The GPRD

is not population-based; therefore, its incidenc

The GPRD

is not population-based; therefore, its incidence estimate represents that of the GPRD and not the general population. Moreover, the code for PSC was not validated, and this poses additional challenges to its validity. These two studies were not fully comparable with the other studies included in the analysis. The incidence of PSC appears to be increasing; however, additional studies are necessary to confirm this observation. This increase in PSC incidence may be a direct result of its link to IBD because recent evidence suggests that the incidence of IBD is still increasing in many regions of the world.26, 29-32 Studies investigating the incidence of PSC with and without IBD may help to resolve this issue; however, the decrease in power when these analyses GSK3235025 are conducted may hinder the finding of statistical evidence. One study reported

time trends in PSC with and without IBD but failed to find a statistically significant increase.9 Additionally, the observed increase may be due to improvements in the diagnostic abilities of physicians and diagnostic tools such as noninvasive imaging (i.e., http://www.selleckchem.com/products/INCB18424.html magnetic resonance cholangiopancreatography).33, 34 Magnetic resonance cholangiopancreatography permits fast and highly accurate imaging of the biliary tree and has been used with increasing frequency as a noninvasive alternative to endoscopic retrograde cholangiopancreatography.33, 35-37 Furthermore, the increasing use of biological therapies (e.g., infliximab) and immunosuppressants (e.g., azathioprine

and methotrexate), particularly in those with IBD,38-40 may have contributed to the greater detection of PSC over time. Biologics and immunosuppressants have been associated with drug-induced liver complications, hepatobiliary disease, and liver toxicity41, 42; therefore, the routine screening of liver function profiles for individuals taking these therapies has increased. Studies investigating the incidence of PSC should consider assessments of diagnostic tool utilization over time. Moreover, this increase in incidence may be a result of biases in observational studies. In particular, the study by Escorsell et al.7 Selleck Depsipeptide had an unrealistically high AAPC of 27%. Many factors likely contributed to the obvious bias of this estimate. The population estimate used to calculate the incidence was taken from the end of the study period. An increase in the study population (i.e., 12 regions in Spain)43 over the time interval would have overestimated the increase in IR. Additionally, because of the retrospective nature of the study and the need for physicians to respond to a questionnaire, the response rate could have been lower for earlier time periods. Finally, detection bias could have been more pronounced at the end of the study period because of the increased availability and use of diagnostic technologies.

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