bluuebunny/crossref_metadata_2025 huggingface dataset:
A69 THE EFFECT OF COVID-19 PANDEMIC ON CURRENT AND FUTURE ENDOSCOPIC PERSONAL PROTECTIVE EQUIPMENT PRACTICES: A NATIONAL SURVEY OF 77 ENDOSCOPISTS
Authors: Sun W , El Hafid M , Dang J , Mocanu V , Lutzak G , Sultanian R , Wong C , Karmali S
Published: March 2021

Background

Personal protective equipment (PPE) guidelines serve to protect healthcare providers and patients from harmful biohazards. With the rise of the 2019 SARS-CoV-2 disease (COVID-19), many institutions have mandated strictly enforced endoscopic PPE guidelines. We currently do not know how current practitioners perceive these mandates or how they will influence their practice long-term.

Aims

We aimed to survey the PPE practices among endoscopists across Canada and compare their perceived differences in practice between the pre- and post-COVID-19 pandemic eras. We hypothesize that the PPE guidelines during the pandemic will influence changes in PPE practices in endoscopy.

Methods

A 74-item questionnaire was emailed from June 2020 to September 2020 to all members of the Canadian Association of Gastroenterologists and the Canadian Association of General Surgeons through newsletters. The survey was created by expert consensus and distributed using the REDCap software. Survey questions collected basic demographics and differences between PPE practices pre- and post-COVID-19 pandemic eras. PPE practices were categorized into four endoscopic procedure types: diagnostic or therapeutic, and upper or lower gastrointestinal endoscopy. Individual outcomes were reported as rates, or ranges when evaluating for all procedure types.

Results

A total of 77 respondents completed the survey with the majority of respondents aged 40–49 (34 [44.2%]) and identifying as Gastroenterologists (54 [70.1%]). Gender was evenly split (38 females [49.4%] versus 39 males [50.6%]). In the pre-pandemic era, the majority of endoscopists wore gowns (91.0–93.9%) and all endoscopists wore gloves (100%). However, the majority of endoscopists did not wear surgical masks (20.9%-31.3%), N95 respirators (1.5%-3.2%), face shields (13.4%-33.9%), eye protection (13.4%-21.3%), or hair protection (11.1%-12.5%).

In the post-pandemic era, endoscopists reported a plan to dramatically change their pre-pandemic practices and adopt current PPE mandates. All endoscopists reported a plan to fully gown and glove (100%) with the majority reporting they will continue wearing surgical masks (87.7%-90.5%), face shields (57.8%-75.0%), and hair protection (50.8%-53.8%). However, the majority reported a plan to decrease universal use of N95 respirators (6.5%-23.7%) or eye protection (36.5%-40.0%). Over half of the respondents reported changing their practice from no masking pre-pandemic to implementing routine masking.

Conclusions

The COVID-19 pandemic has changed the attitudes of many endoscopists regarding future PPE use in routine endoscopy. Ongoing studies comparing the rates of transmission of hospital-acquired infections in the setting of endoscopy are needed to develop a new post-pandemic PPE consensus.

Funding Agencies

None
A93 VOLUME OF EMR EXPOSURE IN TRAINING IS CORRELATED WITH POLYPECTOMY COGNITIVE COMPETENCE AMONGST RECENT GASTROENTEROLOGY GRADUATES
Authors: Jeyalingam T , Walsh C M , Grover S C , Heitman S , Mosko J
Published: March 2021

Background

Competence in performing polypectomy is increasingly appreciated as a colonoscopy quality metric, as incomplete resection can lead to post-colonoscopy colorectal cancer, particularly for polyps removed using piecemeal endoscopic mucosal resection (EMR). The relationship between training experiences and cognitive competence in polypectomy has not been previously described.

Aims

We aimed to examine associations between training and assessment experiences, self-reported comfort, and cognitive competence in polypectomy amongst recent graduates of Canadian gastroenterology training programs.

Methods

An online survey was distributed to recent GI graduates (≤5 years in independent practice). The survey comprised 4 sections: (1) demographics; (2) training and assessment experiences in colonoscopy, polypectomy, and EMR; (3) self-reported comfort in performing aspects of polypectomy outlined in the Direct Observation of Polypectomy Skills Assessment Tool; and (4) performance on a 22-item multiple choice quiz intended to assess cognitive competence in polypectomy (items and correct responses to which were determined a priori based on agreement of two experts). Data was analyzed using descriptive statistics and associations between predictors (demographics, training/assessment experiences, self-reported comfort) and outcomes (quiz score) were assessed using multiple linear regression.

Results

There were 28 survey respondents, comprising 13 (46%) who trained in advanced endoscopy, 5 (18%) in hepatology, 2 (7%) in motility, 1 (4%) in IBD, 1 (4%) in nutrition, and 6 (21%) with no advanced training. This cohort had a mean (SD) duration in independent practice of 29.0 (18.4) months. Their mean (SD) annual volume of colonoscopy, polypectomy, and EMR in independent practice was 530 (221), 182 (76), 28 (16), respectively and they had completed 525 (203) colonoscopies, 146 (92) polypectomies, and 23 (20) EMRs in their prior training. Their mean (SD) quiz score was 71.9% (13.2%). ANOVA revealed significant score differences based on fellowship history, with those trained in advanced endoscopy achieving the highest scores (81.1%, P=0.01). Multiple linear regression revealed that the number of EMRs completed during training was significantly correlated with quiz performance (B=0.60, P=0.03).

Conclusions

EMR experience during training appears to be associated with cognitive competence in polypectomy in independent practice. These results suggest increasing exposure to EMR in training may improve polypectomy quality amongst practicing endoscopists.

Funding Agencies

CAG
A94 BARRIERS TO ADVANCEMENT ALONG THE GASTROENTEROLOGY CAREER PATHWAY: A RESIDENT PERSPECTIVE
Authors: Pattni C , Jawaid N , Bollegala N
Published: March 2021

Background

GI residency training programs in Canada are comprised of approximately 30% females. Survey data from procedural specialities reveal gender related differences relating to work-life balance, parental obligations, access to role models, and workplace gender discrimination.

Aims

To determine gender specific differences affecting the choice of GI as a sub-specialty and the experience of GI as a career during residency and fellowship.

Methods

A 91-question mixed methods survey was electronically disseminated in two recruitment waves to PGY4-6 gastroenterology residents and fellows across Canada between May 7th-July 1st, 2020. The survey consisted of nine groups of questions aimed at understanding personal, professional, financial, and training characteristics. Comparisons were made between self-identified male and female genders. Wilcoxon (Mann Whitney U test) was used for continuous variables while chi-squared test and fisher’s exact test was applied for categorical variables using SAS software. Qualitative thematic analysis was applied for short answer responses with two independent reviewers.

Results

A total of 122 residents were surveyed with a response rate of 36% (44/122).There were 17 PGY4s, 15 PGY5s, and 12 PGY6s. Females comprised 41% (18/44) of respondents. Women were statistically more likely to take on a predominant caregiver role for children (p=0.012) and state that having children would slow their career advancement (p=0.046). Men were more likely to state that it is preferable to have children during residency (p=0.036) and that their partner’s preference factored into their subspecialty training choice (p=0.009) than women. Male PGY4/5 trainees were more likely to select therapeutic endoscopy for advanced training (p=0.033). No statistical difference was found regarding aspirations for administrative/leadership positions, desired future income, practice setting, academic pursuits, and perspectives on compromising marriage for career. Qualitative analysis suggests non-gender specific challenges related to achieving work-life balance, securing a desired location of practice, and obtaining financial stability are common resident and fellow concerns.

Conclusions

Our study is the first of its kind within the field of gastroenterology to focus on GI residents and fellows’ experiences within Canadian training programs. Our results show that there exist gender related differences in relation to work-life balance and career advancement. Women may benefit from supports to cope with increased caregiver demands in order to allow them to meet career goals which are similar to their male peers.

Funding Agencies

None
A110 PATIENT-GUIDED COMPLICATION TRACKING SYSTEM (PACTS): BUILDING ALLIANCES WITH PATIENTS FOR THE CONTINUED IMPROVEMENT OF POST-PROCEDURAL OUTCOMES.
Authors: Calman T’ien L , Macdonnell C A , Yonge J , Galorport C , Enns R A
Published: March 2021

Background

In Healthcare, interventions using Short Message Service (SMS) are growing as more patients have mobile phones. To date, studies have investigated using SMS to remind patients of upcoming appointments and provide preventative medical care. Although SMS interventions exist, little is known about their potential as a post-procedural follow-up tool.

SMS follow-up systems present a unique opportunity for clinics to provide support to patients having unplanned post-procedural events. Moreover, the identification of these cases promotes the adoption of preventative measures. Before SMS follow-up programs can be integrated in clinics, proof-of-concept research needs to be conducted to assess the feasibility of this intervention.

Aims

This study aims to determine intervention design elements to maximize the response rate of a novel follow-up program implemented at St. Paul’s Hospital in Vancouver, BC.

Methods

An iterative prospective study was conducted to assess the effects of various design features on the response rate of an SMS follow-up system.

Outpatients having a colonoscopy and/or gastroscopy at St. Paul’s Hospital between 11/19-03/20 were considered for inclusion in this pilot. Patients were asked to participate if they understood Grade 10-level English and had a mobile phone.

For this pilot, a PAtient-guided Complication Tracking System (PACTS) was designed to send SMS to patients one week post-procedure. During each program round, adjustments were made to PACTS with the goal of increasing the response rate. The design changes made to the pilot were cumulative.

One-way ANOVA and Tukey’s Honestly Significant Difference tests were completed to assess response rate differences between rounds.

Results

A total of 1829 patients met the inclusion criteria and consented to participate in the pilot. The overall median response rate was 93%. ANOVA test revealed a statistically significant difference in response rates between rounds, F(6, 196) = 3.369, p = 0.0035. Only the mean response rates between Rounds 1 and 7 yielded a significant pairwise difference (p < 0.001).

Conclusions

The PACTS pilot demonstrates that high response rates are achievable by SMS follow-up systems. This study identified several design elements to optimize SMS intervention response rates. These features included: sending a 1st SMS that explains the program’s purpose, sending a 2nd SMS to participants that did not respond to the first, and providing pilot information to patients upon admission and discharge.

Future research on SMS follow-up systems should explore designing a program that can be integrated in clinics with minimal staff involvement.

Funding Agencies

None
A112 THE IMPACT OF CENTRAL COORDINATION ON ENDOSCOPY EFFICIENCY
Authors: Stewart M J , Farina D , Jones J
Published: March 2021

Background

The impacts of the COVID-19 pandemic have been far reaching and have necessitated many changes to healthcare delivery. At the QEII Health Sciences Center physical space limitations for patient check-in and recovery have restricted outpatient endoscopy to 3 of 4 available endoscopy suites. On June 1, 2020 a new system of central endoscopy triage and coordination for the Division of Digestive Care and Endoscopy (DC&E) was implemented in an effort to increase efficiency and maintain patient access to endoscopy. The components of the RESET (Re-introduce Endoscopy Safely and EfficienTly) Plan included a) a new endoscopy coordinator role to manage a common endoscopy waitlist, endoscopist schedules, and booking clerks, b) a modified triage system to improve waitlist consistency, c) a common endoscopy waitlist with patients booked in the next available appointment regardless of endoscopist, d) discontinuation of fixed endoscopy slots for endoscopists, and e) appointment scheduling no sooner than 4-weeks in advance to minimize no-shows and last-minute cancellations.

Aims

The aim of this study is to evaluate the impact of the RESET Plan on the efficiency of DC&E endoscopy.

Methods

A retrospective pre- and post-implementation study evaluating the volume and efficiency of outpatient endoscopy before and after implementation of the RESET Plan. The Pre-RESET period included all procedures performed from June 1, 2019 to October 31, 2019. The Post-RESET period included all procedures performed from June 1, 2020 to October 31, 2020. A separate endoscopy suite and triage system is used for endoscopic retrograde cholangiopancreatography (ERCP) and these cases were excluded. Early effectiveness outcomes were reported including a comparison of the number of endoscopic procedures per week and per list, pre- and post- implementation. Data analysis was primarily descriptive with data expressed as frequencies, means (SD), and proportions (%). Exploratory group comparisons were performed using independent-samples T-Test.

Results

During the 5-month Pre-RESET period, 2203 endoscopic procedures were performed. During the Post-RESET period a total of 1920 procedures were performed. Due to pandemic restrictions, there was a 29% decrease in available endoscopy lists from 2019 to 2020. There was a 24% increase in the number procedures performed per endoscopy list, from 6.4 to 8.0 (p=0.004, 95% CI 0.52–2.53), pre- and post-RESET.

Conclusions

While the COVID-19 pandemic has disrupted healthcare delivery, it has also provided an opportunity to implement health system structure and process changes. The RESET Plan resulted in significant gains in efficiency which largely offset losses in endoscopy throughput imposed by COVID-19 pandemic restrictions. Future research will determine what patient and health system factors most significantly impact system efficiency as well as the cost-effectiveness of the RESET Plan.

Funding Agencies

CAG
A124 GASTRIC RETENTION IN CAPSULE STUDIES – IS AN ENDOSCOPY ALWAYS REQUIRED?
Authors: Nassiri S , Ou G , Galorport C , Enns C A , Enns R A
Published: March 2021

Background

Capsule endoscopy (CE) is a non-invasive procedure for evaluating small bowel (SB) disorders but is limited by the completion rate. Gastric retention (GR), whereby the capsule remains in the stomach for the duration of the recording, can contribute to incomplete examinations given CE’s finite battery life. Although this may be mitigated by using real-time imaging and/or endoscopic placement of capsule into the SB, such strategies require additional resource allocation. While other risk factors associated with incomplete examinations are well known, GR is not often discussed in the literature.

Aims

To describe the management and outcomes of patients with GR. We hypothesize that most patients with previous gastric retention of the capsule, without known obstruction, will pass the capsule normally through the stomach with a second attempt without requiring endoscopic placement into the duodenum.

Methods

Case series of patients with GR at a tertiary care centre in Vancouver, Canada. Prior to CE, all patients had undergone appropriate investigations to exclude obstructive pathology. All patients ingested 2L of polyethylene glycol-based bowel preparation the evening prior to the procedure and were fasting after midnight. Ingestion of the capsule occurred at 0700h. In patients who required repeat CE due to previous GR, capsule progress was assessed via real-time imaging at 1–2 hrs. If the capsule had not entered the SB by three hours, an attempt at endoscopic advancement of the capsule into the duodenum was made and/or endoscopic placement of capsule was arranged for a later date.

Results

GR was found in 21 (2%) of 1024 patients between 09/2015 - 09/2020. The mean age of patients with GR was 58 ± 20.9 years (48% female). The most common indication for CE in this group was obscure gastrointestinal bleeding (n = 12, 57%). The mean Charlson Comorbidity Index was 2.9 ± 3.5. Thirteen patients (62%) had a history of abdominal/pelvic surgery. Fourteen patients (67%) had repeat CE, nine (64%) of which passed into the SB without endoscopic assistance. Of those requiring endoscopic assistance (n = 5), two had successful endoscopic placement, one required dilation of pyloric stenosis prior to successful placement, one failed endoscopic placement due to stenotic gastroplasty orifice, and another required upper endoscopy for further evaluation. None experienced delayed adverse events related to GR.

Conclusions

CE can be safely repeated in patients with previous GR; most capsules will pass through the stomach spontaneously when repeated and do not require endoscopic assistance.

Funding Agencies

None
A142 TRENDS IN HELICOBACTER PYLORI TREATMENT AND CURE IN EDMONTON: 2015–2020
Authors: Krahn T , van Zanten S
Published: March 2021

Background

Therapies for Helicobacter pylori infection have changed significantly over time due to changes in resistance patterns. In 2016, the Toronto H. pylori consensus guidelines recommended treatment for 14 days. First-line therapies are concomitant therapy with a proton-pump inhibitor (PPI) and clarithromycin-amoxicillin-metronidazole (CLAMET) or bismuth-based quadruple therapy (PPI-bismuth-metronidazole-tetracycline, PBMT). Second and/or third line therapies are PBMT or PPI-amoxicillin-levofloxacin (PAL) and the fourth line PPI-amoxicillin-rifabutin (PAR) for 10 days.

Aims

To describe and compare the efficacy of current treatment regimens for H. pylori infection in Edmonton.

Methods

This retrospective study reviewed records of patients treated for H. pylori infection at the University of Alberta Hospital (UAH) in Edmonton, Alberta from January 1, 2015 - November 1, 2020. Diagnosis of H. pylori infection and test-of-cure were documented with a positive urea breath test, stool antigen test, histology on endoscopy, or positive culture. Patients who had no post-treatment testing were excluded. The per protocol efficacy of different regimens was calculated as well as cumulative success rates when given as 2nd, 3rd or 4th line therapy.

Results

Overall, 170 of 237 (71.7 %) confirmed H. pylori cases achieved cure. The majority were female (64%) and 113 (48%) were born outside of Canada. CLAMET initiated at UAH had the highest success rate 41/45 (91%), and in referred patients who were previously treated was successful as first-line therapy in 45/70 (64%). Overall success rate of regimens were as follows (Table 1): CLAMET 49/98 (50%), PBMT 45/114 (40%), PAL 33/99 (33%), and PAR 16/31 (51%). Alternative regimens were not successful 27/223 (12%). Cultures and resistance profiles were available for 53 cases that failed initial treatment. Resistance to clarithromycin (84%), metronidazole (48%), and levofloxacin (41%) was highly prevalent (Figure 1).

Conclusions

Test-of-cure is important to verify H. pylori eradication as antibiotic resistance is common to clarithromycin, metronidazole, and levofloxacin when prior treatments failed. These results support the H. pylori treatment regimens recommended by the Toronto consensus guidelines.

Funding Agencies

None
A159 ANTI-TUMOR NECROSIS FACTOR THERAPY PERSISTENCE IN PATIENTS WITH PERIANAL CROHN’S DISEASE AND LUMINAL CROHN’S DISEASE: A COMPARATIVE COHORT STUDY
Authors: Fung M , Chin Koon Siw K , McCurdy J D
Published: March 2021

Background

Anti-tumor necrosis factor therapy has revolutionized the management of Crohn’s disease. Despite its effectiveness, a substantial proportion of patients discontinue therapy over time. Evaluating drug persistence rates reveals a real-world pattern of biologic use. Perianal Crohn’s disease (PCD) is considered one of the most difficult phenotypes of Crohn’s disease (CD) to treat. Therefore, we hypothesized that patients with PCD have a shorter biologic persistence time due to refractory disease.

Aims

Our aim is to compare drug persistence rates of anti-TNF therapy between PCD and LCD patients.

Methods

We performed a retrospective, comparative cohort study at a tertiary care center between Nov 2019 and July 2020. Patients with CD were identified by our institutional data-base, using the ICD-10 code K50.90. A longitudinal chart review determine anti-TNF utilization and classified patients based on luminal CD only [LCD] or PCD. Patients with PCD were matched (1:1) to patients with LCD based on sex, age, and year of first anti-TNF initiation within 5 years. Time to discontinuation of anti-TNF therapy was estimated by Kaplan-Meier methods and compared between groups by Log-rank test.

Results

A total of 142 patients with PCD (55% male, 38.7 ± 13.7 years old at anti-TNF start) were matched to 142 patients with LCD (55% male, 38.7 ± 14.0 years old at anti-TNF start). The initial treatments included infliximab (67.6% vs. 57.7%) and adalimumab (32.4% vs. 42.3%) for patients with PCD and LCD respectively. Concomitant immunomodulator were used in 61.3% of patients with PCD and 54.9% of patients with LCD. The cumulative persistence of the initial anti-TNF therapy was similar between cohorts (Log rank, p = 0.633; Figure 1): mean time to discontinuation was 27.7 ± 26.8 months for patients with PCD and 26.5 ± 23.0 months for patients with LCD. The reasons for treatment discontinuation included: refractory disease (19% vs. 16%), anti-drug antibodies (6% vs. 12%), and side effects (12.7% vs. 16.2%) in patients PCD and LCD respectively. Of the patients who discontinued their first anti-TNF therapy, 36 patients (55.4%) with PCD and 42 patients (60.9%) with LCD were treated with a second anti-TNF therapy. Discontinuation of the second-line anti-TNF therapy occurred in 18 patients (50%) with PCD and 18 patients (42.9%) with LCD: mean time to discontinuation was 17.3 ± 14.3 months and 27.8 ± 28.8 months respectively.

Conclusions

In this single-center, observational study a substantial percentage of patients discontinue anti-TNF therapy overtime, and there does not appear to be a difference between patients with PCD and LCD.

Funding Agencies

None
A169 EXPLORING PATIENT PERSPECTIVES ON AN ONLINE STRESS REDUCTION BASED WELLNESS INTERVENTION IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE (IBD)
Authors: Watt M , Hyde A , Madsen K , Peerani F , Tandon P
Published: March 2021

Background

Despite strong connections between stress and inflammatory bowel disease (IBD) associated symptoms, there has been limited research on stress reduction interventions for patients with IBD. Moreover, the research that has been conducted on this topic has shown mixed results with very few studies having used qualitative methodology to explore the patient experience.

Aims

Our objectives for this study were to explore: (i) the experience of having IBD, (ii) the influence of an online 12-week stress reduction program on participant’s physical and emotional symptoms of IBD and (iii) the acceptability of the online program.

Methods

We used a qualitative descriptive approach embedded within a larger randomised control trial (RCT) to explore the experiences of participants. Upon completion of the program, participants were invited to participate in semi-structured interviews. Interviews were analysed through an inductive process whereby transcripts were coded, with codes grouped into larger categories and then themes. Data collection and analysis occurred in a concurrent and iterative manner to enable refinement of interview questions and reflections on the research process.

Results

We analysed a total of 55 interviews. Three main themes emerged from the data: (i) IBD as a source of stress and uncertainty, (ii) understanding the positive impacts of the stress reduction program, and (iii) enhancing program desirability. Participants reported a reduction in IBD symptom burden with improvements in their ability to manage everyday and disease-associated stressors, while building a positive mindset. Weekly check-ins with program facilitators enabled participants to build routine, enhancing accountability. Variation in program content and fostering connections with others in the IBD community were identified as potential program improvements.

Conclusions

Our findings highlight the debilitating nature of IBD, with participants reporting significant disruptions to daily activities, uncertainty, and stress which served to worsen symptoms. Stress reduction programs like the one explored in our study offer an accessible avenue for reducing perceived stress, enhancing resilience and improving the physical condition of individuals diagnosed with IBD. Future research should explore the application of online stress reduction programs in patients experiencing other gastrointestinal disease.

Funding Agencies

CIHRUniversity Hospital Foundation, American College of Gastroenterology, CIHR IMAGINE grant
A177 METHOTREXATE FOR THE INDUCTION OF REMISSION IN ULCERATIVE COLITIS
Authors: Hudson D , Lakhani R , MacDonald J , Chande N , McDonald J W
Published: March 2021

Background

Obtaining steroid-free remission in Ulcerative Colitis (UC) is a clinically important parameter that can mitigate the development of disease-related complications and lead to improved quality of life.

Aims

A systematic review to assess the effects and safety of methotrexate for induction in patients with UC.

Methods

MEDLINE, EMBASE, CENTRAL were searched from inception to August 20, 2020. Randomized controlled trials (RCTs) comparing methotrexate with placebo or an active comparator in patients with active ulcerative colitis were considered for inclusion. The primary outcome measure was the proportion of patients who achieved clinical remission and withdrawal from steroids as defined by the studies and expressed as a percentage of the total number of patients randomized (intention-to-treat analysis). The overall quality of the evidence supporting the primary outcome was assessed using the GRADE criteria.

Results

Three studies (n=212) were included in the review. Two studies were randomized controlled trials comparing methotrexate to placebo for induction of remission of active ulcerative colitis. The first study (n = 67) compared oral methotrexate (12.5 mg/week) to placebo. Forty-seven percent (14/30) of methotrexate patients achieved clinical remission and complete withdrawal from steroids during the study period compared to 49% (18/37) of placebo patients (RR 0.96, 95% CI 0.58 to 1.59). A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was low due to very sparse data. The second study (n=111) compared subcutaneous/intramuscular methotrexate 25 mg/week to placebo. The primary outcome, steroid-free remission at week 16, was present in 32% (19/60) of patients on methotrexate in comparison to 20%(10/51) of patients in the placebo arm (RR 1.62; 95% CI 0.83 to 3.15; P-value of 0.15). A GRADE analysis indicated downgrading of the evidence to low given very sparse data (29 events). An additional head-to-head randomised controlled study (n = 34) compared oral methotrexate (15 mg/week) to 6-mercaptopurine (1.5 mg/kg/day) and 5-aminosalicylic acid (3 g/day). This final study was judged to be at high risk of bias due to an open-label design. At 30 weeks, 58% (7/12) of methotrexate patients achieved clinical remission and withdrawal from steroids compared to 79% (11/14) of 6-mercaptopurine patients (RR 0.74, 95% CI 0.43 to 1.29) and 25% (2/8) of 5-aminosalicylic acid patients (RR 2.33, 95% CI 0.64 to 8.49). GRADE analyses indicated that the overall quality of the evidence was very low due to very sparse data and high risk of bias.

Conclusions

Methotrexate demonstrated no benefit over placebo or active comparators for the induction of steroid-free remission. Future research is ongoing to explore the utility of combination therapy with monoclonal antibody biologic therapy for the treatment of active ulcerative colitis.

Funding Agencies

None
A204 PATIENT FACTORS AND STONE FEATURES AS PROGNOSTIC PREDICTORS IN BILIARY STONE LITHOTRIPSY BY SINGLE-OPERATOR CHOLANGIOPANCREATOSCOPY
Authors: Sljivic I , Chahal D , Trasolini R , Donnellan F
Published: March 2021

Background

Single-operator cholangiopancreatoscopy (SOC) is a therapeutic modality for pancreaticobiliary stone disease that is refractory to traditional ERCP. SOC is still considered a relatively novel technology with limited access in many centers and significant associated costs. Thus, it is imperative to understand the influence patient-based factors and ancillary actions have on the outcome of SOC.

Aims

We hope to determine if the differences in clinical outcomes amongst cohorts suffice to indicate a re-evaluation of SOC in unfavourable patient populations. We present a series of patients who underwent SOC for biliary stone lithotripsy at a tertiary center with exploratory analysis of factors related to efficacy and adverse events.

Methods

This is a retrospective, descriptive case series. Cases were identified via query of the electronic medical record between March 2016 and May 2019. We evaluated patient demographics, past medical history, clinical presentation, disease characteristics, complication rates, and patient outcomes. Descriptive statistics are reported.

Results

25 unique patients underwent a total of 44 SOC procedures. Mean age was 68 (range 22–88). 13 patients were male. 29 procedures involved a stone in the Common Bile Duct (CBD), 5 in the Common Hepatic & Intrahepatic Ducts (CIHD), 4 in the Pancreatic Duct (PD) and 6 in the Cystic Duct (CD). Symptomatic improvement was achieved in 100% of patients. After a single session, 22.7% of procedures resulted in complete clearance and 59.1% of cases led to partial fragmentation. CBD stones however had an 86.2% clearance rate, compared to an 88–91% success rate in literature. The total complication rate was 16% across age and sex groups. The most common complication was bacteremia in 4 (9.1%) cases. Undifferentiated complication rates were highest with CD stones, while bacteremia was most likely with PD stones. A strong trend was noticed between past SOC procedures and increasing ongoing stone burden, with repeat SOC required less often in patient’s with fewer past SOC procedures. We further observed poorer fragmentation rates for PD stones and a rising trend for repeat SOCs for proximal CBD stones.

Conclusions

SOC is useful against difficult biliary stones and can provide therapeutic relief without theoretical risks associated with surgery and ERCP. While our study was underpowered to provide generalizable statistics, it is one of the few studies that showed the influence certain comorbidities, stone characteristics and age have on the efficacy and safety of SOC. Our data illustrates the relative effect location and stone-size has on fragmentation and complications rates. Poorer outcomes are more frequent in those with systemic comorbidities and previous surgeries, and rates of complications and failed fragmentation are further exacerbated by age.

Funding Agencies

None
A210 DECLINE IN HEPATITIS B QUANTITATIVE SURFACE ANTIGEN LEVELS IN CHRONIC HEPATITIS B PATIENTS ON TREATMENT WITH NUCLEOS(T)IDE ANALOGUES
Authors: Stach J , Zhao I , Frolkis A , Haylock-Jacobs S , Israelson H , Pinto J , Williams S , Swain M , Stinton L , Aspinall A , Borman M , Sadler M D , Burak K W , Congly S E , Lee S , Coffin C S
Published: March 2021

Background

The Hepatitis B virus (HBV) affects over 250 million people worldwide and can lead to cirrhosis and hepatocellular carcinoma. HBV surface antigen (HBsAg) quantification is increasingly used to predict disease activity and treatment response. As there is no virologic cure, clinicians are seeking a “functional cure”, or HBsAg loss, as a guide to safely stopping nucleos(t)ide analogue therapy. Tenofovir Disoproxil Fumarate (TDF) and Entecavir (ETV) are first line therapy but require prolonged treatment to achieve HBsAg clearance.

Aims

To assess the association between nucleos(t)ide therapy and decline in quantitative HBsAg (qHBsAg) in patients with HBV from Calgary, Alberta.

Methods

A retrospective review of adult patients with chronic HBV, followed at the University of Calgary Liver Clinic, was conducted between January 2012 and October 2020. Patients were excluded if treatment was discontinued or changed, only had a single qHBsAg measurement, or were co-infected with hepatitis C virus, hepatitis delta virus, or HIV. Patients were stratified according to therapy with TDF, ETV, or no treatment. To identify associations between mean changes in qHBsAg by medication exposure, one-way ANOVAs and t-tests were performed. Results were reported as means and 95% confidence intervals (CI). The median time from initial qHBsAg to most-recent was calculated.

Results

187 patients were included in the final analysis (Table 1). 77 were excluded for being on more than one medication over the study period, 10 were excluded due to discontinuation of treatment, and 195 were excluded for single qHBsAg measurements. The mean qHBsAg decline was -750.04 IU/mL (95% CI -1311.58, -188.50) in the TDF group (n=45) and -309.20 IU/mL (95% CI -600.90, -17.50) in the ETV group (n=35) (p=0.20). In the no treatment group (n=107), the mean qHBsAg increased by 711.29 IU/mL (95% CI -600.78, 2023.80)(Figure 1). The median time from initial qHBsAg to most-recent was 980 days.

Conclusions

Quantitative HBsAg levels declined in patients on TDF and ETV, but increased in untreated patients. Although HBsAg levels showed a trend for greater decline in TDF-treated patients, results failed to reach statistical significance, and may be affected by overall treatment duration. Future studies will explore medication use as a time-varying covariate to identify how change in treatment influences changes in HBsAg over time.

Funding Agencies

None
A224 LIVER CIRRHOSIS AND VENOUS THROMBOEMBOLISM: A NATIONAL INPATIENT SAMPLE STUDY
Authors: Balubaid I , Alghamdi W , Khanna R , Teriaky A
Published: March 2021

Background

The sequelae of decompensated cirrhosis include a reduction in both hepatic coagulation factors and platelets. While historically it was felt that patients with cirrhosis were naturally anticoagulated, recent studies have refuted this. As a result, cirrhotic patients may be a risk for development of venous thromboembolism (VTE). Conflicting data regarding VTE risks limits guidance for clinicians.

Aims

National Inpatient Sample (NIS) data were analyzed to compare the prevalence of VTE among hospitalized patients with and without cirrhosis.

Methods

NIS is a database of US inpatient admissions. The 2014 NIS database was interrogated using ICD-9-CM codes to identify adult patients with cirrhosis and VTE. Baseline characteristics for patients with and without cirrhosis were compared. Multivariate regression models identified risks of VTE adjusting for survey procedures. Data were presented with odds ratio (OR) with 95% confidence intervals (95% CI). A p-value <0.05 was statistically significant.

Results

605,825 patients with cirrhosis were included. VTE occurred in 8,940 patients with cirrhosis and 627,490 controls (1.5% and 2.2% respectively). The corresponding values for PE were 0.5% and 1.1%; and for DVT were 1.1% and 1.4%. The OR for VTE in patients with cirrhosis was 0.547 [95% CI (0.520–0.576), p <0.001] when adjusting for risk factors for VTE (table 1).

Conclusions

Prevalence of VTE was lower among inpatients with cirrhosis compared to controls. Use of anticoagulation was not controlled as these data were not available, which could limit some associations. Further prospective studies are needed to overcome the limitations of retrospective analysis.

Funding Agencies

None
A239 AN APPROACH TO GASTRIC BALLOON RETRIEVAL ADMIDST COVID-19 RELATED TRAVEL RESTRICTIONS
Authors: Dahiya M , Tomaszewski M , Bond A , Donnellan F , Mohamed R
Published: March 2021

Background

Given the COVID-19 pandemic, international travel restrictions have been in effect since March 2020 in Canada. As a result, some patients requiring international travel for medical care have experienced delays. Therefore, innovative techniques were required to provide care that would not routinely be performed in Canada, as in the case of Orbera® gastric balloon retrieval.

Aims

To describe an approach to gastric balloon retrieval amidst COVID-19 related travel restrictions

Methods

Case review of three cases of gastric balloon retrieval was performed

Results

1: A 41-year-old (yo) woman had an Orbera® gastric balloon placement in Washington state in September 2019. She lost 42lbs. Retrieval was scheduled for March 2020, but was delayed due to COVID-19 restrictions. In May 2020, she developed symptoms of balloon dysfunction. The patient was referred to a Canadian tertiary care centre. Gastroscopy was performed under conscious sedation. The Orbera® balloon was in the distal gastric body. The balloon was punctured with a 19G EUS FNA needle; 600cc of blue tinted liquid was aspirated. The emptied balloon was retrieved successfully using rat tooth forceps.

2: A 35-yo woman had an Orbera® gastric balloon placed in October 2019 in Toronto at a private health facility. She lost 20lbs. Retrieval of the balloon was scheduled for March 2020, but due to COVID-19 restrictions, it was not possible at the original facility. She did not have symptoms related to the balloon. Gastroscopy was performed under general anesthesia (GA) on October 8, 2020. The balloon was intact in the distal gastric body. The balloon was punctured with a 19G Cook Echotip Needle and vacuum suction applied; 400cc of blue tinted fluid was removed. Alligator forceps were used to create holes in the underside of the balloon, allowing excess fluid to be expelled as the balloon was pulled up against the GEJ. Once the balloon was deflated, it was removed successfully through the mouth.

3: A 38-yo man had an Orbera® gastric balloon placed in his native Columbia in March 2020. He did not achieve weight loss. Due to COVID-19 restrictions, he was unable to return for planned removal. He did not have symptoms related to the balloon. Gastroscopy was performed under GA on October 8, 2020. The balloon was intact in the distal gastric body. The balloon was punctured with a 19G Cook Echotip Needle and vacuum suction applied; 600cc of blue tinted fluid was removed. Alligator forceps were used in retroflexion to tear the underside of the flattened balloon to ensure all liquid and air had escaped from the balloon. Once the balloon was deflated, it was removed successfully through the mouth.

Conclusions

Although Orbera® gastric balloon retrieval is not routinely performed in Canada, we demonstrate that gastroscopy with balloon puncture and forceps-retrieval is a safe option.

Funding Agencies

None
A244 SUCCESS RATE AND SAFETY OF SINGLE-OPERATOR PANCREATOSCOPY (SOP) IN THE EVALUATION OF SUSPECTED PANCREATIC DUCT NEOPLASIA: A RETROSPECTIVE COHORT STUDY
Authors: Abdel Moaein T , Moffatt D C , Coneys G
Published: March 2021

Background

Pancreatic intraductal papillary mucinous neoplasms (IPMNs) carry malignant risk and they account for up to 7% of pancreatic neoplasms, hence it is crucial to identify high-risk lesions to determine timely therapy

Distinction between main duct-IPMN (MD-IPMN) and other pancreatic disorders often relies on endoscopic ultrasound, MRI, and CT findings. These findings are very accurate in advanced cases, yet they are less sensitive for the diagnosis of early lesions

Direct endoscopic visualization of the biliary and pancreatic ducts has gained an increased interest due to the development of single-operator scopes with a better image resolution. Several case series and a retrospective single-center cohort study report the beneficial role of single operator pancreatoscopy (SOP) in the evaluation and sampling of indeterminate PD lesions

Aims

Evaluate our experience with SOP and determine its

1.Efficacy and safety in diagnosing MD-IPMN and PD neoplasia

2.Sensitivity (Sn) and specificity (Sp) in diagnosing high risk PD lesions

Methods

All patients (age ≥18 year old) who had attempted SOP using the SpyGlass (Boston Scientific Corp, Natick, MA) between June 2013 and November 2019 for the evaluation of indeterminate main PD strictures, dilatation, or with suspected or known MD-IPMN were included

The primary outcome was the efficacy and safety of SOP in diagnosing high-risk PD lesions

A minimum of 12 months follow-up (F/U) from index SOP was required to define a true negative for patients (pts) with benign SOP findings

Results

A total of 43 pts underwent SOP; 18 (42%) males and 25 (58%) females, with a mean age of 66.1 years. Technical success was (n=35/43; 81.4%)

In the diagnosed MD-IPMN group (n=14/35; 40%), all underwent surgery except three; one is awaiting surgery, the second had an aborted Whipple’s and the last was lost to F/U. The remaining eleven pts (78.6%) had confirmed diagnosis of MD-IPMN with moderate or high-grade dysplasia, or pancreatic cancer

Of those who had benign SOP findings (n=21), nineteen (90.5%) did not develop pancreatic neoplasm during a mean F/U period of 59.3 months (range 13 to 84 months). One Pt developed mild pancreatitis

Conclusions

This study suggests that SOP is a safe, effective and feasible procedure that should be considered in the diagnostic algorithm of indeterminate main PD strictures, dilatation, or those with suspected or known MD-IPMN with or without side branch involvement. We demonstrate a high technical success rate, Sn, and Sp of 81.4%, 100%, and 100%, respectively

If all pts with incomplete outcomes data are considered to have be diagnostically inaccurate, the Sn and Sp remain high at 81.4% and 86.4% respectively. The adverse events seem similar to ERCP with only one Pt. (2.7%) developed mild pancreatitis, although this sample has insufficient numbers to evaluate rare events

Funding Agencies

None
Reliability of the classification of cartilage and labral injuries during hip arthroscopy
Authors: Mayer Stephanie W , Fauser Tobias R , Marx Robert G , Ranawat Anil S , Kelly Bryan T , Lyman Stephen , Nawabi Danyal H
Published: March 2021

To determine interobserver and intraobserver reliabilities of the combination of classification systems, including the Beck and acetabular labral articular disruption (ALAD) systems for transition zone cartilage, the Outerbridge system for acetabular and femoral head cartilage, and the Beck system for labral tears. Additionally, we sought to determine interobserver and intraobserver agreements in the location of injury to labrum and cartilage. Three fellowship trained surgeons reviewed 30 standardized videos of the central compartment with one surgeon re-evaluating the videos. Labral pathology, transition zone cartilage and acetabular cartilage were classified using the Beck, Beck and ALAD systems, and Outerbridge system, respectively. The location of labral tears and transition zone cartilage injury was assessed using a clock face system, and acetabular cartilage injury using a five-zone system. Intra- and interobserver reliabilities are reported as Gwet’s agreement coefficients. Interobserver and intraobserver agreement on the location of acetabular cartilage lesions was highest in superior and anterior zones (0.814–0.914). Outerbridge interobserver and intraobserver agreement was >0.90 in most zones of the acetabular cartilage. Interobserver and intraobserver agreement on location of transition zone lesions was 0.844–0.944. The Beck and ALAD classifications showed similar interobserver and intraobserver agreement for transition zone cartilage injury. The Beck classification of labral tears was 0.745 and 0.562 for interobserver and intraobserver agreements, respectively. The Outerbridge classification had almost perfect interobserver and intraobserver agreement in classifying chondral injury of the true acetabular cartilage and femoral head. The Beck and ALAD classifications both showed moderate to substantial interobserver and intraobserver reliabilities for transition zone cartilage injury. The Beck system for classification of labral tears showed substantial agreement among observers and moderate intraobserver agreement. Interobserver agreement on location of labral tears was highest in the region where most tears occur and became lower at the anterior and posterior extents of this region. The available classification systems can be used for documentation regarding intra-articular pathology. However, continued development of a concise and highly reproducible classification system would improve communication.
The Behavioral Response to Heat in the Common Bed Bug,Cimex lectularius (Hemiptera: Cimicidae)
Authors: Berry Raymond
Published: March 2021

The bed bug, Cimex lectularius L., is a common ectoparasite found to live among its vertebrate hosts. Antennal segments in bugs are critical for sensing multiple cues in the environment for survival. To determine whether the thermo receptors of bed bugs are located on their antennae; innovative bioassays were created to observe the choice between heated and unheated stimuli and to characterize the response of bugs to a heat source. Additionally, the effect of complete antenectomized segments on heat detection were evaluated. Heat, carbon dioxide, and moisture are cues that are found to activate bed bug behavior; a temperature at 38°C was used to assess the direction/degree at which the insect reacts to the change in distance from said stimulus. Using a lightweight spherical ball suspended by air through a vacuum tube, bed bugs and other insects are able to move in 360° while on a stationary point. Noldus EthoVision XT was used to capture video images and to track the bed bugs during 5-min bioassays. A bioassay was created using four Petri dish arenas to observe bed bug attraction to heat based on antennae segments at 40°C. The purpose of this study was to evaluate the effects of heat on complete antenectomized segments of the antennae. The results in this experiment suggest that bed bugs detect and are attracted to heat modulated by nutritional status. Learning the involvement of antennae segments in heat detection will help identify the location and role of thermoreceptors for bed bug host interaction.
‘This spasm upon canvas’: George Eliot, Gustave Courbet and Realist Aesthetics
Authors: Jones Charlotte
Published: March 2021

This article offers sustained consideration for the first time of George Eliot’s entanglement with mid-nineteenth-century French art. Taking realism’s transnational nature as its point of origin, this essay probes Eliot’s claim in Adam Bede (1859) for seventeenth-century genre painting as the most conspicuous visual precedent to define, embody and vindicate her aesthetic choices – at just the moment when Gustave Courbet makes realism scandalous in the Salons of the Second Empire. Questioning Eliot’s deliberate disavowal of influence, I trace the modes of transmission through which Courbet’s art was exported to and circulated within Britain during the 1850s; while London’s official art world was unreceptive to French art in the nineteenth century, a different picture emerges if we consider the visibility afforded by independent galleries and the periodical press, and if we take account of these diverse reading, viewing and citational practices. I then offer close readings of works by Eliot and Courbet to suggest that both evidence a discomfort with representation as the primary methodology of realism, and consider the consequences for the ideological, epistemological and affective energies of realist aesthetics. Reading Eliot alongside Courbet reveals her radicalism, but this only becomes clear when we place her realism within the orbit of a broader European tradition and understand her aesthetics as a form of praxis.