bluuebunny/crossref_metadata_2025 huggingface dataset:
A117 VALIDITY EVIDENCE FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY COMPETENCY ASSESSMENT TOOLS: A SYSTEMATIC REVIEW
Authors: Khan R , Homsi H , Gimpaya N , Sabrie N , Gholami R , Bansal R , Scaffidi M , Lightfoot D , James P , Siau K , Forbes N , Wani S , Keswani R , Walsh C , Grover S
Published: March 2023

Background

Assessment of competence in endoscopic retrograde cholangiopancreatography (ERCP) is essential to ensure trainees possess the skills needed for independent practice. Traditionally, ERCP training has used the apprenticeship model, whereby novices learn skills under the supervision of an expert. A growing focus on procedural quality, however, has supported the implementation of competency-based medical education models which require documentation of a trainee’s competence for independent practice. Observational assessment tools with strong evidence of validity are critical to this process. Validity evidence supporting ERCP observational assessment tools has not been systematically evaluated.

Purpose

To conduct a systematic review of ERCP assessment tools and identify tools with strong evidence of validity using a unified validity evidence framework

Method

We conducted a systematic search using electronic databases and hand-searching from inception until August 2021 for studies evaluating observational assessment tools of ERCP performance. We used a unified validity framework to characterize validity evidence from five sources: content, response process, internal structure, relations to other variables, and consequences. Each domain was assigned a score of 0-3 (maximum score 15). We assessed educational utility and methodological quality using the Accreditation Council for Graduate Medical Education framework and the Medical Education Research Quality Instrument, respectively.

Result(s)

From 2769 records, we included 17 studies evaluating 7 assessment tools. Five tools were studied for clinical ERCP, one on simulated ERCP, and one on simulated and clinical ERCP. Validity evidence scores ranged from 2-12. The Bethesda ERCP Skills Assessment Tool (BESAT), ERCP Direct Observation of Procedural Skills Tool (ERCP DOPS), and The Endoscopic Ultrasound (EUS) and ERCP Skills Assessment Tool (TEESAT) had the strongest validity evidence with scores of 10, 12, and 11, respectively. Regarding educational utility, most tools were easy to use and interpret, and required minimal additional resources. Overall methodological quality was strong, with scores ranging from 10-12.5 (maximum 13.5).

Conclusion(s)

The BESAT, ERCP DOPS, and TEESAT have strong validity evidence compared to other assessments. Integrating tools into training may help drive learners’ development and support competency decision-making.

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CAG

Disclosure of Interest

None Declared
A121 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN PATIENTS WITH PANCREATICODUODENECTOMY USING DYNAMIC RIGIDIZING OVERTUBE
Authors: Low D , Liu C , Lee J , Shaukat Ali F , Al Nakshabandi A , Coronel E
Published: March 2023

Background

Dynamic rigidizing overtubes have recently been described as a useful tool in challenging endoscopic procedures. These devices have the ability to dynamically rigidize, which stabilizes endoscope position, reduce loop formation and assist in the traversal of acute angulation. Its use has been best described in difficult colonoscopies by preventing loop formation and subsequently facilitating cecal intubation. However, the use of rigidizing overtubes for endoscopic retrograde cholangiopancreatography is sparsely described in the literature. In particular, rigidizing overtubes may be beneficial in patients with surgically-altered anatomy, including post-pancreaticoduodenectomy (PD) patients, as traversal to the surgical anastomosis is often challenging because of loop formation and acute angulation. In this study, a retrospective analysis was conducted on post-PD patients undergoing ERCP with dynamic rigidizing overtube.

Purpose

The purpose of this study was to evaluate the technical and clinical success of post-PD patients undergoing ERCP with rigidizing overtube.

Method

A retrospective analysis was conducted on all post-PD patients who underwent ERCP with rigidizing overtube between 2006 and 2021. Demographic information including age, gender and primary malignancy was collected. Pertinent procedure-related information including indication and anastomosis identification was obtained. The primary outcomes evaluated included technical and clinical success rate. Technical success (TS) was defined as the ability to perform an intended therapeutic intervention (stent insertion, cannulation, etc). Clinical success (CS) was operationalized as improvement in patient symptoms or normalization of bilirubin.

Result(s)

A total of 5 patients underwent 11 ERCPs with rigidizing overtube for biliary indications. There was a total of 3 (60.0%) male and 2 (40.0%) female patients. The average age of the patients was 62.5 years of age. There were 3 (60.0%) patients with pancreas cancer, 1 (20.0%) with metastatic renal cell carcinoma, and 1 (20.0%) with duodenal adenoma with high grade dysplasia. The indications for ERCP included stent evaluation (n = 6; 54.5%), obstructive jaundice (n =3; 27.3%), cholangitis (n = 1; 9.1%), and stricture evaluation (n = 1; 9.1%). The surgical anastomosis was identified in all patients (n = 11; 100%). The overall technical and clinical success rates were both 90.9%.

Conclusion(s)

The use of rigidizing overtubes in ERCP may be beneficial in patients with surgically altered anatomy. In this small sample, technical and clinical success rates were excellent in post-PD patients. However, additional studies need to be conducted to validate these findings further.

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None

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None Declared
A135 ENDOSCOPIC SUBMUCOSAL DISSECTION OF GASTRIC ADENOMAS AND EARLY CARCINOMAS
Authors: Zhao B , Kim H J , Trasolini R , Chahal D , Lam E
Published: March 2023

Background

Management of gastric adenoma and early gastric cancer requires endoscopic resection. This can often be achieved with endoscopic mucosal resection (EMR), which has been shown to be effective with a good safety profile. One disadvantage of EMR is that it is often completed piecemeal, leading to indeterminant margins and higher rates of recurrences that require additional intervention. Endoscopic submucosal dissection (ESD) is a more advanced endoscopic resection technique that has been shown to be more effective than EMR at en-bloc resection. ESD requires high technical proficiency but it is becoming more widely available in western countries.

Purpose

The purpose of this study is to report on the outcomes and rates of complications of gastric ESD completed in a tertiary centre in British Columbia.

Method

All gastric ESD was completed by a senior therapeutic endoscopist who has previously received training in Japan. Retrospective data were collected on all gastric ESD procedures done in St. Paul’s Hospital from May 7th, 2015, when the procedure first became available, to Aug 30th, 2022. Inclusion criteria were all adults who have undergone ESD for resection of a gastric lesion. Exclusion criteria were patients younger than 18. Data collected included demographic variables, polyp characteristics, procedural outcomes, and complications.

Result(s)

A total of 49 ESD procedures were completed. The mean size of the resected lesions was 25.3 mm (range: 5 – 100 mm). Technical success, defined as successful resection of all polypoid tissue, was achieved in 48/49 procedures (98.0%). En bloc resection was achieved in 42/48 (87.5%) completed ESD. The rate of R0 resection was also 42/48 (87.5%). Curative resection, defined as technically successful ESD with an R0 margin and no lymphovascular invasion, was achieved in 41/49 (83.7%) of the cases. In our cohort, 8 patients had adenocarcinoma, 5 of which had a curative resection with no evidence of recurrence. None of the ESD resulted in any intra-procedural or delayed perforation. 5/49 (10.2%) patients had clinically significant post-endoscopic resection bleeding. Out of 37 patients that completed follow-up, 3 (8.1%) had recurrence, and all of them were managed endoscopically. 4/49 (8.2%) of patients required surgery post-ESD.

Conclusion(s)

In our cohort, ESD is an effective endoscopic resection modality for gastric lesions with a high rate of technical success and curative resection. Despite a deeper plane of resection versus other endoscopic resection modalities, its complication rate remains low. Although ESD requires high technical proficiency, its favorable outcomes along with low rates of complication make ESD highly feasible for the resection of gastric lesions. Further research will be needed to study the implementation and outcomes of

ESD in a western setting.

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None

Disclosure of Interest

None Declared
A157 FIT-POSITIVE COLONOSCOPY FINDINGS IN NOVA SCOTIA STRATIFIED BY SEX, RACE, AND REGIONAL POPULATION DENSITY
Authors: Sullivan R , Jones J , Williams C , Kilfoil E , MacIntosh D , Stewart M
Published: March 2023

Background

Population-based colorectal cancer (CRC) screening programs aim to minimize disparities in CRC rates through universal access. However, Canadian CRC mortality rates remain inversely associated with socioeconomic status and rural residence. In the United States some racialized groups have higher rates of advanced adenomas and CRC. Little is known about pre-cancerous findings or CRC mortality amongst racialized groups in Canada because race and ethnicity data are not routinely collected.

Purpose

To determine whether FIT-positive colonoscopy incident adenomas and CRC differ on the basis of sex, race, and regional population density in a provincial CRC screening program.

Method

In this retrospective cohort study drawn from the Nova Scotia Colon Cancer Prevention Program database, we identified adults who had a positive FIT from 2011 to 2021. This report describes incident adenomas and CRC, stratified by sex, race (white vs. racialized groups), and regional population density (urban vs. rural). Racialized groups included those who self-identified as Black/African Canadian, Asian, Middle Eastern and Indigenous. Urban was defined as population centers with more than 5000 individuals. Colonoscopy findings were categorized as no findings, low-risk adenoma (LRA), high-risk adenoma (HRA), or CRC. Comparison between categorical variables was performed with a chi-square test and a t-test for continuous variables. P-value <0.05 was considered significant.

Result(s)

41,209 adults (mean age 63.9) had a positive FIT and 34,636 went on to have a colonoscopy offered by the screening program. The FIT-positive colonoscopy participation rate was 84%. Of the 16% overall with a positive FIT but no screening program colonoscopy, 83% had a program consultation but did not proceed with endoscopy for unspecified reasons, 9% declined, and 8.2% are unknown. The overall rate of CRC was 2.4% (n=825) and the adenoma-detection rate was 60.4% (n=20,932). CRC (mean age 65.4) and HRA (mean age 64.6) were associated with older age (p <0.01). Males were more likely to have HRA (38.4% of males) or LRA (26.6% of males) identified compared to females, and females were more likely to have no colonoscopy findings (47.8% of females). CRC was more likely to be identified in urban (2.8%) than rural sub-populations (2.0%). No difference in adenomas or CRC incident rates were noted between white and racialized sub-groups.

Image

Conclusion(s)

This analysis of a provincial CRC screening program suggests that males and urban sub-populations had more high-risk findings during FIT-positive colonoscopies. In the first reported Canadian data, incident rates of adenomas and CRC were similar in white and racialized sub-groups.

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None

Disclosure of Interest

None Declared
A167 HISTOLOGICAL REMISSION PLACEBO RATES IN ULCERATIVE COLITIS TRIALS: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Youssef M , Dong K , Lee S J , Narula N
Published: March 2023

Background

High histologic remission rates have been reported with placebos in randomized controlled trials (RCTs) evaluating ulcerative colitis (UC) therapies and have varied based on trial designs. We performed a systematic review and meta-analysis to quantify placebo histological remission rates and identify factors influencing those rates.

Purpose

This systematic review aims to improve future trials design and minimize placebo rates in UC trials.

Method

MEDLINE, EMBASE, and the Cochrane library were searched from inception of the databases until December 2021. We included placebo-controlled RCTs of adult patients with UC treated with aminosalicylates, corticosteroids, immunosuppressives, biologics, and small molecules. We pooled estimates using a random-effects model and performed subgroup analysis as well as meta-regression to evaluate the effect of different covariates on placebo rates.

Result(s)

Thirty-three studies (30 induction and 3 maintenance) were included. The overall placebo histological remission rate was 15.7% [95% CI 12.9-19%] across all 33 studies (Figure). High heterogeneity was observed among studies with I2 = 62.10%. In induction studies, the pooled estimate of histological remission was 15.8% [95% CI 12.7-19.5%], while in maintenance studies the pooled estimate was 14.5% [95% CI 8.4-24%]. Subgroup analysis revealed statistically significant differences in placebo rates when accounting for background medications, the intervention drug class, and disease severity [p= 0.041, 0.025, and 0.025, respectively]. There was no statistical difference between induction vs. maintenance studies or between different histological scales [p= 0.771, and 0.075, respectively]. Meta-regression showed similar results except that the therapy used was not statistically significant [p-value= 0.059].

Image

Conclusion(s)

Placebo histological remission rates range from 13-19% in UC RCTs, but studies are highly heterogeneous. Factors found to influence placebo rates include presence of background medications, the drug used and the disease severity in UC patients. These observations have important implications in informing future trial designs to minimize placebo rates and reduce heterogeneity.

Disclosure of Interest

M. Youssef: None Declared, K. Dong: None Declared, S. J. Lee: None Declared, N. Narula Speakers bureau of: received honoraria from Janssen, Abbvie, Takeda, Pfizer, Merck, Sandoz, Novartis, and Ferring
A168 COSTS OF MISSED WORK AMONG PEOPLE WITH INFLAMMATORY BOWEL DISEASE: A CROSS-SECTIONAL POPULATION-REPRESENTATIVE STUDY
Authors: Kuenzig E , Lebenbaum M , Mason J , Vyas M V , Kaplan G G , Murthy S K , Targownik L E , Benchimol E I
Published: March 2023

Background

The relapsing and remitting symptoms experienced by people with inflammatory bowel disease (IBD), including abdominal pain and diarrhea, may impact their employability and workplace productivity.

Purpose

Report the impact of IBD on missed work and its associated costs using population-representative data with the goal of understanding the population-level indirect costs of IBD in Canada.

Method

We used the 2010 and 2014 waves of the Canadian Community Health Survey (CCHS) to compare missed work and its associated costs among survey respondents aged 20 to 64 years with physician-diagnosed IBD compared to those without IBD. Students and those with non-IBD bowel disorders were excluded. The cost of missed work was derived from reported annual income and the number of workdays missed. Survey weights were used for descriptive statistics. Poisson regression modified for binary outcomes was used to compare employment within the past 3 months among those with and without IBD. Heckman models (two-stage models accounting for the likelihood of being employed) were used to compare the number of days missed and the cost of missed work in the two groups. Models were adjusted for age, sex, education, marital status, immigration status, visible minority status, number of non-IBD chronic conditions, and mood or anxiety disorder. All costs were inflation-adjusted to 2022 Canadian dollars.

Result(s)

Among 67,907 eligible respondents, 810 (weighted 1.0%) had IBD. Employment in the last 3 months was reported among 70% of people with IBD compared to 80% of people without IBD (RR 0.92, 95% CI 0.88 to 0.96). Among those employed in the prior 3 months, employed people with IBD missed an average of 1.6 (SD 4.4) days of work compared to 1.0 (SD 3.5) days missed among those without IBD, corresponding to $415 (SD 1315) in lost wages among those with IBD and $235 (SD 932) among those without IBD. Accounting for the higher rates of unemployment in those with IBD using Heckman models, people with IBD missed an additional 1.1 days (95% CI 0.7 to 1.5) of work and lost an additional $270 (95% CI 163 to 377) in income over 3 months. Extrapolating to the estimated 184,460 employed Canadians with IBD, the attributable indirect cost of missed work due to IBD is nearly $200 million annually.

Conclusion(s)

The economic burden of IBD resulting from missed work is substantial. Since IBD is often diagnosed during adolescence and early adulthood, employability and productivity are important long-term patient-centered outcomes. Novel interventions that could mitigate these attendant effects of IBD are urgently needed to improve patient outcomes.

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None

Disclosure of Interest

None Declared
A200 HIGH-DEFINITION CHROMOENDOSCOPY RESULTS IN MORE SIGNIFICANT DYSPLASIA DETECTION THAN WHITE LIGHT ENDOSCOPY WITH RANDOM BIOPSIES IN ULCERATIVE COLITIS PATIENTS
Authors: Hoang T T , Leung Y , Rosenfeld G , Bressler B
Published: March 2023

Background

Ulcerative colitis (UC) is an inflammatory bowel disease that results in inflammation of the colonic mucosa, leading to abdominal pain, rectal bleeding, weight loss, and diarrhea. This chronic inflammation results in a 2.4-fold increased future risk of developing colorectal cancer (CRC) in UC patients compared to the general population. Thus, careful dysplasia screening modalities are required to prevent progression to CRC. Currently, both high-definition white light endoscopy with non-targeted biopsies (HD-WLR) and dye-spray chromoendoscopy (HDCE) are regularly used across Canada for dysplasia surveillance given existing research has been inconclusive regarding superiority of one particular method, and that recent guidelines do not suggest a preference.

Purpose

The primary objective of this study was to determine which surveillance modality yielded a higher dysplasia detection rate in UC patients, both by calculating the total number of dysplastic lesions detected, as well as calculating the number of patients with at least one dysplastic lesion detected using either technique.

Method

We conducted a single-centre retrospective chart review of 150 UC patients who underwent dysplasia surveillance at our site between January 2019-2021. We calculated the dysplasia detection rate of both techniques at the time of the first CRC screening colonoscopy.

Result(s)

Eighteen dysplastic lesions were detected in total, three by HD-WLR and fifteen by HDCE. Dysplasia was detected in 4% (3/75) and 14.5% (15/75) of UC patients by HD-WLR and HDCE respectively, with significantly fewer biopsies (4.44 + 4.3 vs 29.1 + 13.0) required. HD-WLR detected two polypoid and one non-polypoid lesion, while HDCE detected eleven polypoid and four non-polypoid lesions. No invisible dysplasia or colorectal cancer was detected. Screening was performed at 10.8 + 4.8 and 9.72 + 3.05 years following UC diagnosis for HDCE and HD-WLR respectively. Median withdrawal time was 9.0 + 2.7 min (HD-WLR) vs 9.6 + 3.9min (HDCE).

Image

Conclusion(s)

HDCE resulted in higher dysplasia detection rates compared to HD-WLR in a UC patient population. Given the former technique is less tedious and costly, our findings suggest HDCE should be considered over HD-WLR for UC dysplasia surveillance.

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None

Disclosure of Interest

None Declared
A202 INVESTIGATION OF THE DIRECT EFFECT OF HEMIN-HEMOPEXIN AND HAPTOGLOBIN STIMULATION IN INFLAMMATORY BOWEL DISEASE
Authors: Ajayi A S , Hajjar R , Oliero M , Cuisiniere T , Gerkins C , Fragoso G , Calve A , Vennin-Rendos H , Santos M M
Published: March 2023

Background

Inflammatory bowel disease (IBD) is a global health issue defined by persistent intestinal epithelial inflammation resulting in bleeding, and it is one of the major risk factors of colorectal cancer (CRC). Hemin is an activator of heme-oxygenase and has anti-inflammatory, cytoprotective, and antiapoptotic properties by stimulating hemopexin and haptoglobin production. Hemopexin and haptoglobin are scavenging proteins with high affinity for hemin and hemoglobin, and are activated by interleukin (IL)-22.

Purpose

To evaluate the protective role of hemin through the stimulation of hemopexin and haptoglobin in experimental acute colitis.

Method

Mice were preconditioned with hemin by intraperitoneal injection with 5mg/kg body weight of hemin for three days while control mice were treated with PBS. Colitis was induced by giving 2.5-3% dextran sulfate sodium (DSS) in drinking water for 12 days. The disease activity index (DAI) was determined by daily monitoring of body weight, fecal bleeding and stool consistency. At the end of the experiment, liver, feces, serum and colon samples were harvested for the evaluation of fecal levels of hemopexin, fecal haptoglobin, IL-22, IL-22BP, IL-6 and TNF-α. Fecal microbiota composition will be determined using 16S rRNA sequencing.

Result(s)

We found that hemin treatment resulted in the presence of hemopexin and haptoglobin in fecal samples, where they may exert a protective role and influence the growth of pathobionts able to acquire iron using heme and hemoglobin as sources.

Conclusion(s)

The findings from this study will contribute to the understanding of the possible protective role of hemopexin and haptoglobin in ulcerative colitis.

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CIHR

Disclosure of Interest

None Declared
A209 ASSESSMENT OF OUTCOMES OF PATIENTS ADMITTED WITH ACUTE, SEVERE ULCERATIVE COLITIS ON ESTABLISHED BIOLOGIC THERAPY: A SINGLE CENTRE RETROSPECTIVE ANALYSIS
Authors: Sabrie N , Jogendran M , Jogendran R , Targownik L
Published: March 2023

Background

Acute, severe, ulcerative colitis (ASUC) is associated with a high morbidity and mortality. Current guidelines recommend the initiation of high dose intravenous steroids, followed by anti-TNF therapy if a satisfactory therapeutic response is not rapidly achieved. However, guidelines are agnostic on how to manage patients who are admitted for ASUC despite being on established biologic therapy. Furthermore, short-term clinical outcomes in this population are not well characterized.

Purpose

The aim of this study is to assess the differences in short-term clinical outcomes in patients admitted with ASUC who are on established biologic therapy compared to those not on established biologic therapy.

Method

We conducted a retrospective chart review of patients admitted with ASUC to Mount Sinai Hospital (MSH) in Toronto, Ontario from January 2018 until December 2021. Patients were included if they were deemed to have a severe flare, defined as having 6 or more loose bowel movements per day with at least one of the following features: temperature of 38.0 Celsius, tachycardia, anemia, or elevated inflammatory markers. Included subjects were considered to be on established biologic therapy if they had a biologic within 56 days prior to admission, all other admitted subjects were included as controls. Our primary outcome was the difference in hospital length of stay (HLOS). We also contrasted duration of intravenous steroids, rates of surgical consultation, rates of in-hospital colectomy, and readmission rates within 90 days of discharge.

Result(s)

130 charts were included in our study, 53 of which were patients on established biologic therapy, and 77 of which were patients not on established biologic therapy. The HLOS between the two groups was not significantly different, (7.23 days [established biologic therapy] vs.7.47 days [not on biologic therapy], p value = 0.77). Patients on established biologic therapy were more likely to receive an inpatient surgical consultation (33.96% vs 7.79%, p-value <0.001). However, rates of colectomy prior to discharge were not statistically different (1.89% vs 0%, p-value = 0.23). Patients on established biologic therapy were significantly more likely to be readmitted within 90 days of discharge (30.19% vs 12.99%, p-value = 0.016).

Image

Conclusion(s)

Although there were no differences in HLOS and colectomy rates between the 2 groups, patients with ASUC on established biologic therapy were more likely to be readmitted within 3 months of discharge. Further work is required to define optimal medical management of persons admitted with ASUC who are failing biologic therapies.

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None

Disclosure of Interest

None Declared
A212 THE IMPACT OF COMBINED MEDICAL AND SURGICAL TREATMENT FOR PERIANAL CROHN’S DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Fung M , Farbod Y , Kankouni H , McCurdy J
Published: March 2023

Background

Multidisciplinary care involving surgical drainage via examinations under anesthesia (EUA) and anti-tumor necrosis factor (TNF) therapy is recommended for perianal Crohn’s disease (PCD). However, the impact of this combined modality approach is not well-established.

Purpose

To determine the impact of combined modality (surgical and anti-TNF) vs. single modality (either surgical or anti-TNF) therapy on fistula healing in perianal Crohn’s disease.

Method

MEDLINE, EMBASE, and Cochrane databases were searched systematically from inception through September 15, 2022 independently in duplicate. We included studies that reported on fistula outcomes after treatment with combined modality vs. single modality therapy for PCD. Surgery was defined as EUA ± seton or closure procedure. Weighted summary estimates with 95% CI were estimated by random effects models. Study quality was determined using an adapted version of the Newcastle-Ottawa scale.

Result(s)

Thirteen studies met inclusion criteria. The total population included 1279 patients: 685 patients treated with single modality therapy with either surgical or anti-TNF therapy and 594 patients treated with combined modality therapy. Patients treated with combined modality therapy were more likely to achieve fistula healing compared to single modality therapy (65.4% vs. 57.7%; OR 1.68; 95% CI 1.03-2.73, p = 0.04) (Figure 1a). In a subgroup analysis, the rates of fistula healing were higher with combined modality therapy than with surgical therapy alone (OR 2.34; 95% CI 0.85-6.46, p = 0.10) but not anti-TNF therapy alone (OR 1.19; 95% CI 0.78-1.81, p = 0.43), although neither comparison was statistically significant (Figures 1b and c). The majority of studies were rated low-quality due to risk of bias from uncontrolled confounding variables.

Image

Conclusion(s)

Limited high-quality evidence suggests that fistula healing occurs more frequently in patients treated with combined modality therapy. However, the benefit of a combined modality approach appears to be driven mainly by anti-TNF therapy. Further prospective randomized trials are needed to confirm these findings.

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None

Disclosure of Interest

None Declared
A221 EFFECT OF PROXIMITY TO A SPECIALTY TERTIARY CENTRE ON OUTCOMES IN INFLAMMATORY BOWEL DISEASE: A POPULATION-BASED RETROSPECTIVE COHORT STUDY
Authors: Mikail M , Alkhateeb Q , Pope V , Khanna R
Published: March 2023

Background

The etiology of inflammatory bowel disease (IBD) is unknown; however, developed nations such as Canada ranking amongst the highest worldwide. With many diseases patients in urban and rural areas have different access to care and resources.

Purpose

To describe the differences in outpatient healthcare utilization, use of biologic agents and complication of IBD based on proximity to a tertiary health care centre.

Method

A retrospective cohort study was conducted comparing IBD patients seen in IBD clinics at affiliated with Western University in London, Canada between August 2019 – December 2019. IBD patients were compared on their use of outpatient healthcare utilization, biologic agents and IBD complications based on their proximity to a tertiary care centre (>100 km and <100 km). Patients residing >100 km from a tertiary centre were termed “rural” while <100 km from a tertiary centre were termed “urban.” Retrospective chart review occurred over a six-month period between January to June 2021.

Result(s)

A total of 481 were reviewed. Of those, 97 (UC, n=29; CD, n=68) and 95 (UC, n=30; CD, n=65) met inclusion for the urban and rural groups respectively. Patient demographics were similar between the two groups except IBD disease location with pancolitis seen more commonly in urban patients compared to ileocolonic in rural patients (urban, n=39; rural, n=34). IBD patients in both groups had similar number of appointments (urban, n=20.1 ± 13.8; rural, n=17.5 ± 12.1) and endoscopic procedures (urban, n= 4.9 ± 3.1; rural, n= 4.7 ± 3.2) with their gastroenterologists. More urban patients were managed with no therapy for their IBD (urban, n=16; rural, n=5). A higher rate of rural patients were managed with biologics (urban, n=56; rural, n=66) and combination therapy (urban, n=16; rural, n=27). The most common related IBD-related complications were IBD flares (urban, n=55; rural, n=60), intestinal strictures (urban, n=25; rural, n=34), intestinal obstructions (urban, n=10; rural, n=23) and rectal/genitourinary fistulas (urban, n=6; rural, n=21). Similar numbers of intra-abdominal surgery were seen between both groups with partial bowel resection (urban, n=13; rural, n=12) and right hemicolectomy (urban, n=10; rural, n=18) as the predominant surgery in urban and rural patients, respectively.

Conclusion(s)

This study demonstrated outpatient healthcare utilization when attending specialty gastroenterology appointments and outpatient endoscopies were numerically similar in rural and urban patients. IBD patient residing further from a tertiary care centre were numerically more likely to be managed with biologics and combination therapy. However the dataset is small and generalizations cannot be made.

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None

Disclosure of Interest

None Declared
A222 EFFECT OF CLINICAL FACTORS ON IBD TREATMENT RESPONSE: FINDINGS FROM A NOVEL SINGLE CENTER PATIENT REGISTRY
Authors: Lavalle C , Khanna R , Asfaha S
Published: March 2023

Background

Inflammatory bowel disease (IBD), comprising both Crohn’s disease as well as ulcerative colitis, has shown heterogenous response to therapy. Over the past decades, targeted biologic therapies have become the mainstay of treatment. Even with the rapid pace of progress in this field, roughly a third of patients do not show an initial response to these treatments. The ability to accurately predict treatment response to therapy would both improve patient safety and satisfaction as well as decrease costs from ineffective therapies.

Purpose

The primary aim of this project is to identify clinical factors predictive of disease response to induction biologic therapy in inflammatory bowel disease through the creation of a novel single center patient registry.

Method

Initially, a single center tissue biopsy registry of IBD patients receiving colonoscopy was created. Retrospective clinical data was subsequently collected on patients identified to have initiated or changed biologic therapy after entry into the registry. Clinical data regarding age, sex, comorbidities, lifestyle factors, time since initial diagnosis, extra intestinal manifestations, serum markers, prior IBD treatments, planned treatment, clinical response, as well as endoscopic response were collected. A Pilot study of the first 30 patients identified was undertaken. Individual clinical factors were compared between patients with a documented clinical response to biologic therapy and non-responders at the group level as well as by biologic therapy initiated.

Result(s)

No statistically significant differences in collected clinical data parameters were observed between treatment responders and non responders in aggregate as well as when sub selected by individual biologic therapy initiated, bio-naive status, and steroid dependence.

Conclusion(s)

This project has demonstrated that clinical factors alone do not adequately predict disease response in inflammatory bowel disease. Future work will expand this data registry to further clinical factors and continue patient enrolment. Next steps also include the addition of tissue level data, in particular tissue level RNA data. It is hoped that these parameters, either individually or in combination, will provide a robust and accessible predictor of response to biologic therapy in inflammatory bowel disease.

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Other

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Western University Department of Medicine

Disclosure of Interest

None Declared
A243 THROMBOELASTOGRAPHY-GUIDED COAGULOPATHY CORRECTION IN CIRRHOTIC PATIENTS DECREASES BLOOD PRODUCT TRANSFUSION: A SYSTEMATIC REVIEW AND ANALYSIS
Authors: Komeylian H , Ching C , Zhu J
Published: March 2023

Background

Patients with cirrhosis are a risk factor for coagulopathy and bleeding complications. Thromboelastography (TEG) guided therapy is available to rapidly assess and guide blood product transfusion in this population.

Purpose

This study aims to determine if TEG-guided therapy is able to decrease the administration of blood products and reduce adverse events such as bleeding and mortality compared to standard coagulation testing (SCT).

Method

We performed a systematic review and meta-analysis of literature in PubMed, EMBASE, and The Cochrane Library and pooled six randomized-controlled trials comparing thromboelastography versus standard coagulation testing in patients with cirrhosis. A total of six studies were pooled (n= 386). Primary outcomes were mean platelet transfusion units and fresh frozen plasma (FFP) transfusion units. Secondary outcomes were mortality and bleeding events.

Result(s)

Compared to SCT, there was a significant standard mean decrease in platelet (P<0.00001) and FFP (P<0.00001) administration compared to TEG perioperatively prior to a liver transplant. However, there was no significant difference in the pooled odds ratio between TEG and SCT in patients receiving both platelets and FFP (OR 1.40 [95% Cl 0.61-3.23, P=0.42]). Recurrent variceal bleeding was significantly reduced in the TEG group compared to SCT for platelet transfusion (OR 0.05 [95% Cl 0.01-0.20, P<0.0001]) or FFP transfusions (OR 0.18 [95% Cl 0.05-0.63, P=0.007]). With regards to the 5-day, 28-day, 42-day, and 90-day mortality, there was no significant difference between the pooled odds ratio between the TEG and SCT groups (OR 0.69 [95% Cl 0.47-1.02, P=0.06]). The 24-hour, 48-hour, 5-day, and 42-day rebleeding rates were significantly lower in TEG versus SCT groups (OR 0.50 [95% Cl 0.29-0.85, P = 0.01)].

Conclusion(s)

The use of TEG-guided therapy favors a reduction in platelet and FFP transfusion compared to SCT in patients with cirrhosis. Additionally, TEG-guided therapy is able to improve patient care by reducing the rebleeding rate of patients with cirrhosis compared to SCT. However, this same effect was not seen for mortality.

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A244 SIMILAR RISK OF INCIDENT HEPATOCELLULAR CARCINOMA IN IMMIGRANTS/REFUGEES WITH HEPATITIS B CIRRHOSIS REGARDLESS OF THEIR REGION OF ORIGIN
Authors: Wang P , Djerboua M , Flemming J
Published: March 2023

Background

In Canada, over 75% of new immigrants/refugees come from HBV-endemic areas. Whether the risk of hepatocellular carcinoma (HCC) in immigrants/refugees with HBV cirrhosis is associated with their region of origin has not been reported.

Purpose

The aim of our study was to describe the epidemiology of HCC in foreign-born individuals with HBV cirrhosis stratified by region of origin.

Method

Population-based retrospective cohort study using administrative healthcare data in Ontario, Canada. Recent immigrants/refugees with HBV (sAg+ or DNA+) and cirrhosis from 2000–2017 were identified and stratified by World Bank region of origin by linkage to the Immigration, Refugees and Citizenship Canada Permanent Resident Database. Individuals were followed until HCC, death, liver transplant, or end of study (2020). The 1-, 5-, and 10-year cumulative incidences (CI) of HCC were calculated. Using adjusted competing risks regression, the subdistribution hazard ratios (sHR) for HCC were calculated with region of origin as the main exposure where death/LT were competing events.

Result(s)

4,438 immigrants/refugees were included (64% male, median age 47 years [IQR 37–56], 72% Asia/Pacific, 9% South Asia, 6% Sub-Saharan Africa, 3% Latin America/Caribbean, 7% Europe/Central Asia, 3% Middle East/North Africa) with 430 (10%) developing incident HCC over a median of 7.9 years (IQR 4.5-11.7). Age at HCC diagnosis was lowest in those from Sub-Saharan Africa (53 years IQR [44-58]). Overall, the annual incidence of HCC was 1.14/100 person-years. The CI of HCC at 1-, 5-, and 10 years was highest in those from Latin American/Caribbean (6.8%, 10.3%, and 13.1%), East Asia/Pacific (4.5%, 7.7%, 10.3%) and South Asia (4.0%, 7.2%, 10.3%). After adjusted competing risk regression (Table), decompensated cirrhosis (sHR 2.5; 95% CI 1.7–3.5), male sex (sHR 2.2; 95% CI 1.7–2.7), and age (sHR 1.05, 95% CI 1.04–1.06) were independently associated with HCC, while region of origin was not.

Conclusion(s)

Among immigrants/refugees with HBV cirrhosis, HCC is associated with male sex, older age, and decompensated cirrhosis but not with their region of origin. Efforts ensuring timely detection and evaluation of HBV in immigrants/refugees with a goal to prevent development of decompensated cirrhosis and provide early detection of HCC should be aggressively pursued regardless of their region of origin.

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A251 NON-ALCOHOLIC FATTY LIVER DISEASE AT A CANADIAN TERTIARY CARE CENTRE: RISK FACTORS AND SEVERITY OF DISEASE
Authors: Klemm N K , Zhu K , Jaffer A , Ramji A , Mohajerani A
Published: March 2023

Background

Non-alcoholic fatty liver disease (NAFLD) is the leading cause of liver disease worldwide with an increasing prevalence of 25-40%. Although the prevalence increases to 57.5-74% in obese patients, lean individuals also develop NAFLD. Patients are commonly asymptomatic and the diagnosis is often incidental or when progressed to cirrhosis. Once fibrosis has developed, the risk of cardiovascular and liver-related death increases exponentially. The increasing prevalence of NAFLD presents significant healthcare and economic consequences.

The severity of NAFLD and its risk factors have been studied in various countries, which guide decisions on screening and management. Similar studies have not been performed in Canada.

Purpose: To determine the severity of NAFLD in a tertiary care centre and associated risk factors.

Method

Retrospective review of patients with NAFLD diagnosed on ultrasound, or fibroscan from January 1, 2019 to December 31, 2021. Patients were 18 years or older and were excluded if they had co-existent liver disease, significant alcohol use or CAP <238. CAP and fibrosis scores were determined using transient elastography. Chi-square and multivariate analysis were performed for statistical analysis.

Result(s): A total of 583 patients were included in the study; 312 (53.5%) were male and the mean age was 54.04 years. The majority of cases, 317 (56.8%), were diagnosed by ultrasound or CT scan and only 30 (5%) patients had a known family history of NAFLD. Lean-NAFLD (L-NAFLD) was present in 83 (15.2%) patients, overweight NAFLD (OW-NAFLD) 220 (40.2%), obese-NAFLD (OB-NAFLD) 206 (37.7%) and morbidly obese-NAFLD (MB-NAFLD) 38 (6.9%).

The prevalence of T2DM was 28.6%, dyslipidemia 37.4%, hypertension 35.5%, coronary artery disease 6.2% and obstructive sleep apnea 6.7%. Risk factors for Stage 3 steatosis (CAP>290) included BMI>30 (2.84) and type 2 diabetes (OR 2.45), but not dyslipidemia, hypertension, age or gender. Type 2 diabetes, dyslipidemia, hypertension, BMI, gender and age were not significantly predictive of moderate steatosis (CAP 260-289).

The proportion of patients with transient elastography scores of F2, F3, and F4 were 16.0%, 7.7%, and 11.0%, respectively. F2 and F3 scores were associated with T2DM (OR 1.94), BMI > 30 (OR 1.83, p<0.05) and age >60 (OR 1.90, p<0.05), but not dyslipidemia or hypertension. F4 scores were significantly associated with age > 60 (OR 1.89), T2DM (OR 2.60), dyslipidemia (OR 1.79), hypertension (OR 1.86) and BMI>30 (OR 2.54).

Conclusion(s)

Diabetes and BMI were associated with severe steatosis and fibrosis. Dyslipidemia and hypertension were only associated with advanced fibrosis. Our study demonstrates challenges in identification of early NAFLD given that metabolic syndrome factors were not associated with mild to moderate steatosis.

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A253 PRIMARY PROPHYLAXIS FOR SPONTANEOUS BACTERIAL PERITONITIS IN HOSPITALIZED CIRRHOTIC PATIENTS WITH LOW PROTEIN ASCITES AND RENAL DYSFUNCTION OR LIVER FAILURE: A RETROSPECTIVE REVIEW FROM A TERTIARY CENTRE IN BRITISH COLUMBIA
Authors: Fetz A , Li L , Lee C , Leung L
Published: March 2023

Background

Spontaneous bacterial peritonitis (SBP) is a severe and often fatal infection that can occur in patients with cirrhosis and ascites. The benefits of primary prophylaxis with antibiotics for SBP have been demonstrated in patients with cirrhosis presenting with gastrointestinal (GI) bleeding; patients hospitalized for other reasons with an ascitic protein less than 10 g/L; and patients with ascitic protein less than 15 g/L with either impaired renal function (serum creatinine greater than 106 µmol/L, BUN greater than 8.9 mmol/L, or serum sodium less than or equal to 130 mEq/L) or liver failure (Child-Pugh score greater than or equal to 9 or bilirubin greater than 50 umol/L).

Purpose

To evaluate the rate of primary prophylaxis in patients discharged from a tertiary care hospital with low protein ascites and impaired renal function or liver failure, and subsequent episodes of SBP, hospitalizations, or deaths.

Method

A retrospective chart review at St. Paul’s Hospital in Vancouver, British Columbia, from November 2019 to August 2021 was conducted. Hospitalized patients with cirrhosis who had an ascitic protein less than 15 g/L and met criteria for either renal dysfunction or liver failure were included in the study. The rate of primary prophylaxis prescribed in eligible patients as well as the subsequent incidence of SBP, hospitalizations, or all-cause mortality were evaluated. Patients were followed up to 12 months after the index paracentesis.

Result(s)

A total of 279 patients with cirrhosis were hospitalized during the study period. 69 patients underwent a diagnostic paracentesis and 41 patients met the inclusion criteria for primary SBP prophylaxis. 28 patients were excluded with most common reasons being ascitic protein above 15 g/L (n=12), no documented ascitic protein concentration (n=9), or index paracentesis met the criteria for the diagnosis of SBP (n=5). Of the patients included, 37 (90.2%) did not receive primary prophylaxis. 8 of these patients (21.6%) developed subsequent SBP. 30 patients (81.1%) were hospitalized at least once in the following 12 months. 18 (48.6%) died during the follow-up period with 1 death attributed to SBP. 4 patients (9.76%) received primary prophylaxis and were prescribed either ciprofloxacin or trimethoprim/sulfamethoxazole. None of these patients developed SBP, however, 3 (75%) were hospitalized and died from other causes.

Conclusion(s)

The rate of primary prophylaxis for SBP in hospitalized patients with low protein ascites and impaired renal function or liver failure at our institution is low. The guarded prognosis in this subset of patients is also demonstrated. Further studies are needed to assess the root causes for the lack of primary prophylaxis given.

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A260 PYOGENIC LIVER ABSCESS FORMATION SIX MONTHS AFTER PERFORATED APPENDICITIS IN AN OTHERWISE HEALTHY CHILD
Authors: Sutton H , Carman N
Published: March 2023

Background

Pyogenic liver abscesses (PLA) in children are uncommon in the developed world. When they are diagnosed, it is often in patients with hepatobiliary cancers, biliary diseases and liver transplants. PLA post perforated appendicitis has been reported as an aetiology in non-immunocompromised children. Reported cases of PLA’s developing as a late complication of perforated appendicitis are rare. The longest time from appendicitis to PLA diagnosis previously reported was four months.

Purpose

To report a rare case of liver abscess formation, post ruptured appendicitis, in a previously healthy and review the recent literature relevant to this topic.

Method

Retrospective chart review through electronic patient records was conducted for our reported case. Literature review of the relevant medical literature was performed.

Result(s)

Patient is an 11-year-old female with no significant past medical history apart from a perforated appendix requiring laparotomy for washout and 10 days of antibiotics, 6 months prior to presentation. The patient presented to her local emergency room with 6-week history of right flank pain and 10 days of fever. Abdominal ultrasound (US) identified a 3cm x 3cm x 3cm mass in the right lobe of the liver consistent with an abscess which was confirmed with magnetic resonance imaging (MRI). She was transferred to Toronto Hospital for Sick Children for management and investigation. At the Hospital for Sick Children she was started on Intravenous (IV) cefotaxime and metronidazole. After a repeat US on transfer it was determined the liver abscess was not amenable to drainage. Echinococcosis and Entamoeba serology were negative and neutrophil oxidative burst test (NOBT) test was within normal limits. Liver enzymes never exceeded 2x the upper limit of normal and synthetic function remained intact. After 7 days of IV antibiotics the patient’s inflammatory markers had improved and she had remained afebrile, but repeat US and MRI showed little to no change in abscess size. The decision was made for a prolonged course of IV antibiotics. After another two weeks of IV antibiotics her repeat US showed reduction in abscess size by roughly one third, and she was switched to oral antibiotics, after a total of 28 days, for a further four weeks with ongoing improvement.

Conclusion(s)

A review of the literature identified one nationwide population-based analysis in the United States reporting 4075 cases of PLAs, as well as three single centre reviews, from Iran, Tailand and the United Kingdom, reporting 18, 15 and 38 cases of liver abscesses, respectively. Common underlying aetiologies included primary immunodeficiency’s, liver transplantation, hepatobiliary cancers and non-PLA intra-abdominal infections. Managements included IV antibiotics plus/minus drainage when amenable. No cases of liver failure or death were reported.

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