch for more papers by this authorStephen E. Congly MD, FRCPC, MSc, Stephen E. Congly MD, FRCPC, MSc Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Division of Transplant Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, CanadaSearch for more papers by this author Kelly W. Burak MD, FRCPC, MSc (Epid), Corresponding Author Kelly W. Burak MD, FRCPC, MSc (Epid) [email protected] Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Division of Transplant Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Division of Medical Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Address correspondence to Kelly W. Burak, Calgary Liver Unit, Division of Gastroenterology and Hepatology, Division of Transplant Medicine, Departments of Medicine and Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. E-mail: [email protected]Search for more papers by this authorLisa Douglas RN, NP, Lisa Douglas RN, NP Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, CanadaSearch for more papers by this authorStephen E. Congly MD, FRCPC, MSc, Stephen E. Congly MD, FRCPC, MSc Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Division of Transplant Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, CanadaSearch for more papers by this author First published: 07 March 2023 https://doi.org/10.1002/jum.16200 Kelly W. Burak received honorarium from Canadian Multidisciplinary HCC meeting for organizing and speaking in 2021 and from CADTH for expert review of "Y90 for HCC" Health Technology Assessment in 2020. Lisa Doulgas has nothing to declare. Stephen E. Congly has research grants from Bristol-Myers Sqibb Canada, has received consulting fees from AstraZeneca and is on the Board of Directors for the Canadian Association for the Study of the Liver. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL References 1Marrero JA, Kulik L, Sirlin CB, et al. Diagnosis, staging and management of hepatocellular carcinoma: 2018 practice guidance by the American Association for the Study of Liver Diseases. Hepatology 2018; 68: 723– 750. 2 European Association for the Study of the Liver. EASL clinical practice guidelines: management of hepatocellular carcinoma. J Hepatology 2018; 69: 182– 236. 3Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology 2011; 53: 1020– 1022. 4Jo PC, Jang HJ, Burns PN, et al. Integration of CEUS into a multimodality approach to imaging of nodules in a cirrhotic liver: how I do it. Radiology 2017; 282: 317– 331. 5Aubé C, Oberti F, Lonjon J, et al. EASL and AASLD recommendations for the diagnosis of HCC to the test of daily practice. Liver Int 2017; 37: 1515– 1525. 6van der Pol CB, McInnes MDF, Salameh JP, et al. CT/MRI and CEUS LI-RADS major features association with hepatocellular carcinoma: individual patient data meta-analysis. Radiology 2022; 302: 326– 335. 7Hu J, Burrowes DP, Caine BA, et al. Nodules identified on surveillance ultrasound for HCC: CEUS or MRI as the initial test? J Ultrasound Med 2023; 42: 1181– 1190. 8Westwood M, Joore M, Grutters J, et al. Contrast-enhanced ultrasound using SonoVue® (sulphur hexafluoride microbubbles) compared with contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging for the characterisation of focal liver lesions and detection of liver metastases: a systematic review and cost-effectiveness analysis. Health Technol Assess 2013; 17: 1– 243. 9Tanaka H, Iijima H, Nouso K, et al. Cost-effectiveness analysis on the surveillance for hepatocellular carcinoma in liver cirrhosis patients using contrast-enhanced ultrasonography. Hepatol Res 2012; 42: 376– 384. 10Smajerova M, Petrasova H, Little J, et al. Contrast-enhanced ultrasonography in the evaluation of incidental focal liver lesions: a cost-effectiveness analysis. World J Gastroenterol 2016; 22: 8605– 8614. 11Streb JW, Tchelepi H, Malhi H, Deurdulian C, Grant EG. Retrospective analysis of contrast-enhanced ultrasonography effectiveness in reducing time to diagnosis and imaging-related expenditures at a single large United States county hospital. Ultrasound Q 2019; 35: 99– 102. 12 Centers for Medicare & Medicaid Services. CMS-1772-FC Hospital Outpatient Prospective Payment-Notice of Final Rulemaking with Comment Period (NFRM). https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientppshospital-outpatient-regulations-and-notices/cms-1772-fc. Accessed February 2, 2023. 13Terzi E, Iavarone M, Pompili M, et al. Contrast ultrasound LI-RADS LR-5 identifies hepatocellular carcinoma in cirrhosis in a multicenter retrospective study of 1,006 nodules. J Hepatol 2018; 68: 485– 492. 14 Guideline Resource Unit Alberta Health Services. Hepatocellular Carcinoma. https://www.albertahealthservices.ca/assets/info/hp/cancer/if-hp-cancer-guide-gi007-hepatocellular-carcinoma.pdf. Accessed February 2, 2022. 15Bansal S, Gui J, Merrill C, et al. Contrast-enhanced US in local ablative therapy and secondary surveillance for hepatocellular carcinoma. Radiographics 2019; 39: 302– 1322. 16Bansal S, Lu F, Frehlich L, et al. A new proposal for secondary surveillance following potentially curative therapy of HCC: alternating MRI and CEUS. Abdom Radiol (NY) 2022; 47: 618– 629. Volume42, Issue6June 2023Pages 1175-1180 ReferencesRelatedInformation

PURPOSE:We have long noted unique portal venous phase (PVP) imaging discordance of focal liver masses between CEUS, showing rapid marked washout, and MRI, showing progressive or sustained enhancement. We postulate association of this unique discordance with intrahepatic cholangiocarcinoma (ICC) and causal relationship to different contrast agent behavior. We investigate this unique discordance, propose its clinical significance for ICC diagnosis, and confirm further histologic associations. METHODS:Cases were collected within our CEUS department and from pathology records over a ten-year interval. This retrospective review includes 99 patients, 73 with confirmed ICC and 26 other diagnoses, showing unique PVP discordance. The CEUS and MRI enhancement characteristics were compared for all patients. RESULTS:Unique discordance is identified in 67/73 (92%) ICC and difference between the PVP appearance on MRI and CEUS is statistically significant (p < 0.0001). Arterial phase enhancement did not show statistically significant difference between CEUS and MRI, p > 0.05. Other diagnoses showing unique discordance include especially lymphoma (n = 7), sclerosed hemangioma (n = 6), HCC (n = 4), metastases (n = 2), and other rare entities. CONCLUSION:ICC shows this discrepant intermodality enhancement pattern in a statistically significant number of cases and should be considered along with other LR-M features in at-risk patients. Discordance is also rarely seen in a number of other liver lesions.

Background: Hepatocellular carcinoma (HCC) a leading cause of cancer mortality worldwide and approximately one-third of patients present with intermediate-stage disease. The treatment landscape of intermediate-stage HCC is rapidly evolving due to developments in local, locoregional and systemic therapies. Treatment recom-mendations focused on this heterogenous disease stage and that take into account the Canadian reality are lacking. To address this gap, a pan-Canadian group of experts in hepatology, transplant, surgery, radiation therapy, nuclear medicine, interventional radiology, and medical oncology came together to develop consensus recommendations on management of intermediate-stage HCC relevant to the Canadian context. Methods: A modified Delphi framework was used to develop consensus statements with strengths of recommendation and supporting levels of evidence graded using the AHA/ACC classification system. Tentative consensus statements were drafted based on a systematic search and expert input in a series of iterative feedback cycles and were then circulated via online survey to assess the level of agreement. Results & Conclusion: The pre-defined ratification threshold of 80 % agreement was reached for all statements in the areas of multidisciplinary treatment (n = 4), intra-arterial therapy (n = 14), biologics (n = 5), radiation therapy (n = 3), surgical resection and transplantation (n = 7), and percutaneous ablative therapy (n = 4). These generally reflected an expansion in treatment options due to developments in previously established or emergent techniques, introduction of new and more active therapies and increased therapeutic flexibility. These developments have allowed for greater treatment tailoring and personalization as well as a paradigm shift toward strategies with curative intent in a wider range of disease settings.

Abstract Background Frailty is defined as a clinical state of increased vulnerability to health and age associated stressors. The liver frailty index (LFI), composed of grip strength, chair stand and balance testing, is an accepted predictor of morbidity and mortality in cirrhosis. With the need for COVID-19 related social distancing, many appointments are being carried out virtually. The chair stand subcomponent of the LFI has the potential to be evaluated virtually, with a high reliability as compared to in-person testing noted in other disease populations. Aims To determine if the chair stand test is an independent predictor of morbidity and mortality in patients with cirrhosis. Methods 822 adult patients with cirrhosis were prospectively enrolled from five centers (3 in Canada, 1 in the United States, and 1 in India). Inclusion criteria included adult patients with cirrhosis. 787 of these patients completed a chair stand test at baseline, measured as the time (seconds) a patient takes to rise from sitting with their arms folded across their chest five times (measured in-person). The times were divided into 3 categories: >15 seconds, between 10 and 15 seconds, and <10 seconds. Patients who could not complete 5 chair stands were classified in the >15 seconds category. Primary outcome was all-cause mortality. Secondary outcome was unplanned all-cause hospital admission. Fine-Gray proportional hazard regression models were used to evaluate the association between the chair stand time and the outcomes. We adjusted for baseline age, sex, and MELD score and accounted for liver transplantation as a competing risk. Cumulative incidence functions were used to create a graphical representation of the survival analysis. Results Patients were divided into three groups: group 1, <10 seconds (n = 276); group 2, 10–15 seconds (n = 290); and group 3, >15 seconds (n = 221). Mortality was increased in group 3 in comparison to group 1 (HR 3.21, 95% CI: 2.16–4.78, p<0.001). Similarly, the hazard of non-elective hospitalizations was higher in group 3 in comparison to group 1 (HR 2.24, 95% CI: 1.73–2.91, p<0.001). Overall, patients with chair stand times greater than 15 seconds had increased all-cause mortality (HR 2.78, 95% CI 2.01–3.83, p<0.001) and non-elective hospitalizations (HR 1.84, 95% CI 1.48–2.29, p<0.001) when compared to patients with times less than 15 seconds. Conclusions A time to complete 5 chair stands of >15 seconds predicts morbidity and mortality in patients with cirrhosis. This test shows promise as a frailty measure that could be evaluated over a virtual platform. Funding Agencies None

Abstract Background Alcohol-related hepatitis (AH) is the most severe form of alcohol-related liver disease, with rising incidence. Stay-at-home orders for the COVID-19 pandemic were associated with increased alcohol consumption. Online sales reported a 262% increase from March 2019 to 2020. Aims The purpose of this study was to track the epidemiology of hospitalizations for AH by sex before and after the COVID-19 pandemic. We hypothesized that AH would be more severe in females and younger individuals during the pandemic. Methods Using the Discharge Abstract Database, we identified all hospitalizations in Alberta with international classification of disease-10 codes for AH between March 2018 and September 2020. We merged this dataset with provincial laboratory data to identify all inpatient lab values. We calculated Model for End-Stage Liver Disease (MELD) and Maddrey scores and validated a laboratory-based algorithm for AH. Severe AH was defined as Maddrey score > 32. Onset of the pandemic was defined as March 2020. Stratified by pandemic onset, descriptive statistics were done with Chi-squared and Kruskal Wallis tests. Inpatient mortality was assessed as a primary outcome. Binomial regression was used to assess changes in frequency of admission for AH with the denominator as all cirrhosis-related admissions over the same time-period. Results We identified 991 hospitalizations for AH prior to the pandemic (n=381, 38.5% female) and 417 during the pandemic (n=144, 34.5% female). Hospitalizations for AH significantly increased during the pandemic (p = 0.04) (Figure 1). Median Maddrey score for females (30.5) before the pandemic was significantly higher than for males (22.9), p < 0.01. During the pandemic, median Maddrey for females (28.7) was higher than males 21.4, p = 0.07. Median age at admission was significantly lower for both males and females during the pandemic (age 44 and 41, respectively) as compared to prior (age 47 and 45, respectively) p < 0.05. There was no significant difference in MELD between sexes before (13.5 for females, 14.0 for males, p = 0.15) and during the pandemic (13.3 for females, 13.0 for males, p = 0.75). Additionally, there was no significant difference in mortality between sexes before (10.4% in females, 11.5% in males, p = 0.22) and after the pandemic (9.2% in females, 9.9% in males, p = 0.67). Conclusions Hospitalizations for AH rose during the pandemic and occurred at younger ages. There was no significant difference in disease severity or mortality before and during the pandemic. Overall, females have more severe AH than males. Public health efforts should continue to be made to educate about the harms of alcohol excess and offer community support. Future studies will expand the trend through multiple pandemic waves. Funding Agencies None

OBJECTIVES:The prevalence and effects of anxiety on health-related quality of life and clinical outcomes in cirrhosis are not well understood. This is increasingly relevant during COVID-19. Our aim was to use the Mini-International Neuropsychiatric Interview (MINI) to determine the prevalence of anxiety, its association with clinical outcomes in cirrhosis and to develop a rapid cirrhosis-specific anxiety screening nomogram. METHODS:Adults with a diagnosis of cirrhosis were prospectively recruited as outpatients at three tertiary care hospitals across Alberta and followed for up to 6 months to determine the association with unplanned hospitalization/death. The Hospital Anxiety and Depression scale (HADS) was used as a screening tool as it is free of influence from somatic symptoms. Anxiety was diagnosed using the MINI. RESULTS:Of 304 patients, 17% of patients had anxiety by the MINI and 32% by the HADS. Anxious patients had lower health-related quality of life as assessed by the chronic liver disease questionnaire (P < 0.001) and EuroQol Visual Analogue Scale (P < 0.001), and also had higher levels of frailty using the Clinical Frailty score (P = 0.004). Multivariable analysis revealed smoking and three HADS subcomponents as independent predictors of anxiety. These were used to develop a rapid screening nomogram. CONCLUSION:A formal diagnosis of anxiety was made in approximately one in five patients with cirrhosis, and it was associated with worse HrQoL and frailty. The use of a 4-question nonsomatic symptom-based nomogram requires validation but is promising as a rapid screen for anxiety in cirrhosis.

BACKGROUND & AIMS: Coronavirus disease 2019 (COVID-19) pandemic lockdown and restrictions had significant disruption to patient care. We aimed to evaluate the impact of COVID-19 restrictions on hospitalizations of patients with alcoholic and nonalcoholic cirrhosis as well as alcoholic hepatitis (AH) in Alberta, Canada. METHODS: We used validated International Classification of Diseases (ICD-9 and ICD-10) coding algorithms to identify liver-related hospitalizations for nonalcoholic cirrhosis, alcoholic cirrhosis, and AH in the province of Alberta between March 2018 and September 2020. We used the provincial inpatient discharge and laboratory databases to identify our cohorts. We used elevated alanine aminotransferase or aspartate aminotransferase, elevated international normalized ratio, or bilirubin to identify AH patients. We compared COVID-19 restrictions (April-September 2020) with prior study periods. Joinpoint regression was used to evaluate the temporal trends among the 3 cohorts. RESULTS: We identified 2916 hospitalizations for nonalcoholic cirrhosis, 2318 hospitalizations for alcoholic cirrhosis, and 1408 AH hospitalizations during our study time. The in-hospital mortality rate was stable in relation to the pandemic for alcoholic cirrhosis and AH. However, nonalcoholic cirrhosis patients had lower in-hospital mortality rate after March 2020 (8.5% vs 11.5%; P = .033). There was a significant increase in average monthly admissions in the AH cohort (22.1/10,000 admissions during the pandemic vs 11.6/10,000 admissions before March 2020; P < .001). CONCLUSIONS: Before and during COVID-19 monthly admission rates were stable for nonalcoholic and alcoholic cirrhosis; however, there was a significant increase in AH admissions. Because alcohol sales surged during the pandemic, future impact on alcoholic liver disease could be detrimental.

BACKGROUND: Identifying strategies for stopping nucleos(t)ide analogues (NUC) in patients with chronic hepatitis B (CHB) is a major goal in CHB management. Our study describes our tertiary-centre experience stopping nucleos(t)ide analogues (NUC) in CHB. METHODS: We conducted a retrospective cohort study of all individuals with CHB seen at the Calgary Liver Unit between January 2009 and May 2020 who stopped NUC. We collected baseline demographics and HBV lab parameters before and after stopping NUC with results stratified by off-treatment durability. Clinical flare was defined as alanine aminotransferase (ALT) above twice upper limit of normal and virological flare as HBV DNA >2000 IU/mL. RESULTS: Forty-seven (3.5%) of the 1337 individuals with CHB stopped NUC therapy. During follow-up, six patients (12.8%) restarted NUCs due to flare. All flares occurred within six months of discontinuation. Median time to restart treatment was 90 days (Q1 65, Q3 133). Upon restarting, all showed suppression of HBV DNA and ALT normalization. Factors associated with restarting NUC therapy included hepatitis B e antigen (HBeAg) positive status at first appointment and longer NUC consolidation therapy. Age, sex, ethnicity, liver stiffness measurement, choice of NUC, and quantitative hepatitis B surface antigen (qHBsAg) level at stopping were not associated with sustained response off-treatment. Six patients had functional cure with HBsAg loss. CONCLUSIONS: Stopping long-term NUC is feasible in HBeAg negative CHB. Hepatic flares can occur despite low levels of qHBsAg. Finite NUC therapy can be considered in eligible patients who are adherent to close monitoring and follow-up, particularly in the first six months after stopping NUC therapy.