Choosing Wisely Canada-Top Five List in Hepatology: Official Position Statement of the Canadian Association for the Study of the Liver (CASL) and Choosing Wisely Canada (CWC)

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Renner, Carla S. Coffin, Eric M. Yoshida, Phil Wong, Marilyn Zeman, Hemant Shah" "autores" => array:7 [ 0 => array:4 [ "nombre" => "Mayur" "apellidos" => "Brahmania" "email" => array:1 [ 0 => "mbrahmania@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Eberhard L." "apellidos" => "Renner" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "†" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Carla S." "apellidos" => "Coffin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "‡" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Eric M." "apellidos" => "Yoshida" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "§" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "Phil" "apellidos" => "Wong" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "||" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "Marilyn" "apellidos" => "Zeman" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "¶" "identificador" => "aff0030" ] ] ] 6 => array:3 [ "nombre" => "Hemant" "apellidos" => "Shah" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "**" "identificador" => "aff0035" ] ] ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "University of Western, Canada." "etiqueta" => "*" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "University of Manitoba, Canada." "etiqueta" => "†" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "University of Calgary, Canada." "etiqueta" => "‡" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "University of British Columbia, Canada." "etiqueta" => "§" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "McGill University, Canada." "etiqueta" => "||" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "University of Alberta, Canada." "etiqueta" => "¶" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Francis Family Liver Clinic, University of Toronto, Canada, Canada." "etiqueta" => "**" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "*" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 493 "Ancho" => 2075 "Tamanyo" => 102665 ] ] "descripcion" => array:1 [ "en" => "Framework for physician list development as per Choosing Wisely Canada." ] ] ] "textoCompleto" => "IntroductionThe prevalence of chronic liver disease (CLD) is increasing in many countries around the world. It has been estimated that between 1990 and 2010 the overall prevalence of chronic liver disease has increased by 15% in the entire population and with that CLD has become one of the top 12 causes of hospitalizations, liver cancers and death among all gastrointestinal, liver and pancreatic diseases.<a class="elsevierStyleCrossRefs" href="#bib0005">1</a>–<a class="elsevierStyleCrossRef" href="#bib0020">4</a> CLD can affect quality of life through debilitating symptoms, reduction in ability to work and social stigma. Moreover, the burden CLD places on the individual health care system, and society is staggering. The overall cost of > $2 billion dollars is expected to continue to rise in annual direct medical costs of treating persons with CLD and indirectly with lost productivity.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> However, rising health care costs may partly be due to the inappropriate overuse of investigations, treatments, and procedures that can also contribute to or cause patient harm.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>The American Board of Internal Medicine (ABIM) launched the Choosing Wisely campaign in 2012, which sought to create discussions between patients and providers that promote better value care.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> One of the most visible platforms for these discussions has been the dissemination of lists created by professional societies of “Five Things that Physicians and Patients Should Question”. In the form of declarative statements, the lists identify practices that should be reduced or eliminated because they lack proven benefit or may cause harm to patients. This campaign was introduced in Canada in 2014 and by mid-2017 over 40 medical and surgical society lists have been created.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Choosing Wisely Canada has encouraged professional societies to preferentially focus on practices that are within their purview of practice to develop statements that are directly actionable by their members. Currently, there are variations in Hepatology practice that lead some patients to receive therapies or investigations that lack benefit and may be potentially harmful.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>This position statement describes the initiative led by the Canadian Association for the Study of the Liver (CASL) to develop a Choosing Wisely Canada list of “Five Things that Physicians and Patients Should Question in Hepatology”.Material and MethodsThe CASL education committee struck a working group to develop the CWC top five list of recommendations using the framework proposed by Choosing Wisely Canada (<a class="elsevierStyleCrossRef" href="#f0005">Figure 1</a>).<elsevierMultimedia ident="f0005"></elsevierMultimedia>Initial survey of meSmbershipThe Choosing Wisely Canada (CWC) framework was first introduced to CASL members through an e-mail communication that provided an overview of the campaign as well as a request to members to submit recommendations on tests, treatments or procedures that should be reduced or eliminated based on members opinions that represent low-value care (June 2015). From the initial survey 8 recommendations were obtained that were compatible with CWC’s mission statement and aims.CASL Choosing Wisely Task ForceIn July 2016, a task force of seven members was convened representing a diverse group of adult Hepatologists with a broad range of clinical experience from several geographical regions, practice settings and institution types. Over a six-month period this task force conducted four teleconferences to develop a draft list of recommendations. The task force began by reviewing the initial suggestions and also added additional statements to this list. In total, there were eight statements incorporated from the membership survey and five new statements added by the task force members, for a total of thirteen suggestions that were developed into formal statements. The thirteen statements related to practices that met the following four criteria:<ul class="elsevierStyleList" id="l0005"><li class="elsevierStyleListItem" id="u0005">•Within the purview of Hepatology practice.</li><li class="elsevierStyleListItem" id="u0010">•Frequently seen in practice.</li><li class="elsevierStyleListItem" id="u0015">•Significant potential for uptake by other physicians and societies.</li><li class="elsevierStyleListItem" id="u0020">•Likely to have significant overall impact on the value of care provided by the members of our profession.</li></ul>Discussions were held until consensus was reached regarding the top eight statements. All members contributed edits to both the eight statements and the accompanying rationales.Vetting and endorsement of list by the CASL membershipThe draft recommendations were shared electronically with CASL membership via online survey sent in February and March, 2017 to provide an opportunity for feedback and to vote on a top five list. The task force based on member suggestions made changes and the revised recommendations were presented at a clinical symposium held at the Canadian Digestive Disease Week (CDDW) annual conference in Banff, Alberta, on March 5, 2017. During this forum members were provided the opportunity to engage in open discussion to review and rank the eight statements in order to generate a top five list. Real-time polling software (surveymonkey.com) was used to enable members to vote anonymously. Among those in attendance, none believed that any alternative statements should replace any of the eight statements presented. On final voting, all agreed that the top five declarative statements should be endorsed and disseminated by both CASL and Choosing Wisely Canada.Dissemination by CASL and Choosing Wisely CanadaFollowing the annual meeting, minor refinements to the declarative statements were made by the task force based on feedback from the session. The CASL Executive Committee provided full endorsement of the final list that was disseminated on July 19, 2017.ResultsThe final top five declarative statements of Hepatology practices that physicians and patients should question are listed in <a class="elsevierStyleCrossRef" href="#t0005">table 1</a>. In this section, we provide the reasoning behind the selection of each recommendation and how the statement may ultimately be incorporated into Hepatology practice to improve the value of care provided.<elsevierMultimedia ident="t0005"></elsevierMultimedia>Statement 1: Don’t order serum ammonia to diagnose or manage hepatic encephalopathy (HE)This statement was the most highly ranked. Members of the task force and those surveyed stated that ordering serum ammonia is highly prevalent within the practice of Hepatology and other specialties and that there was potential for significant uptake of this recommendation by other physicians and societies. The liver mostly clears ammonia with some extra-hepatic metabolism in muscle tissue. HE is caused by accumulation of unmetabolized ammonia resulting in neuropsychiatric toxicity and encephalopathy. However, elevated ammonia levels also occur in urea cycle disorders, Porto systemic shunting, gastrointestinal bleeding, shock, renal disease, etc.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Moreover, the accuracy of ammonia measurement is influenced by many factors including whether it is a venous or arterial sample, fist clenching, tourniquet use, and whether the sample is placed on ice and transfer time, as well as the analytical assay technique (direct or indirect) used. This may possibly prevent accurate measurements of ammonia in most clinical settings and rendering the results inaccurate/inconclusive. Thus, elevated ammonia levels do not add any diagnostic, staging, or prognostic value. The diagnosis of HE should be based on clinical judgment, and a trial of medications such as lactulose and rifaximin.<a class="elsevierStyleCrossRefs" href="#bib0060">12</a>–<a class="elsevierStyleCrossRef" href="#bib0080">16</a> If there is an inadequate response to medical therapy, the diagnosis of HE should be questioned and other etiologies considered.Statement 2: Don’t routinely transfuse fresh frozen plasma, vitamin K, or platelets to reverse abnormal tests of coagulation in patients with cirrhosis prior to abdominal paracentesis, endoscopic variceal band ligation, or any other minor invasive proceduresThis statement was ranked highly because it addresses a common problem in patients with end stage liver disease (ESLD), is highly relevant to Hepatologists, and has significant uptake potential by other specialties. Abdominal paracentesis and endoscopic variceal band ligation are common procedures in ESLD and most patients have abnormal coagulation parameters, hence the administration of prophylactic blood products (i.e., fresh frozen plasma, platelets, vitamin K) is commonplace. The transfusion of blood products pre-procedure may be unnecessary, pose increased risks of an adverse reaction, delay diagnosis, and increase the access and costs of care. Although ESLD is characterized by clinical bleeding and coagulopathy due to an imbalance between naturally occurring pro- and anti-coagulants, seminal studies have shown this is not the case and that blood coagulation is rebalanced with thrombin levels (the final enzyme of coagulation) being the same levels in both cirrhotic and normal healthy patients.<a class="elsevierStyleCrossRefs" href="#bib0085">17</a>–<a class="elsevierStyleCrossRef" href="#bib0095">19</a> Moreover, prothrombin (PT) time is expressed as an INR and this was devised initially, and validated, to standardize across laboratories the PT in patients receiving anticoagulation therapy with vitamin k antagonists such as warfarin.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> Thus, the test should be used in similar clinical scenarios and not standardized across all patient populations. Similarly, platelets provide a hemostatic plug through an interaction with von Willebrand factors (vWf) and thrombin generation, however, it has been shown vWf is up-regulated in cirrhotic patients restoring platelet adhesion while levels of ADAMTS 13 (a metalloprotease limiting vWf) are down-regulated.<a class="elsevierStyleCrossRef" href="#bib0105">21</a>,<a class="elsevierStyleCrossRef" href="#bib0110">22</a> While the Task force acknowledged that there are clinical circumstances that warrant the use of these products (i.e., platelets < 20, INR > 2.5), their routine use should be discouraged. Moreover, since physicians are often basing treatment decisions on individualized clinical scenarios, personal experience, and inherent judgment of risk vs. benefit, the word ‘routinely’ was selected to respect these circumstances.Statement 3: Don’t order HFE genotyping based on serum ferritin values alone to diagnose hereditary hemochromatosisHemochromatosis refers to excessive iron accumulation. The initial approach to diag-nosing hemochromatosis involves indirect markers of iron metabolism such as transferrin saturation (TS, a measure of the saturation of iron transport capacity in plasma) and serum ferritin (a measure of intracellular iron stores). Although studies have differed in use of cutoff values, a value of TS greater than 45% is often chosen for its high sensitivity for detecting C282Y homozygotes and will identify persons with minor secondary iron overload as well as some C282Y/ wild-type heterozygotes.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Serum ferritin has a significant false positive rate because of elevations related to inflammation and can be elevated in the absence of increased iron stores in patients with other liver diseases such as excess alcohol consumption, hepatitis B and C, and nonalcoholic fatty liver disease (NAFLD). It can also be elevated in non-liver diseases such as systemic inflammatory conditions. Thus, in a patient with a suggestive history, physical findings, or family history, a combination of TS and ferritin should be obtained before ordering an HFE mutation analysis.<a class="elsevierStyleCrossRef" href="#bib0120">24</a>Statement 4: Don’t perform computed tomography (CT) or magnetic resonance imaging (MRI) routinely to monitor benign focal liver lesions (ex. focal nodal hyperplasia, hemangioma)The widespread use of imaging modalities has steadily increased the detection rate of benign focal lesions.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> More importantly, the evaluation of liver lesions has taken on greater importance due to the increasing incidence of hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA).<a class="elsevierStyleCrossRef" href="#bib0130">26</a> Therefore, a thorough and systematic approach to the management of focal liver lesions is important with critical components including a detailed history, physical exam, blood tests, and selective radiological tests. For example, a liver lesion in the setting of chronic liver disease/ ESLD and portal hypertension should lead to a high index of suspicion for HCC. A radiological test is the most important aspect in the evaluation of a liver lesion and should begin with a high-quality ultrasound, followed by cross-sectional imaging with either a triple-phase CT or MRI. The combined imaging will give the clinician information about the characteristics of the liver lesion, its location and relationship to anatomical structures (such as the gallbladder and hepatic vasculature), and, in the case of malignancy, allow staging. In the case of benign lesions such as Hemangiomas and FNH, routine imaging follow-up is not needed unless patients experience pain or the lesion size is larger than 10 cm (which may require intervention).<a class="elsevierStyleCrossRef" href="#bib0135">27</a> Additionally, a hepatic adenoma (a benign lesion) would need closer follow-up to ensure size stability and no malignant transformation.Statement 5: Don’t repeat hepatitis C viral load testing in an individual who has established chronic infection, outside of antiviral treatmentHighly sensitive quantitative assays of hepatitis C RNA (viral load) are widely available. The test is appropriately used to confirm infection after a positive hepatitis C antibody test, to determine the duration of treatment for certain regimens, and to confirm sustained virological response at week 12 (SVR 12) after therapy is completed. It has been suggested that assessment of viral load at week 4 of therapy may help determine initial response to therapy and adherence. However, there is no data on how to use viral load levels during treatment to determine when to stop treatment for futility, and thus far the test utility is solely based on expert opinion. The utility of using HCV RNA testing periodically in individuals with chronic infection who are not being treated is not established, as it tends to remain stable and has no link to prognosis.<a class="elsevierStyleCrossRef" href="#bib0140">28</a>DiscussionThrough a structured consensus process, we have made recommendations to avoid 5 diagnostic and therapeutic interventions that are unnecessary, over utilized, costly, and potentially harmful.Hepatologists play an active role in our health care system through resource stewardship. The Choosing Wisely Canada campaign has stimulated discussion within our specialty and challenged CASL members to identify further opportunities for resource stewardship that are within our purview of practice. The CASL-Choosing Wisely Canada Top Five List in Hepatology is not a guideline document, but is meant to facilitate conversations between physicians and patients, and between physicians and other health care providers related to low-value practices.There are several important strengths of the Choosing Wisely Canada statements developed by CASL. First, this list was developed through broad consultation and engagement of CASL members with ample opportunity for contribution from members at large. Consensus was reached on the final five recommendations by the task force as well as by members of CASL who were present at our annual meeting. Second, the process created by the task force involved the application of objective criteria to rank each declarative statement. Third, all statements relate to practices within the purview of the field of Hepatology, which is important as it allows for immediate action by CASL members in effecting change in these areas, and teaching and modelling of these practices for other health care providers who provide care to patients with CLD. Additionally, although the Canada Health Act provide the framework for Canada’s universal health care system health care is administered by provincial and territorial government, highlighting the importance of developing consensus recommendations by CWC for application within a diverse health care system.The creation of the final top five recommendations also carries limitations. First, it does not represent a comprehensive list of low-value practices within Hepatology. Additional practices could have been included, however, we limited the list to five statements to adhere to the Choosing Wisely Canada (CWC) format. Second, some of the recommendations may be of lower cost impact than others that could have been included. However, the purpose of CWC is to improve quality (as well as decrease costs) and adherence to the recommendations selected will improve the quality of Hepatology care. Lastly, we should note the task force comprised adult Hepatologists and the literature search focused on data from adult populations. Consequently, these recommendations target patients with liver disease who are 18 years and older and their respective providers.ConclusionThe CWC statements in Hepatology endorsed by CASL represent a starting point to engage Hepatologists in a broader discussion related to healthcare utilization in Hepatology and to implement recommendations to improve care and reduce spiralling health care costs. The next step will include evaluation of the impact of these statements both at the local/provincial and national level and represents a valuable opportunity for research and collaboration among CASL members. Implementation of the CWC statements will improve healthcare utilization and delivery of care to all Canadians living with liver disease.Abbreviations<ul class="elsevierStyleList" id="l0010"><li class="elsevierStyleListItem" id="u0025">•ABIM: American Board of Internal Medicine.</li><li class="elsevierStyleListItem" id="u0030">•CASL: Canadian Association for the Study of the Liver.</li><li class="elsevierStyleListItem" id="u0035">•CDDW: Canadian Digestive Disease Week.</li><li class="elsevierStyleListItem" id="u0040">•CWC: Choosing Wisely Canada.</li><li class="elsevierStyleListItem" id="u0045">•CLD: chronic liver disease.</li><li class="elsevierStyleListItem" id="u0050">•CT: computed tomography.</li><li class="elsevierStyleListItem" id="u0055">•ESLD: end stage liver disease.</li><li class="elsevierStyleListItem" id="u0060">•HE: hepatic encephalopathy.</li><li class="elsevierStyleListItem" id="u0065">•HCC: hepatocellular carcinoma.</li><li class="elsevierStyleListItem" id="u0070">•MRI: magnetic resonance imaging.</li><li class="elsevierStyleListItem" id="u0075">•NAFLD: nonalcoholic fatty liver disease.</li><li class="elsevierStyleListItem" id="u0080">•PT: prothrombin.</li><li class="elsevierStyleListItem" id="u0085">•SVR 12: sustained virological response at week 12.</li><li class="elsevierStyleListItem" id="u0090">•TS: transferrin saturation.</li><li class="elsevierStyleListItem" id="u0095">•vWf: von Willebrand factors.</li></ul>Conflict of InterestThe authors declares that there is no conflict of interest regarding the publication of this article.DisclosuresThe authors have no financial disclosures to declare.AcknowledgmentsThe authors acknowledge Michelle Menard and Rebecca Swanson for providing administrative support to CASL. We would also like to thank Dr. Wendy Levinson and Karen MacDonald of Choosing Wisely Canada for their review and edits of the final Choosing Wisely statements and manuscript. Lastly, we would like to acknowledge Dr. Rick Schreiber and Dr. Marc Bilodeau from the CASL executive committee for taking an interest in promoting quality and patient safety in Canadian Hepatology practice." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1224760" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abs0010" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1138826" "titulo" => "Key words" ] 2 => array:2 [ "identificador" => "s0005" "titulo" => "Introduction" ] 3 => array:3 [ "identificador" => "s0010" "titulo" => "Material and Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "s0015" "titulo" => "Initial survey of meSmbership" ] 1 => array:2 [ "identificador" => "s0020" "titulo" => "CASL Choosing Wisely Task Force" ] 2 => array:2 [ "identificador" => "s0025" "titulo" => "Vetting and endorsement of list by the CASL membership" ] 3 => array:2 [ "identificador" => "s0030" "titulo" => "Dissemination by CASL and Choosing Wisely Canada" ] ] ] 4 => array:3 [ "identificador" => "s0035" "titulo" => "Results" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "s0040" "titulo" => "Statement 1: Don’t order serum ammonia to diagnose or manage hepatic encephalopathy (HE)" ] 1 => array:2 [ "identificador" => "s0045" "titulo" => "Statement 2: Don’t routinely transfuse fresh frozen plasma, vitamin K, or platelets to reverse abnormal tests of coagulation in patients with cirrhosis prior to abdominal paracentesis, endoscopic variceal band ligation, or any other minor invasive procedures" ] 2 => array:2 [ "identificador" => "s0050" "titulo" => "Statement 3: Don’t order HFE genotyping based on serum ferritin values alone to diagnose hereditary hemochromatosis" ] 3 => array:2 [ "identificador" => "s0055" "titulo" => "Statement 4: Don’t perform computed tomography (CT) or magnetic resonance imaging (MRI) routinely to monitor benign focal liver lesions (ex. focal nodal hyperplasia, hemangioma)" ] 4 => array:2 [ "identificador" => "s0060" "titulo" => "Statement 5: Don’t repeat hepatitis C viral load testing in an individual who has established chronic infection, outside of antiviral treatment" ] ] ] 5 => array:2 [ "identificador" => "s0065" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "s0070" "titulo" => "Conclusion" ] 7 => array:2 [ "identificador" => "s0075" "titulo" => "Abbreviations" ] 8 => array:2 [ "identificador" => "s0080" "titulo" => "Conflict of Interest" ] 9 => array:2 [ "identificador" => "s0085" "titulo" => "Disclosures" ] 10 => array:2 [ "identificador" => "s0090" "titulo" => "Acknowledgments" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-01-01" "fechaAceptado" => "2018-03-16" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Key words" "identificador" => "xpalclavsec1138826" "palabras" => array:4 [ 0 => "Choosing Wisely Canada" 1 => "Health care resources" 2 => "Hepatology" 3 => "Value" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Introduction and aim. The prevalence and incidence of chronic liver disease is increasing resulting, in substantial direct and indirect medical costs. Overuse of investigations, treatments and procedures contribute to rising health care costs and can expose patients to unnecessary harm and delay in receiving care. The Choosing Wisely Canada (CWC) campaign has encouraged professional societies to develop statements that are directly actionable by their members in an effort to promote higher-value health care that will lead to downstream effect on how other practitioners make decisions.Material and methods. The Canadian Association for the Study of the Liver (CASL) established its Choosing Wisely top five list of recommendations using the framework put forward by CWC. CASL convened a task force that developed a list of draft recommendations and shared this with CASL membership electronically with eventual ranking of the top five recommendations by consensus at Canadian Digestives Disease Week (CDDW) 2017. Following revisions, the CASL Executive Committee endorsed the final list, which was disseminated online by CWC (July 2017).Results. The top five recommendations physicians and patients should question include: 1) Don’t order serum ammonia to diagnose or manage hepatic encephalopathy (HE). 2) Don’t routinely transfuse fresh frozen plasma, vitamin K, or platelets to reverse abnormal tests of coagulation in patients with cirrhosis prior to abdominal paracentesis, endoscopic variceal band ligation, or any other minor invasive procedures. 3) Don’t order HFE genotyping based on serum ferritin values alone to diagnose hereditary hemochromatosis. 4) Don’t perform computed tomography (CT) or magnetic resonance imaging (MRI) routinely to monitor benign focal liver lesions. 5) Don’t repeat hepatitis C viral load testing in an individual who has established chronic infection, outside of anti-viral treatment.Conclusion. The Choosing Wisely recommendations will foster patient-physician discussions, reduce unnecessary treatment and testing, avert adverse effects from testing and treatment along with reducing medical expenditure in hepatology." ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "f0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 493 "Ancho" => 2075 "Tamanyo" => 102665 ] ] "descripcion" => array:1 [ "en" => "Framework for physician list development as per Choosing Wisely Canada." ] ] 1 => array:7 [ "identificador" => "t0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Rationale \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Don’t order serum ammonia to diagnose or manage hepatic encephalopathy (HE). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High blood-ammonia levels alone do not add any diagnostic, staging, or prognostic value in HE patients known to have chronic liver disease. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Don’t routinely transfuse fresh frozen plasma, platelets or give Vitamin K to reverse abnormal tests of coagulation in patients with cirrhosis prior to abdominal paracentesis, endoscopic variceal band ligation, or any other minor invasive procedures. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Routine tests of coagulation do not reflect bleeding risk in patients with cirrhosis and bleeding complications of these procedures are rare. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Don’t order HFE genotyping based on serum ferritin values alone to diagnose hereditary hemochromatosis. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Serum ferritin values reflect an increase in hepatic iron content and have a significant false positive rate because of elevations due to inflammation. Thus, in patients with evidence of liver disease, hemochromatosis genotyping should only be performed among individuals with an elevated ferritin and fasting transferrin saturation >45% (TSat) or a known family history of hemochromatosis-associated hereditary hemochromatosis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Don’t perform computed tomography (CT) or magnetic resonance imaging (MRI) routinely to monitor benign focal liver lesions (ex. focal nodal hyperplasia, hemangioma). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with benign focal liver lesions who do not have underlying liver disease and have demonstrated clinical (asymptomatic) and radiologic stability do not need repeated imaging as the likelihood of evolving into neoplastic lesions is very low. In contrast, patients with radiologic evidence of hepatocellular adenoma may have an increased risk of complications and/or neoplasia thus warranting closer observation. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Don’t repeat hepatitis C viral load testing in an individual who has established chronic infection, outside of antiviral treatment. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Highly sensitive quantitative assays of hepatitis C RNA are appropriate at the time of diagnosis (to confirm infection) and as part of antiviral therapy, which is typically at the beginning and after therapy is completed to confirm sustained virological response at week 12 (SVR 12). Outside of these circumstances the results of virologic testing do not usually change clinical management or outcomes. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2092089.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Canadian Association for the Study of Liver Diseases-Choosing Wisely Canada Physician Recommendations for Hepatology." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bs0010" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Changes in the prevalence of the most common causes of chronic liver diseases in the United States from 1988 to 2008." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Younossi ZM" 1 => "Stepanova M" 2 => "Afendy M" 3 => "Fang Y" 4 => "Younossi Y" 5 => "Mir H" 6 => "Srishord M" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/lt.25613" "Revista" => array:6 [ "tituloSerie" => "Clinical Gastroenterology & Hepatology" "fecha" => "2011" "volumen" => "9" "paginaInicial" => "524" "paginaFinal" => "530" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31344758" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The state of US health, 1990-2010: burden of diseases, injuries, and risk factors." "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:7 [ 0 => "Murray CJ" 1 => "Atkinson C" 2 => "Bhalla K" 3 => "Birbeck G" 4 => "Burstein R" 5 => "Chou D" 6 => "Dellavalle R" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Am Med Associat" "fecha" => "2013" "volumen" => "310" "paginaInicial" => "591" "paginaFinal" => "608" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Burden of Gastrointestinal, Liver, and Pancreatic Diseases in the United States." "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:7 [ 0 => "Peery AF" 1 => "Crockett SD" 2 => "Barritt AS" 3 => "Dellon ES" 4 => "Eluri S" 5 => "Ganga-rosa LM" 6 => "Jensen ET" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.gastro.2015.08.045" "Revista" => array:6 [ "tituloSerie" => "Gastroenterology" "fecha" => "2015" "volumen" => "149" "paginaInicial" => "1731" "paginaFinal" => "1741" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26327134" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4." "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Kochanek KD, Murphy SL, Xu J, Thejada-Vera B. National Vital Statistics Reports Deaths: Final Data for 2014. 2016. Available from: https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf." ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current and Future Burden of Chronic Nonmalignant Liver Disease." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Udompap P" 1 => "Kim D" 2 => "Kim WR" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.cgh.2015.08.015" "Revista" => array:6 [ "tituloSerie" => "Clin Gastroenterol Hepatol" "fecha" => "2015" "volumen" => "13" "paginaInicial" => "2031" "paginaFinal" => "2041" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26291665" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6." "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Ruhl CE, Sayer B, Byrd-Holt DE, Brown DM. Costs of digestive diseases. The Burden of Digestive Diseases in the United States. NIH publication; 2008, p. 137-43." ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "High-value health care -a sustainable prop-osition." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Curfman GD" 1 => "Morrissey S" 2 => "Drazen JM" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "New Engl J Med" "fecha" => "2013" "volumen" => "369" "paginaInicial" => "1163" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Choosing Wisely Helping Physicians and Patients Make Smart Decisions About Their Care." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Cassel CK" 1 => "Guest JA" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Am Med Associat" "fecha" => "2012" "volumen" => "307" "paginaInicial" => "1801" "paginaFinal" => "1802" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Engaging physicians and patients in conversations about un-necessary tests and procedures: Choosing Wisely Canada." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Levinson W" 1 => "Huynh T" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1503/cmaj.131674" "Revista" => array:6 [ "tituloSerie" => "Canadian Medical Association Journal" "fecha" => "2014" "volumen" => "186" "paginaInicial" => "325" "paginaFinal" => "326" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24549128" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The quality of care provided to patients with cirrhosis and ascites in the Department of Veterans Affairs." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:8 [ 0 => "Kanwal F" 1 => "Kramer JR" 2 => "Buchanan P" 3 => "Asch SM" 4 => "Assioun Y" 5 => "Bacon BR" 6 => "Li J" 7 => "El-Serag HB" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.gastro.2012.03.038" "Revista" => array:6 [ "tituloSerie" => "Gastroenterology" "fecha" => "2012" "volumen" => "143" "paginaInicial" => "70" "paginaFinal" => "77" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22465432" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Blood ammonia levels and hepatic encephalopathy." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Lockwood AH" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Metabolic Brain Disease" "fecha" => "2004" "volumen" => "19" "paginaInicial" => "345" "paginaFinal" => "349" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15554426" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hepatic Encephalopathy in Chronic Liver Disease: 2014 Practice Guideline by AASLD and EASL." "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:7 [ 0 => "Vilstrup H" 1 => "Amodio P" 2 => "Bajaj J" 3 => "Cordoba J" 4 => "Ferenci P" 5 => "Mullen KD" 6 => "Weissenborn K" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/hep.27210" "Revista" => array:6 [ "tituloSerie" => "Hepatology" "fecha" => "2014" "volumen" => "60" "paginaInicial" => "715" "paginaFinal" => "735" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25042402" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Role of determination of partial pressure of ammonia in cirrhotic patients with and without hepatic encephalo-pathy." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Nicolao F" 1 => "Efrati C" 2 => "Masini A" 3 => "Merli M" 4 => "Attili AF" 5 => "Riggio O" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Hepatol" "fecha" => "2003" "volumen" => "38" "paginaInicial" => "441" "paginaFinal" => "446" "itemHostRev" => array:3 [ "pii" => "S0266613814001752" "estado" => "S300" "issn" => "02666138" ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Correlation between ammonia levels and the severity of hepatic encephalopathy." "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:7 [ 0 => "Ong JP" 1 => "Aggarwal A" 2 => "Krieger D" 3 => "Easley KA" 4 => "Karafa MT" 5 => "Van Lente F" 6 => "Arroliga AC" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0002-9343(02)01477-8" "Revista" => array:7 [ "tituloSerie" => "Am J Med" "fecha" => "2003" "volumen" => "114" "paginaInicial" => "188" "paginaFinal" => "193" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12637132" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S026661381300274X" "estado" => "S300" "issn" => "02666138" ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "How to diagnose hepatic encephalopathy in the emergency department." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Gundling F" 1 => "Zelihic E" 2 => "Seidl H" 3 => "Haller B" 4 => "Umgelter A" 5 => "Schepp W" 6 => "Dodt C" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Hepatol" "fecha" => "2013" "volumen" => "12" "paginaInicial" => "108" "paginaFinal" => "114" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23293201" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rifaximin treatment in hepatic encephalopathy." 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"autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Dahlback B" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Internat J Hematol" "fecha" => "2004" "volumen" => "79" "paginaInicial" => "109" "paginaFinal" => "116" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acquired coagulation disorders: revisited using global coagulation/anticoagulation testing." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Tripodi A" 1 => "Chantarangkul V" 2 => "Mannucci PM" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Brit J Haematol" "fecha" => "2009" "volumen" => "147" "paginaInicial" => "77" "paginaFinal" => "82" ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Elevated levels of von Willebrand factor in cirrhosis support platelet adhesion despite reduced functional capacity." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Lisman T" 1 => "Bongers TN" 2 => "Adelmeijer J" 3 => "Janssen HL" 4 => "de Maat MP" 5 => "de Groot PG" 6 => "Leebeek FW" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/hep.21231" "Revista" => array:6 [ "tituloSerie" => "Hepatology" "fecha" => "2006" "volumen" => "44" "paginaInicial" => "53" "paginaFinal" => "61" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16799972" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The coagulopathy of chronic liver disease." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Tripodi A" 1 => "Mannucci PM" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMra1011170" "Revista" => array:7 [ "tituloSerie" => "New Engl J Med" "fecha" => "2011" "volumen" => "365" "paginaInicial" => "147" "paginaFinal" => "156" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21751907" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0266613813000077" "estado" => "S300" "issn" => "02666138" ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Biological variability of transferrin saturation and unsaturated iron-binding capacity." "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:7 [ 0 => "Adams PC" 1 => "Reboussin DM" 2 => "Press RD" 3 => "Barton JC" 4 => "Acton RT" 5 => "Moses GC" 6 => "Leiendecker-Foster C" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjmed.2006.07.023" "Revista" => array:6 [ "tituloSerie" => "Am J Med" "fecha" => "2007" "volumen" => "120" "paginaInicial" => "e1" "paginaFinal" => "e7" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18060901" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and Management of hemochromatosis: 2011 practice Guideline by the American Association of for the Study of Liver Disease." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Bacon BR" 1 => "Adams PC" 2 => "Kowdley KV" 3 => "Powell LW" 4 => "Tavill AS" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/hep.24330" "Revista" => array:6 [ "tituloSerie" => "Hepatology" "fecha" => "2011" "volumen" => "54" "paginaInicial" => "328" "paginaFinal" => "334" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21452290" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996-2010." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Smith-Bindman R" 1 => "Miglioretti DL" 2 => "Johnson E" 3 => "Lee C" 4 => "Feigelson HS" 5 => "Flynn M" 6 => "Greenlee RT" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Am Med Associat" "fecha" => "2012" "volumen" => "307" "paginaInicial" => "2400" "paginaFinal" => "2409" ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of hepatocellular carcinoma: an update." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Bruix J" 1 => "Sherman M" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/hep.24199" "Revista" => array:6 [ "tituloSerie" => "Hepatology" "fecha" => "2011" "volumen" => "53" "paginaInicial" => "1020" "paginaFinal" => "1022" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21374666" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ACG Clinical Guideline: The Diagnosis and Manage-ment of Focal Liver Lesions." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Marrero JA" 1 => "Ahn J" 2 => "Reddy R" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/ajg.2014.213" "Revista" => array:6 [ "tituloSerie" => "Am J Gastroenterol" "fecha" => "2014" "volumen" => "109" "paginaInicial" => "1328" "paginaFinal" => "1347" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25135008" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0140" "etiqueta" => "28." "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "AASLD-IDSA. Recommendations for testing, managing, and treating hepatitis C. Available from: http:/www.hcvguidelines.org. 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Mayur Brahmania

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mbrahmania@gmail.com

Corresponding author.

, Eberhard L. Renner†, Carla S. Coffin‡, Eric M. Yoshida§, Phil Wong||, Marilyn Zeman¶, Hemant Shah**

* University of Western, Canada.

† University of Manitoba, Canada.

‡ University of Calgary, Canada.

§ University of British Columbia, Canada.

|| McGill University, Canada.

¶ University of Alberta, Canada.

** Francis Family Liver Clinic, University of Toronto, Canada, Canada.

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0015">Introduction</span><p id="p0005" class="elsevierStylePara elsevierViewall">The prevalence of chronic liver disease &#40;CLD&#41; is increasing in many countries around the world&#46; It has been estimated that between 1990 and 2010 the overall prevalence of chronic liver disease has increased by 15&#37; in the entire population and with that CLD has become one of the top 12 causes of hospitalizations&#44; liver cancers and death among all gastrointestinal&#44; liver and pancreatic diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0005">1</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib0020">4</a> CLD can affect quality of life through debilitating symptoms&#44; reduction in ability to work and social stigma&#46; Moreover&#44; the burden CLD places on the individual health care system&#44; and society is staggering&#46; The overall cost of &#62; &#36;2 billion dollars is expected to continue to rise in annual direct medical costs of treating persons with CLD and indirectly with lost productivity&#46;<a class="elsevierStyleCrossRef" href="#bib0025">5</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0030">6</a> However&#44; rising health care costs may partly be due to the inappropriate overuse of investigations&#44; treatments&#44; and procedures that can also contribute to or cause patient harm&#46;<a class="elsevierStyleCrossRef" href="#bib0035">7</a></p><p id="p0010" class="elsevierStylePara elsevierViewall">The American Board of Internal Medicine &#40;ABIM&#41; launched the Choosing Wisely campaign in 2012&#44; which sought to create discussions between patients and providers that promote better value care&#46;<a class="elsevierStyleCrossRef" href="#bib0040">8</a> One of the most visible platforms for these discussions has been the dissemination of lists created by professional societies of &#8220;Five Things that Physicians and Patients Should Question&#8221;&#46; In the form of declarative statements&#44; the lists identify practices that should be reduced or eliminated because they lack proven benefit or may cause harm to patients&#46; This campaign was introduced in Canada in 2014 and by mid-2017 over 40 medical and surgical society lists have been created&#46;<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Choosing Wisely Canada has encouraged professional societies to preferentially focus on practices that are within their purview of practice to develop statements that are directly actionable by their members&#46; Currently&#44; there are variations in Hepatology practice that lead some patients to receive therapies or investigations that lack benefit and may be potentially harmful&#46;<a class="elsevierStyleCrossRef" href="#bib0050">10</a></p><p id="p0015" class="elsevierStylePara elsevierViewall">This position statement describes the initiative led by the Canadian Association for the Study of the Liver &#40;CASL&#41; to develop a Choosing Wisely Canada list of &#8220;Five Things that Physicians and Patients Should Question in Hepatology&#8221;&#46;</p></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Material and Methods</span><p id="p0020" class="elsevierStylePara elsevierViewall">The CASL education committee struck a working group to develop the CWC top five list of recommendations using the framework proposed by Choosing Wisely Canada &#40;<a class="elsevierStyleCrossRef" href="#f0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Initial survey of meSmbership</span><p id="p0025" class="elsevierStylePara elsevierViewall">The Choosing Wisely Canada &#40;CWC&#41; framework was first introduced to CASL members through an e-mail communication that provided an overview of the campaign as well as a request to members to submit recommendations on tests&#44; treatments or procedures that should be reduced or eliminated based on members opinions that represent low-value care &#40;June 2015&#41;&#46; From the initial survey 8 recommendations were obtained that were compatible with CWC&#8217;s mission statement and aims&#46;</p></span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0030">CASL Choosing Wisely Task Force</span><p id="p0030" class="elsevierStylePara elsevierViewall">In July 2016&#44; a task force of seven members was convened representing a diverse group of adult Hepatologists with a broad range of clinical experience from several geographical regions&#44; practice settings and institution types&#46; Over a six-month period this task force conducted four teleconferences to develop a draft list of recommendations&#46; The task force began by reviewing the initial suggestions and also added additional statements to this list&#46; In total&#44; there were eight statements incorporated from the membership survey and five new statements added by the task force members&#44; for a total of thirteen suggestions that were developed into formal statements&#46; The thirteen statements related to practices that met the following four criteria&#58;<ul class="elsevierStyleList" id="l0005"><li class="elsevierStyleListItem" id="u0005"><span class="elsevierStyleLabel">&#8226;</span><p id="p0035" class="elsevierStylePara elsevierViewall">Within the purview of Hepatology practice&#46;</p></li><li class="elsevierStyleListItem" id="u0010"><span class="elsevierStyleLabel">&#8226;</span><p id="p0040" class="elsevierStylePara elsevierViewall">Frequently seen in practice&#46;</p></li><li class="elsevierStyleListItem" id="u0015"><span class="elsevierStyleLabel">&#8226;</span><p id="p0045" class="elsevierStylePara elsevierViewall">Significant potential for uptake by other physicians and societies&#46;</p></li><li class="elsevierStyleListItem" id="u0020"><span class="elsevierStyleLabel">&#8226;</span><p id="p0050" class="elsevierStylePara elsevierViewall">Likely to have significant overall impact on the value of care provided by the members of our profession&#46;</p></li></ul></p><p id="p0055" class="elsevierStylePara elsevierViewall">Discussions were held until consensus was reached regarding the top eight statements&#46; All members contributed edits to both the eight statements and the accompanying rationales&#46;</p></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Vetting and endorsement of list by the CASL membership</span><p id="p0060" class="elsevierStylePara elsevierViewall">The draft recommendations were shared electronically with CASL membership via online survey sent in February and March&#44; 2017 to provide an opportunity for feedback and to vote on a top five list&#46; The task force based on member suggestions made changes and the revised recommendations were presented at a clinical symposium held at the Canadian Digestive Disease Week &#40;CDDW&#41; annual conference in Banff&#44; Alberta&#44; on March 5&#44; 2017&#46; During this forum members were provided the opportunity to engage in open discussion to review and rank the eight statements in order to generate a top five list&#46; Real-time polling software &#40;surveymonkey&#46;com&#41; was used to enable members to vote anonymously&#46; Among those in attendance&#44; none believed that any alternative statements should replace any of the eight statements presented&#46; On final voting&#44; all agreed that the top five declarative statements should be endorsed and disseminated by both CASL and Choosing Wisely Canada&#46;</p></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0040">Dissemination by CASL and Choosing Wisely Canada</span><p id="p0065" class="elsevierStylePara elsevierViewall">Following the annual meeting&#44; minor refinements to the declarative statements were made by the task force based on feedback from the session&#46; The CASL Executive Committee provided full endorsement of the final list that was disseminated on July 19&#44; 2017&#46;</p></span></span><span id="s0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Results</span><p id="p0070" class="elsevierStylePara elsevierViewall">The final top five declarative statements of Hepatology practices that physicians and patients should question are listed in <a class="elsevierStyleCrossRef" href="#t0005">table 1</a>&#46; In this section&#44; we provide the reasoning behind the selection of each recommendation and how the statement may ultimately be incorporated into Hepatology practice to improve the value of care provided&#46;</p><elsevierMultimedia ident="t0005"></elsevierMultimedia><span id="s0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0050">Statement 1&#58; Don&#8217;t order serum ammonia to diagnose or manage hepatic encephalopathy &#40;HE&#41;</span><p id="p0075" class="elsevierStylePara elsevierViewall">This statement was the most highly ranked&#46; Members of the task force and those surveyed stated that ordering serum ammonia is highly prevalent within the practice of Hepatology and other specialties and that there was potential for significant uptake of this recommendation by other physicians and societies&#46; The liver mostly clears ammonia with some extra-hepatic metabolism in muscle tissue&#46; HE is caused by accumulation of unmetabolized ammonia resulting in neuropsychiatric toxicity and encephalopathy&#46; However&#44; elevated ammonia levels also occur in urea cycle disorders&#44; Porto systemic shunting&#44; gastrointestinal bleeding&#44; shock&#44; renal disease&#44; etc&#46;<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Moreover&#44; the accuracy of ammonia measurement is influenced by many factors including whether it is a venous or arterial sample&#44; fist clenching&#44; tourniquet use&#44; and whether the sample is placed on ice and transfer time&#44; as well as the analytical assay technique &#40;direct or indirect&#41; used&#46; This may possibly prevent accurate measurements of ammonia in most clinical settings and rendering the results inaccurate&#47;inconclusive&#46; Thus&#44; elevated ammonia levels do not add any diagnostic&#44; staging&#44; or prognostic value&#46; The diagnosis of HE should be based on clinical judgment&#44; and a trial of medications such as lactulose and rifaximin&#46;<a class="elsevierStyleCrossRefs" href="#bib0060">12</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib0080">16</a> If there is an inadequate response to medical therapy&#44; the diagnosis of HE should be questioned and other etiologies considered&#46;</p></span><span id="s0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0055">Statement 2&#58; Don&#8217;t routinely transfuse fresh frozen plasma&#44; vitamin K&#44; or platelets to reverse abnormal tests of coagulation in patients with cirrhosis prior to abdominal paracentesis&#44; endoscopic variceal band ligation&#44; or any other minor invasive procedures</span><p id="p0080" class="elsevierStylePara elsevierViewall">This statement was ranked highly because it addresses a common problem in patients with end stage liver disease &#40;ESLD&#41;&#44; is highly relevant to Hepatologists&#44; and has significant uptake potential by other specialties&#46; Abdominal paracentesis and endoscopic variceal band ligation are common procedures in ESLD and most patients have abnormal coagulation parameters&#44; hence the administration of prophylactic blood products &#40;i&#46;e&#46;&#44; fresh frozen plasma&#44; platelets&#44; vitamin K&#41; is commonplace&#46; The transfusion of blood products pre-procedure may be unnecessary&#44; pose increased risks of an adverse reaction&#44; delay diagnosis&#44; and increase the access and costs of care&#46; Although ESLD is characterized by clinical bleeding and coagulopathy due to an imbalance between naturally occurring pro- and anti-coagulants&#44; seminal studies have shown this is not the case and that blood coagulation is rebalanced with thrombin levels &#40;the final enzyme of coagulation&#41; being the same levels in both cirrhotic and normal healthy patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0085">17</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib0095">19</a> Moreover&#44; prothrombin &#40;PT&#41; time is expressed as an INR and this was devised initially&#44; and validated&#44; to standardize across laboratories the PT in patients receiving anticoagulation therapy with vitamin k antagonists such as warfarin&#46;<a class="elsevierStyleCrossRef" href="#bib0100">20</a> Thus&#44; the test should be used in similar clinical scenarios and not standardized across all patient populations&#46; Similarly&#44; platelets provide a hemostatic plug through an interaction with von Willebrand factors &#40;vWf&#41; and thrombin generation&#44; however&#44; it has been shown vWf is up-regulated in cirrhotic patients restoring platelet adhesion while levels of ADAMTS 13 &#40;a metalloprotease limiting vWf&#41; are down-regulated&#46;<a class="elsevierStyleCrossRef" href="#bib0105">21</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0110">22</a> While the Task force acknowledged that there are clinical circumstances that warrant the use of these products &#40;i&#46;e&#46;&#44; platelets &#60; 20&#44; INR &#62; 2&#46;5&#41;&#44; their routine use should be discouraged&#46; Moreover&#44; since physicians are often basing treatment decisions on individualized clinical scenarios&#44; personal experience&#44; and inherent judgment of risk <span class="elsevierStyleItalic">vs&#46;</span> benefit&#44; the word &#8216;routinely&#8217; was selected to respect these circumstances&#46;</p></span><span id="s0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0060">Statement 3&#58; Don&#8217;t order HFE genotyping based on serum ferritin values alone to diagnose hereditary hemochromatosis</span><p id="p0085" class="elsevierStylePara elsevierViewall">Hemochromatosis refers to excessive iron accumulation&#46; The initial approach to diag-nosing hemochromatosis involves indirect markers of iron metabolism such as transferrin saturation &#40;TS&#44; a measure of the saturation of iron transport capacity in plasma&#41; and serum ferritin &#40;a measure of intracellular iron stores&#41;&#46; Although studies have differed in use of cutoff values&#44; a value of TS greater than 45&#37; is often chosen for its high sensitivity for detecting C282Y homozygotes and will identify persons with minor secondary iron overload as well as some C282Y&#47; wild-type heterozygotes&#46;<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Serum ferritin has a significant false positive rate because of elevations related to inflammation and can be elevated in the absence of increased iron stores in patients with other liver diseases such as excess alcohol consumption&#44; hepatitis B and C&#44; and nonalcoholic fatty liver disease &#40;NAFLD&#41;&#46; It can also be elevated in non-liver diseases such as systemic inflammatory conditions&#46; Thus&#44; in a patient with a suggestive history&#44; physical findings&#44; or family history&#44; a combination of TS and ferritin should be obtained before ordering an HFE mutation analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0120">24</a></p></span><span id="s0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0065">Statement 4&#58; Don&#8217;t perform computed tomography &#40;CT&#41; or magnetic resonance imaging &#40;MRI&#41; routinely to monitor benign focal liver lesions &#40;ex&#46; focal nodal hyperplasia&#44; hemangioma&#41;</span><p id="p0090" class="elsevierStylePara elsevierViewall">The widespread use of imaging modalities has steadily increased the detection rate of benign focal lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0125">25</a> More importantly&#44; the evaluation of liver lesions has taken on greater importance due to the increasing incidence of hepatocellular carcinoma &#40;HCC&#41; and cholangiocarcinoma &#40;CCA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130">26</a> Therefore&#44; a thorough and systematic approach to the management of focal liver lesions is important with critical components including a detailed history&#44; physical exam&#44; blood tests&#44; and selective radiological tests&#46; For example&#44; a liver lesion in the setting of chronic liver disease&#47; ESLD and portal hypertension should lead to a high index of suspicion for HCC&#46; A radiological test is the most important aspect in the evaluation of a liver lesion and should begin with a high-quality ultrasound&#44; followed by cross-sectional imaging with either a triple-phase CT or MRI&#46; The combined imaging will give the clinician information about the characteristics of the liver lesion&#44; its location and relationship to anatomical structures &#40;such as the gallbladder and hepatic vasculature&#41;&#44; and&#44; in the case of malignancy&#44; allow staging&#46; In the case of benign lesions such as Hemangiomas and FNH&#44; routine imaging follow-up is not needed unless patients experience pain or the lesion size is larger than 10 cm &#40;which may require intervention&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0135">27</a> Additionally&#44; a hepatic adenoma &#40;a benign lesion&#41; would need closer follow-up to ensure size stability and no malignant transformation&#46;</p></span><span id="s0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0070">Statement 5&#58; Don&#8217;t repeat hepatitis C viral load testing in an individual who has established chronic infection&#44; outside of antiviral treatment</span><p id="p0095" class="elsevierStylePara elsevierViewall">Highly sensitive quantitative assays of hepatitis C RNA &#40;viral load&#41; are widely available&#46; The test is appropriately used to confirm infection after a positive hepatitis C antibody test&#44; to determine the duration of treatment for certain regimens&#44; and to confirm sustained virological response at week 12 &#40;SVR 12&#41; after therapy is completed&#46; It has been suggested that assessment of viral load at week 4 of therapy may help determine initial response to therapy and adherence&#46; However&#44; there is no data on how to use viral load levels during treatment to determine when to stop treatment for futility&#44; and thus far the test utility is solely based on expert opinion&#46; The utility of using HCV RNA testing periodically in individuals with chronic infection who are not being treated is not established&#44; as it tends to remain stable and has no link to prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0140">28</a></p></span></span><span id="s0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0075">Discussion</span><p id="p0100" class="elsevierStylePara elsevierViewall">Through a structured consensus process&#44; we have made recommendations to avoid 5 diagnostic and therapeutic interventions that are unnecessary&#44; over utilized&#44; costly&#44; and potentially harmful&#46;</p><p id="p0105" class="elsevierStylePara elsevierViewall">Hepatologists play an active role in our health care system through resource stewardship&#46; The Choosing Wisely Canada campaign has stimulated discussion within our specialty and challenged CASL members to identify further opportunities for resource stewardship that are within our purview of practice&#46; The CASL-Choosing Wisely Canada Top Five List in Hepatology is not a guideline document&#44; but is meant to facilitate conversations between physicians and patients&#44; and between physicians and other health care providers related to low-value practices&#46;</p><p id="p0110" class="elsevierStylePara elsevierViewall">There are several important strengths of the Choosing Wisely Canada statements developed by CASL&#46; First&#44; this list was developed through broad consultation and engagement of CASL members with ample opportunity for contribution from members at large&#46; Consensus was reached on the final five recommendations by the task force as well as by members of CASL who were present at our annual meeting&#46; Second&#44; the process created by the task force involved the application of objective criteria to rank each declarative statement&#46; Third&#44; all statements relate to practices within the purview of the field of Hepatology&#44; which is important as it allows for immediate action by CASL members in effecting change in these areas&#44; and teaching and modelling of these practices for other health care providers who provide care to patients with CLD&#46; Additionally&#44; although the Canada Health Act provide the framework for Canada&#8217;s universal health care system health care is administered by provincial and territorial government&#44; highlighting the importance of developing consensus recommendations by CWC for application within a diverse health care system&#46;</p><p id="p0115" class="elsevierStylePara elsevierViewall">The creation of the final top five recommendations also carries limitations&#46; First&#44; it does not represent a comprehensive list of low-value practices within Hepatology&#46; Additional practices could have been included&#44; however&#44; we limited the list to five statements to adhere to the Choosing Wisely Canada &#40;CWC&#41; format&#46; Second&#44; some of the recommendations may be of lower cost impact than others that could have been included&#46; However&#44; the purpose of CWC is to improve quality &#40;as well as decrease costs&#41; and adherence to the recommendations selected will improve the quality of Hepatology care&#46; Lastly&#44; we should note the task force comprised adult Hepatologists and the literature search focused on data from adult populations&#46; Consequently&#44; these recommendations target patients with liver disease who are 18 years and older and their respective providers&#46;</p></span><span id="s0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0080">Conclusion</span><p id="p0120" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">CWC</span> statements in Hepatology endorsed by CASL represent a starting point to engage Hepatologists in a broader discussion related to healthcare utilization in Hepatology and to implement recommendations to improve care and reduce spiralling health care costs&#46; The next step will include evaluation of the impact of these statements both at the local&#47;provincial and national level and represents a valuable opportunity for research and collaboration among CASL members&#46; Implementation of the CWC statements will improve healthcare utilization and delivery of care to all Canadians living with liver disease&#46;</p></span><span id="s0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0085">Abbreviations</span><p id="p0125" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0010"><li class="elsevierStyleListItem" id="u0025"><span class="elsevierStyleLabel">&#8226;</span><p id="p0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">ABIM&#58;</span> American Board of Internal Medicine&#46;</p></li><li class="elsevierStyleListItem" id="u0030"><span class="elsevierStyleLabel">&#8226;</span><p id="p0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">CASL&#58;</span> Canadian Association for the Study of the Liver&#46;</p></li><li class="elsevierStyleListItem" id="u0035"><span class="elsevierStyleLabel">&#8226;</span><p id="p0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">CDDW&#58;</span> Canadian Digestive Disease Week&#46;</p></li><li class="elsevierStyleListItem" id="u0040"><span class="elsevierStyleLabel">&#8226;</span><p id="p0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">CWC&#58;</span> Choosing Wisely Canada&#46;</p></li><li class="elsevierStyleListItem" id="u0045"><span class="elsevierStyleLabel">&#8226;</span><p id="p0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">CLD&#58;</span> chronic liver disease&#46;</p></li><li class="elsevierStyleListItem" id="u0050"><span class="elsevierStyleLabel">&#8226;</span><p id="p0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">CT&#58;</span> computed tomography&#46;</p></li><li class="elsevierStyleListItem" id="u0055"><span class="elsevierStyleLabel">&#8226;</span><p id="p0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">ESLD&#58;</span> end stage liver disease&#46;</p></li><li class="elsevierStyleListItem" id="u0060"><span class="elsevierStyleLabel">&#8226;</span><p id="p0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HE&#58;</span> hepatic encephalopathy&#46;</p></li><li class="elsevierStyleListItem" id="u0065"><span class="elsevierStyleLabel">&#8226;</span><p id="p0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HCC&#58;</span> hepatocellular carcinoma&#46;</p></li><li class="elsevierStyleListItem" id="u0070"><span class="elsevierStyleLabel">&#8226;</span><p id="p0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">MRI&#58;</span> magnetic resonance imaging&#46;</p></li><li class="elsevierStyleListItem" id="u0075"><span class="elsevierStyleLabel">&#8226;</span><p id="p0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">NAFLD&#58;</span> nonalcoholic fatty liver disease&#46;</p></li><li class="elsevierStyleListItem" id="u0080"><span class="elsevierStyleLabel">&#8226;</span><p id="p0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">PT&#58;</span> prothrombin&#46;</p></li><li class="elsevierStyleListItem" id="u0085"><span class="elsevierStyleLabel">&#8226;</span><p id="p0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">SVR 12&#58;</span> sustained virological response at week 12&#46;</p></li><li class="elsevierStyleListItem" id="u0090"><span class="elsevierStyleLabel">&#8226;</span><p id="p0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">TS&#58;</span> transferrin saturation&#46;</p></li><li class="elsevierStyleListItem" id="u0095"><span class="elsevierStyleLabel">&#8226;</span><p id="p0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">vWf&#58;</span> von Willebrand factors&#46;</p></li></ul></p></span><span id="s0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0090">Conflict of Interest</span><p id="p0205" class="elsevierStylePara elsevierViewall">The authors declares that there is no conflict of interest regarding the publication of this article&#46;</p></span><span id="s0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0095">Disclosures</span><p id="p0210" class="elsevierStylePara elsevierViewall">The authors have no financial disclosures to declare&#46;</p></span><span id="s0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0100">Acknowledgments</span><p id="p0215" class="elsevierStylePara elsevierViewall">The authors acknowledge Michelle Menard and Rebecca Swanson for providing administrative support to CASL&#46; We would also like to thank Dr&#46; Wendy Levinson and Karen MacDonald of <span class="elsevierStyleItalic">Choosing Wisely Canada</span> for their review and edits of the final <span class="elsevierStyleItalic">Choosing Wisely</span> statements and manuscript&#46; Lastly&#44; we would like to acknowledge Dr&#46; Rick Schreiber and Dr&#46; Marc Bilodeau from the CASL executive committee for taking an interest in promoting quality and patient safety in Canadian Hepatology practice&#46;</p></span></span>"
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              "titulo" => "Statement 1&#58; Don&#8217;t order serum ammonia to diagnose or manage hepatic encephalopathy &#40;HE&#41;"
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              "titulo" => "Statement 2&#58; Don&#8217;t routinely transfuse fresh frozen plasma&#44; vitamin K&#44; or platelets to reverse abnormal tests of coagulation in patients with cirrhosis prior to abdominal paracentesis&#44; endoscopic variceal band ligation&#44; or any other minor invasive procedures"
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              "titulo" => "Statement 4&#58; Don&#8217;t perform computed tomography &#40;CT&#41; or magnetic resonance imaging &#40;MRI&#41; routinely to monitor benign focal liver lesions &#40;ex&#46; focal nodal hyperplasia&#44; hemangioma&#41;"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abs0010" class="elsevierStyleSection elsevierViewall"><p id="sp0115" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Introduction and aim&#46;</span> The prevalence and incidence of chronic liver disease is increasing resulting&#44; in substantial direct and indirect medical costs&#46; Overuse of investigations&#44; treatments and procedures contribute to rising health care costs and can expose patients to unnecessary harm and delay in receiving care&#46; The Choosing Wisely Canada &#40;CWC&#41; campaign has encouraged professional societies to develop statements that are directly actionable by their members in an effort to promote higher-value health care that will lead to downstream effect on how other practitioners make decisions&#46;</p><p id="sp0215" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Material and methods&#46;</span> The Canadian Association for the Study of the Liver &#40;CASL&#41; established its Choosing Wisely top five list of recommendations using the framework put forward by CWC&#46; CASL convened a task force that developed a list of draft recommendations and shared this with CASL membership electronically with eventual ranking of the top five recommendations by consensus at Canadian Digestives Disease Week &#40;CDDW&#41; 2017&#46; Following revisions&#44; the CASL Executive Committee endorsed the final list&#44; which was disseminated online by CWC &#40;July 2017&#41;&#46;</p><p id="sp0315" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Results&#46;</span> The top five recommendations physicians and patients should question include&#58; 1&#41; Don&#8217;t order serum ammonia to diagnose or manage hepatic encephalopathy &#40;HE&#41;&#46; 2&#41; Don&#8217;t routinely transfuse fresh frozen plasma&#44; vitamin K&#44; or platelets to reverse abnormal tests of coagulation in patients with cirrhosis prior to abdominal paracentesis&#44; endoscopic variceal band ligation&#44; or any other minor invasive procedures&#46; 3&#41; Don&#8217;t order HFE genotyping based on serum ferritin values alone to diagnose hereditary hemochromatosis&#46; 4&#41; Don&#8217;t perform computed tomography &#40;CT&#41; or magnetic resonance imaging &#40;MRI&#41; routinely to monitor benign focal liver lesions&#46; 5&#41; Don&#8217;t repeat hepatitis C viral load testing in an individual who has established chronic infection&#44; outside of anti-viral treatment&#46;</p><p id="sp0415" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Conclusion&#46;</span> The Choosing Wisely recommendations will foster patient-physician discussions&#44; reduce unnecessary treatment and testing&#44; avert adverse effects from testing and treatment along with reducing medical expenditure in hepatology&#46;</p></span>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Don&#8217;t order serum ammonia to diagnose or manage hepatic encephalopathy &#40;HE&#41;&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">High blood-ammonia levels alone do not add any diagnostic&#44; staging&#44; or prognostic value in HE patients known to have chronic liver disease&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Don&#8217;t routinely transfuse fresh frozen plasma&#44; platelets or give Vitamin K to reverse abnormal tests of coagulation in patients with cirrhosis prior to abdominal paracentesis&#44; endoscopic variceal band ligation&#44; or any other minor invasive procedures&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Routine tests of coagulation do not reflect bleeding risk in patients with cirrhosis and bleeding complications of these procedures are rare&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Don&#8217;t order HFE genotyping based on serum ferritin values alone to diagnose hereditary hemochromatosis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Serum ferritin values reflect an increase in hepatic iron content and have a significant false positive rate because of elevations due to inflammation&#46; Thus&#44; in patients with evidence of liver disease&#44; hemochromatosis genotyping should only be performed among individuals with an elevated ferritin and fasting transferrin saturation &#62;45&#37; &#40;TSat&#41; or a known family history of hemochromatosis-associated hereditary hemochromatosis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Don&#8217;t perform computed tomography &#40;CT&#41; or magnetic resonance imaging &#40;MRI&#41; routinely to monitor benign focal liver lesions &#40;ex&#46; focal nodal hyperplasia&#44; hemangioma&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Patients with benign focal liver lesions who do not have underlying liver disease and have demonstrated clinical &#40;asymptomatic&#41; and radiologic stability do not need repeated imaging as the likelihood of evolving into neoplastic lesions is very low&#46; In contrast&#44; patients with radiologic evidence of hepatocellular adenoma may have an increased risk of complications and&#47;or neoplasia thus warranting closer observation&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Don&#8217;t repeat hepatitis C viral load testing in an individual who has established chronic infection&#44; outside of antiviral treatment&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Highly sensitive quantitative assays of hepatitis C RNA are appropriate at the time of diagnosis &#40;to confirm infection&#41; and as part of antiviral therapy&#44; which is typically at the beginning and after therapy is completed to confirm sustained virological response at week 12 &#40;SVR 12&#41;&#46; Outside of these circumstances the results of virologic testing do not usually change clinical management or outcomes&#46;&nbsp;\t\t\t\t\t\t\n
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      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bs0010"
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            0 => array:3 [
              "identificador" => "bib0005"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Changes in the prevalence of the most common causes of chronic liver diseases in the United States from 1988 to 2008&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Younossi ZM"
                            1 => "Stepanova M"
                            2 => "Afendy M"
                            3 => "Fang Y"
                            4 => "Younossi Y"
                            5 => "Mir H"
                            6 => "Srishord M"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1002/lt.25613"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clinical Gastroenterology &#38; Hepatology"
                        "fecha" => "2011"
                        "volumen" => "9"
                        "paginaInicial" => "524"
                        "paginaFinal" => "530"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31344758"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The state of US health&#44; 1990-2010&#58; burden of diseases&#44; injuries&#44; and risk factors&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Murray CJ"
                            1 => "Atkinson C"
                            2 => "Bhalla K"
                            3 => "Birbeck G"
                            4 => "Burstein R"
                            5 => "Chou D"
                            6 => "Dellavalle R"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Med Associat"
                        "fecha" => "2013"
                        "volumen" => "310"
                        "paginaInicial" => "591"
                        "paginaFinal" => "608"
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0015"
              "etiqueta" => "3&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Burden of Gastrointestinal&#44; Liver&#44; and Pancreatic Diseases in the United States&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Peery AF"
                            1 => "Crockett SD"
                            2 => "Barritt AS"
                            3 => "Dellon ES"
                            4 => "Eluri S"
                            5 => "Ganga-rosa LM"
                            6 => "Jensen ET"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/j.gastro.2015.08.045"
                      "Revista" => array:6 [
                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "2015"
                        "volumen" => "149"
                        "paginaInicial" => "1731"
                        "paginaFinal" => "1741"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26327134"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0020"
              "etiqueta" => "4&#46;"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Kochanek KD&#44; Murphy SL&#44; Xu J&#44; Thejada-Vera B&#46; National Vital Statistics Reports Deaths&#58; Final Data for 2014&#46; 2016&#46; Available from&#58; https&#58;&#47;&#47;www&#46;cdc&#46;gov&#47;nchs&#47;data&#47;nvsr&#47;nvsr65&#47;nvsr65&#95;04&#46;pdf&#46;"
                ]
              ]
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              "identificador" => "bib0025"
              "etiqueta" => "5&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Current and Future Burden of Chronic Nonmalignant Liver Disease&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Udompap P"
                            1 => "Kim D"
                            2 => "Kim WR"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.cgh.2015.08.015"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Gastroenterol Hepatol"
                        "fecha" => "2015"
                        "volumen" => "13"
                        "paginaInicial" => "2031"
                        "paginaFinal" => "2041"
                        "link" => array:1 [
                          0 => array:2 [
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                            "web" => "Medline"
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                  "referenciaCompleta" => "Ruhl CE&#44; Sayer B&#44; Byrd-Holt DE&#44; Brown DM&#46; Costs of digestive diseases&#46; The Burden of Digestive Diseases in the United States&#46; NIH publication&#59; 2008&#44; p&#46; 137-43&#46;"
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              "identificador" => "bib0035"
              "etiqueta" => "7&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "High-value health care -a sustainable prop-osition&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Curfman GD"
                            1 => "Morrissey S"
                            2 => "Drazen JM"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "New Engl J Med"
                        "fecha" => "2013"
                        "volumen" => "369"
                        "paginaInicial" => "1163"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0040"
              "etiqueta" => "8&#46;"
              "referencia" => array:1 [
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                      "titulo" => "Choosing Wisely Helping Physicians and Patients Make Smart Decisions About Their Care&#46;"
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                          "autores" => array:2 [
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                            1 => "Guest JA"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Med Associat"
                        "fecha" => "2012"
                        "volumen" => "307"
                        "paginaInicial" => "1801"
                        "paginaFinal" => "1802"
                      ]
                    ]
                  ]
                ]
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              "identificador" => "bib0045"
              "etiqueta" => "9&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Engaging physicians and patients in conversations about un-necessary tests and procedures&#58; Choosing Wisely Canada&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Levinson W"
                            1 => "Huynh T"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1503/cmaj.131674"
                      "Revista" => array:6 [
                        "tituloSerie" => "Canadian Medical Association Journal"
                        "fecha" => "2014"
                        "volumen" => "186"
                        "paginaInicial" => "325"
                        "paginaFinal" => "326"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24549128"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
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            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10&#46;"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The quality of care provided to patients with cirrhosis and ascites in the Department of Veterans Affairs&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:8 [
                            0 => "Kanwal F"
                            1 => "Kramer JR"
                            2 => "Buchanan P"
                            3 => "Asch SM"
                            4 => "Assioun Y"
                            5 => "Bacon BR"
                            6 => "Li J"
                            7 => "El-Serag HB"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/j.gastro.2012.03.038"
                      "Revista" => array:6 [
                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "2012"
                        "volumen" => "143"
                        "paginaInicial" => "70"
                        "paginaFinal" => "77"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22465432"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Blood ammonia levels and hepatic encephalopathy&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Lockwood AH"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Metabolic Brain Disease"
                        "fecha" => "2004"
                        "volumen" => "19"
                        "paginaInicial" => "345"
                        "paginaFinal" => "349"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15554426"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hepatic Encephalopathy in Chronic Liver Disease&#58; 2014 Practice Guideline by AASLD and EASL&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Vilstrup H"
                            1 => "Amodio P"
                            2 => "Bajaj J"
                            3 => "Cordoba J"
                            4 => "Ferenci P"
                            5 => "Mullen KD"
                            6 => "Weissenborn K"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/hep.27210"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "2014"
                        "volumen" => "60"
                        "paginaInicial" => "715"
                        "paginaFinal" => "735"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25042402"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Role of determination of partial pressure of ammonia in cirrhotic patients with and without hepatic encephalo-pathy&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Nicolao F"
                            1 => "Efrati C"
                            2 => "Masini A"
                            3 => "Merli M"
                            4 => "Attili AF"
                            5 => "Riggio O"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hepatol"
                        "fecha" => "2003"
                        "volumen" => "38"
                        "paginaInicial" => "441"
                        "paginaFinal" => "446"
                        "itemHostRev" => array:3 [
                          "pii" => "S0266613814001752"
                          "estado" => "S300"
                          "issn" => "02666138"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Correlation between ammonia levels and the severity of hepatic encephalopathy&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Ong JP"
                            1 => "Aggarwal A"
                            2 => "Krieger D"
                            3 => "Easley KA"
                            4 => "Karafa MT"
                            5 => "Van Lente F"
                            6 => "Arroliga AC"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/s0002-9343(02)01477-8"
                      "Revista" => array:7 [
                        "tituloSerie" => "Am J Med"
                        "fecha" => "2003"
                        "volumen" => "114"
                        "paginaInicial" => "188"
                        "paginaFinal" => "193"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12637132"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S026661381300274X"
                          "estado" => "S300"
                          "issn" => "02666138"
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                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "How to diagnose hepatic encephalopathy in the emergency department&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Gundling F"
                            1 => "Zelihic E"
                            2 => "Seidl H"
                            3 => "Haller B"
                            4 => "Umgelter A"
                            5 => "Schepp W"
                            6 => "Dodt C"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Hepatol"
                        "fecha" => "2013"
                        "volumen" => "12"
                        "paginaInicial" => "108"
                        "paginaFinal" => "114"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23293201"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Rifaximin treatment in hepatic encephalopathy&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Bass NM"
                            1 => "Mullen KD"
                            2 => "Sanyal A"
                            3 => "Poordad F"
                            4 => "Neff G"
                            5 => "Leevy C"
                            6 => "Sigal S"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa0907893"
                      "Revista" => array:6 [
                        "tituloSerie" => "New Engl J Med"
                        "fecha" => "2010"
                        "volumen" => "362"
                        "paginaInicial" => "1071"
                        "paginaFinal" => "1081"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20335583"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evidence of normal thrombin generation in cirrhosis despite abnormal conventional coagulation tests&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Tripodi A"
                            1 => "Salerno F"
                            2 => "Chantarangkul V"
                            3 => "Clerici M"
                            4 => "Cazzaniga M"
                            5 => "Primignani M"
                            6 => "Mannuccio Mannucci P"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/hep.20569"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "2005"
                        "volumen" => "41"
                        "paginaInicial" => "553"
                        "paginaFinal" => "558"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15726661"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Thrombin generation in patients with cirrhosis&#58; the role of platelets&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Tripodi A"
                            1 => "Primignani M"
                            2 => "Chantarangkul V"
                            3 => "Clerici M"
                            4 => "Dell&#8217;Era A"
                            5 => "Fabris F"
                            6 => "Salerno F"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/hep.21266"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "2006"
                        "volumen" => "44"
                        "paginaInicial" => "440"
                        "paginaFinal" => "445"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16871542"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Progress in the understanding of the protein C anticoagulant pathway&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Dahlback B"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Internat J Hematol"
                        "fecha" => "2004"
                        "volumen" => "79"
                        "paginaInicial" => "109"
                        "paginaFinal" => "116"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acquired coagulation disorders&#58; revisited using global coagulation&#47;anticoagulation testing&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Tripodi A"
                            1 => "Chantarangkul V"
                            2 => "Mannucci PM"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Brit J Haematol"
                        "fecha" => "2009"
                        "volumen" => "147"
                        "paginaInicial" => "77"
                        "paginaFinal" => "82"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Elevated levels of von Willebrand factor in cirrhosis support platelet adhesion despite reduced functional capacity&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Lisman T"
                            1 => "Bongers TN"
                            2 => "Adelmeijer J"
                            3 => "Janssen HL"
                            4 => "de Maat MP"
                            5 => "de Groot PG"
                            6 => "Leebeek FW"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/hep.21231"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "2006"
                        "volumen" => "44"
                        "paginaInicial" => "53"
                        "paginaFinal" => "61"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16799972"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The coagulopathy of chronic liver disease&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Tripodi A"
                            1 => "Mannucci PM"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMra1011170"
                      "Revista" => array:7 [
                        "tituloSerie" => "New Engl J Med"
                        "fecha" => "2011"
                        "volumen" => "365"
                        "paginaInicial" => "147"
                        "paginaFinal" => "156"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21751907"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0266613813000077"
                          "estado" => "S300"
                          "issn" => "02666138"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Biological variability of transferrin saturation and unsaturated iron-binding capacity&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Adams PC"
                            1 => "Reboussin DM"
                            2 => "Press RD"
                            3 => "Barton JC"
                            4 => "Acton RT"
                            5 => "Moses GC"
                            6 => "Leiendecker-Foster C"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjmed.2006.07.023"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Med"
                        "fecha" => "2007"
                        "volumen" => "120"
                        "paginaInicial" => "e1"
                        "paginaFinal" => "e7"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18060901"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnosis and Management of hemochromatosis&#58; 2011 practice Guideline by the American Association of for the Study of Liver Disease&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Bacon BR"
                            1 => "Adams PC"
                            2 => "Kowdley KV"
                            3 => "Powell LW"
                            4 => "Tavill AS"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/hep.24330"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "2011"
                        "volumen" => "54"
                        "paginaInicial" => "328"
                        "paginaFinal" => "334"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21452290"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "25&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems&#44; 1996-2010&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Smith-Bindman R"
                            1 => "Miglioretti DL"
                            2 => "Johnson E"
                            3 => "Lee C"
                            4 => "Feigelson HS"
                            5 => "Flynn M"
                            6 => "Greenlee RT"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Med Associat"
                        "fecha" => "2012"
                        "volumen" => "307"
                        "paginaInicial" => "2400"
                        "paginaFinal" => "2409"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of hepatocellular carcinoma&#58; an update&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Bruix J"
                            1 => "Sherman M"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/hep.24199"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "2011"
                        "volumen" => "53"
                        "paginaInicial" => "1020"
                        "paginaFinal" => "1022"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21374666"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "ACG Clinical Guideline&#58; The Diagnosis and Manage-ment of Focal Liver Lesions&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Marrero JA"
                            1 => "Ahn J"
                            2 => "Reddy R"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/ajg.2014.213"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Gastroenterol"
                        "fecha" => "2014"
                        "volumen" => "109"
                        "paginaInicial" => "1328"
                        "paginaFinal" => "1347"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25135008"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "28&#46;"
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Article information

ISSN: 16652681
Original language: English

DOI:10.5604/01.3001.0012.7908

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 October	32	9	41
2024 September	46	16	62
2024 August	25	18	43
2024 July	37	8	45
2024 June	24	6	30
2024 May	35	10	45
2024 April	29	12	41
2024 March	34	7	41
2024 February	39	7	46
2024 January	40	4	44
2023 December	41	2	43
2023 November	46	7	53
2023 October	61	23	84
2023 September	46	5	51
2023 August	50	2	52
2023 July	80	8	88
2023 June	57	5	62
2023 May	76	4	80
2023 April	82	1	83
2023 March	79	0	79
2023 February	50	7	57
2023 January	47	1	48
2022 December	55	4	59
2022 November	60	11	71
2022 October	54	7	61
2022 September	51	14	65
2022 August	63	8	71
2022 July	52	5	57
2022 June	97	16	113
2022 May	52	8	60
2022 April	54	9	63
2022 March	44	13	57
2022 February	30	4	34
2022 January	44	7	51
2021 December	23	7	30
2021 November	32	11	43
2021 October	37	8	45
2021 September	36	11	47
2021 August	25	6	31
2021 July	21	13	34
2021 June	15	5	20
2021 May	16	10	26
2021 April	37	19	56
2021 March	43	4	47
2021 February	14	3	17
2021 January	15	10	25
2020 December	16	14	30
2020 November	13	2	15
2020 October	7	3	10
2020 September	8	10	18
2020 August	22	6	28
2020 July	18	11	29
2020 June	33	6	39
2020 May	7	7	14
2020 April	9	4	13
2020 March	10	1	11
2020 February	6	6	12
2020 January	11	6	17
2019 December	11	2	13
2019 November	4	4	8
2019 October	5	3	8
2019 September	9	4	13
2019 August	1	7	8
2019 July	9	2	11
2019 June	13	11	24
2019 May	7	19	26

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