bluuebunny/crossref_metadata_2025 huggingface dataset:
A72 THE ENDOSCOPIC YIELD OF PRIORITIZED INDICATIONS USING A PROVINCIAL-WIDE COLONOSCOPY REFERRAL FORM
Authors: Barkun A , Ravanbakhsh K , Kim D , Milky G , Stanowski P , Geraci O , Martel M , Menard C , von Renteln D
Published: February 2024

Background

The widespread use of a standardized and validated province-wide colonoscopy referral form (PCRF), regrouping mutually exclusive indications into suggested priority wait time categories, has allowed for a more comprehensive assessment of routine colonoscopy practice

Aims

To validate the Quebec PCRF by better characterizing endoscopic finding yields according to specific clinical indications.

Methods

This retrospective cohort study includes consecutive adult patients with available data from the PCRF from two tertiary hospitals. The primary outcome was the diagnostic rates of colorectal cancer (CRC). Secondary outcomes assessed incidences of clinically significant lesions (CSL) on endoscopy and confirmed at pathology. These are CRC, advanced adenomas, sessile serrated polyps, polyps ≥ 5mm, colitis, colonic strictures, and miscellaneous other findings excluding hemorrhoids and diverticulosis. Descriptive and inferential statistics, and multivariable regression predictive modeling are reported.

Results

Overall, 14,657 patients (mean age 59.2 ± 14.0 years, 50.9% female) were included from September 2018 to August 2022. The most frequent indications for colonoscopy were polyp surveillance (IN13, 20.8%), recent change in bowel habits (IN7, 11.9%), a positive fecal immunochemical test (IN5, 8.3%), a family history of CRC or polyps (first-degree relative) (IN8, 6.4%), and suspected active inflammatory bowel disease (IBD) (IN3, 5.8%). Overall, 40.6% had CSL, including CRCs in 0.8%. CRCs were found more frequently for IN2 (19.7% vs 2.0%, pampersand:003C0.01), IN5 (29.9% vs 8.2%, pampersand:003C0.01), and an unexplained documented iron deficiency anemia (IN6) (11.8% vs 5.2%, pampersand:003C0.01). CSLs were more frequent for IN3 (1.6% vs 5.8%, p=0.04), IN7 (4.7% vs 12.0%, p=0.01), IN8 (0.8% vs 6.5%, p=0.01), IN13 (7.1% vs 20.9%, pampersand:003C0.01), IBD surveillance (IN15, 0.0% vs 4.0%, p=0.02), and surveillance for a significant family history (IN21, 0.0% vs 3.7%, p=0.02).

On multivariable analysis, CRC was significantly associated with IN2 OR=31.8 (4.86; 208.7), IN5 OR=19.2 (3.86; 95.7), and IN6 OR=15.7 (2.37; 78.0) - (all are high priority PCRF referrals with a suggested shorter wait time than for most other indications). CSLs were significantly associated with age (OR=1.03 (1.02; 1.03)), IN2 (OR=2.32 (1.35; 3.99)), IN5 (OR=2.37 (1.74; 3.22)), and IN13 (OR= 1.66 (1.36; 2.02)).

Conclusions

This large cohort study confirms the validity of indications and corresponding prioritization of wait times of a PCRF.

Funding Agencies

CPAC and MSSS
A74 A RARE CASE OF ANTIDEPRESSANT-INDUCED LYMPHOCYTIC COLITIS IN A TEENAGER
Authors: Binaqail A , Morinville V D , Nguyen V
Published: February 2024

Background

The etiopathogenesis of microscopic colitis may reflect an immunological reaction in genetically predisposed individuals exposed to an external stimulus causing gut microbiota disruption. Numerous factors such as smoking, autoimmune diseases, and medications have been linked to this condition in adults. Steroids may be required as therapy. Pediatric cases of microscopic colitis have only rarely been reported.

Aims

Case report.

Methods

Retrospective single chart review and literature review of microscopic colitis in children.

Results

A 17-year-old female newly diagnosed with major depression disorder following intentional acetaminophen intoxication was started on sertraline, a selective serotonin reuptake inhibitor (SSRI). Within 2 months from initiation, she began to have non bloody watery diarrhea and had a 5 kg weight loss over a 1-month period . Her laboratory workup only revealed a hypochromic, microcytic anemia. Due to severity of symptoms and reluctance of treating team to discontinue sertraline, she underwent an esophagogastroduodenoscopy and ileo-colonoscopy, both showing grossly normal mucosa. Histological assessment of the colon demonstrated increased intraepithelial lymphocytes, up to 50-60 lymphocytes/100 enterocytes (normal ≤ 20 lymphocytes/100 enterocytes), with associated reactive superficial epithelial changes including goblet cell and mucin depletion, compatible with lymphocytic colitis (Figure1). Sertraline was weaned off, and gastrointestinal symptoms resolved completely. A repeat sigmoidoscopy 5 months later confirmed complete normalization of the histology.

Conclusions

Microscopic Colitis encompasses two disorders, lymphocytic colitis and collagenous colitis, in which the endoscopic appearance is unremarkable, but histological changes are diagnostic. The clinical manifestations of both are similar and typically include chronic non bloody watery diarrhea, weight loss and abdominal pain. Certain medications have been implicated in causing lymphocytic colitis, including SSRIs. SSRIs historically have not been frequently prescribed in pediatrics, but their use has increased in recent years. The complete resolution of symptoms and histology, without the need for any medical therapy, strongly supports that this lymphocytic colitis was caused by sertraline. The association of lymphocytic colitis with sertraline is not well-known among pediatric practitioners: neither the pediatrician nor psychiatrist in our case were aware of such a possibility. This case highlights that medication adverse events, even if rare, should always be considered when chronology is supportive, and at times, simple discontinuation of the drug is sufficient to completely resolve the issue.

Funding Agencies

None
A75 PEDIATRIC ABDOMINAL PAIN PRESENTING TO A HOSPITAL-BASED GI CLINIC: EVOLUTION AND DISPOSITION
Authors: Brill H , Patel R
Published: February 2024

Background

Abdominal pain accounts for 50% of pediatric gastroenterology consultations. While data exists on the possible etiologies of abdominal pain, there is a paucity of data on the natural evolution of abdominal pain while under the care of a Pediatric Gastroenterologist. Given limited access to Pediatric Gastroenterologists and long waiting times for initial consultation for abdominal pain, understanding what interventions ameliorate pain may help Gastroenterologists advise referring physicians while the patient awaits a consultation.

Aims

Primary outcome measure was the percentage of patients who reported at least a 75% subjective improvement of pain over baseline consultation.

Methods

A retrospective chart review between April 2014 and Dec 31, 2022 was taken in a hospital based GI clinic. Subjects referred for assessment of abdominal pain were identified, along with subjects referred for reflux and dysphagia as a comparator group. Subsequent visits were abstracted to identify diagnosis disposition and assess which interventions were tried and to what extent they succeeded. Patient loss to follow up were also measured. Results were summarized using descriptive statistics, and regression modeling will be attempted to identify predictors of response.

Results

393 subjects were referred for abdominal pain and 286 for GERD and dysphagia. 439 (64.7%) reported at least 75% improvement in symptoms. 242 (35.6%) underwent endoscopy, 263 (38.7%) used Proton Pump Inhibitors, and 38 (8.54%) used Polyethylene Glycol-3350. Carbohydrate eliminations of various types were used in 13.5 - 27% of subjects with pain. 193 subjects (28.5%) were ultimately lost to follow up though some did report improvement in symptoms. Only 45 (6.6%) remained in active care by the end of the study while only 13 (1.93%) were transitioned to an Adult Gastroenterologist at 18 years old.

Conclusions

Pediatric Abdominal Pain is primarily a transitory population in the Pediatric GI clinic, with a large number responding to successive interventions. There is also a sizable minority who are lost to follow up. Future studies should attempt to identify the reasons for loss to follow up and ultimate disposition.

Funding Agencies

William Osler Health System Summer Student Research Program
A80 SELF-COMPLETED QUESTIONNAIRES IDENTIFY SYMPTOMS IN A PROPORTION OF PATIENTS WITH CELIAC DISEASE CONSIDERED ASYMPTOMATIC DURING CLINICAL VISITS
Authors: Chang N , Khaouli M , Armstrong D , Pinto-Sanchez M
Published: February 2024

Background

Patients with celiac disease (CeD) often experience symptoms despite adhering strictly to a gluten-free diet, and novel therapies are under development to help symptom management. However, recruitment for clinical trials [DA1] can be challenging, as screening is often based on symptoms reported to the physician during a clinic visit. However, symptoms reported by patients during clinic visits may not be an accurate reflection of the true extent of the symptoms.

Aims

To assess whether gastrointestinal (GI) symptoms reported by patients to physicians during a clinic visit differ from those self-reported in questionnaires on the same day.

Methods

A retrospective chart review of patients enrolled in the celiac registry (HiREB #5415, #16758) was performed. We included adult patients enrolled in our celiac registry from January 2021 to August 2023. We collected data on demographics such as age, sex, gender, time since CeD diagnosis (early diagnosis defined as within 2 years versus late diagnosis as greater than 2 years), CeD serology (TTG, DGP, EmA), in addition to GI symptoms 1) reported to the physician during the clinic visit, and 2) recorded on a validated questionnaire (Gastrointestinal Symptoms Rating Scale - GSRS) completed on the same day. A GSRS score greater than 30 for overall GI symptoms and a score greater than 2 for any individual symptom was considered symptomatic.

Results

We reviewed a total of 174 patient charts that met the inclusion criteria during the defined time period. Overall, 107 patients reported symptoms during the clinic visit; of the remaining 67 patients who did not report symptoms at the clinic visit, 29 (43.2%) were identified as symptomatic by the GSRS. Compared to the clinical history, the GSRS identified higher rates of abdominal pain (77% vs 12.6%, p=0.0001), diarrhea (44.8% vs 11.4%, p=0.0001), bloating (87.3% vs 30.5%, p=0.0001), GERD (55.1% vs 5.1%, p=0.0001), constipation (57.4% vs 15.2%, p=0.0001) and nausea (56.3% vs 10.8, p=0.0001). There were no differences in responses between clinical visits and GSRS when subgrouped by gender, age, time since diagnosis or disease activity.

Conclusions

Self-reported questionnaires identify a subgroup of patients with celiac disease who reported GI symptoms when completing a validated questionnaire despite reporting no symptoms during a clinic visit. Screening patients for clinical research studies is often based on symptoms reported to the physician during the clinical visit, and therefore this has direct implications for research recruitment in gastroenterology clinical trials.

Funding Agencies

None
A82 A SURVEY-BASED ASSESSMENT OF RADIATION PROTECTION ATTITUDES AND PRACTICES IN ADVANCED THERAPEUTIC ENDOSCOPY TRAINING CURRICULUMS
Authors: Chin Koon Siw K , Sypkes C , Gozdzik M , Dhaliwal H , Kundra A
Published: February 2024

Background

Fluoroscopy-assisted endoscopic procedures such as endoscopic retrograde cholangiopancreatography (ERCP) expose patients and physicians to the risks of ionizing radiation, including infertility, cataracts, skin hypersensitivity, hair loss and cancer. Radiation exposure from these procedures can have lasting adverse effects on the health and productivity of gastroenterologists. With attention to “as low as reasonably achievable” (ALARA) principles, recent efforts to minimize radiation use have emphasized the importance of formal radiation protection education, including during advanced therapeutic endoscopy (ATE) training. However, teaching of basic protective measures in radiation safety during ATE training remains often overlooked.

Aims

We aimed to learn how radiation safety training is delivered in ATE programs across Canada and the US. Identifying the existing training standards and knowledge will help us understand the current gaps in training curriculums and inform future curricular development.

Methods

Our study was reviewed by the Ottawa Health Science Network Research Ethics Board in September 2023. Surveys were designed and distributed with the REDCap software and sent to ATE trainees (current and recent graduates within the last 3 years) in Canada and Program Directors (PDs) of accredited ATE programs across Canada and the US.

Results

The survey was completed by 12 trainees and 4 PDs. These are preliminary results and further survey responses are being collected. The majority of trainees (75%) believed it would be very important for their program’s curriculum to include dedicated radiation safety teaching, but most trainees (83.3%) received no such training. Familiarity in optimizing modifiable fluoroscopy parameters to minimize radiation exposure (collimation, gain, magnification, frame rate modification or pulsed fluoroscopy) was variable among trainees (36.4%-81.8%). Seventy-five percent of trainees were unaware of the annual limit for radiation exposure and only 25% believed they were operating within a safe level. Most trainees (90.9%) felt they were given inadequate training to optimally reduce their risk of radiation exposure and 90.9% expressed a desire for further radiation safety training. Despite these findings, only 50% of PDs believed it would be beneficial to offer dedicated radiation safety training as part of their program’s curriculum. Among PDs, 75% did not feel their trainees had the knowledge required to reduce their risk of radiation exposure and all (100%) felt that dedicated training would be useful.

Conclusions

These findings indicate a need for more robust radiation safety training. Further studies are needed to understand the most effective way to deliver comprehensive radiation safety training to ATE trainees.

Funding Agencies

None
A83 GENDER-RELATED BARRIERS TO ADVANCEMENT ALONG THE GASTROENTEROLOGY CAREER PATHWAY: AN INTERNAL MEDICINE RESIDENT PERSPECTIVE
Authors: Cintosun A , Pattni C , Jawaid N , Lomonaco J , Bollegala N
Published: February 2024

Background

Women comprise approximately 31% of the Canadian and 19% of the American gastroenterology population. This gender disparity widens throughout training, with relative gender parity in medical school, slightly less female representation in internal medicine, then with the widest gender disparity in gastroenterology training and practice.

Aims

Our aim was to understand the gender-related barriers to advancement along the gastroenterology training pathway specifically among internal medicine residents.

Methods

A 72-question online survey was distributed by email to internal medicine residents from post-graduate years (PGY) 1, 2, and 3 at the University of Toronto. The initial email was followed by two reminder emails over 1 month. Questions pertained to demographic characteristics, social situation, career aspirations, academic pursuits, and career challenges. Data analysis was performed using SAS software. Continuous variables were compared using Wilcoxon (Mann Whitney U test) and categorical variables with chi-squared and Fisher’s exact test.

Results

40 residents completed the survey. 62.5% were female and most were PGY1 or 2 (n=18, 45% for each; PGY3 was n=4, 10%). Women were more likely to be single (44% vs. 27%, p = 0.0423). In terms of scholarly involvement, women more frequently had additional academic pursuits than their male counterparts (92% vs. 60%, p = 0.0195). For training-related challenges, women more often reported different expectations were put on them due to their due to their background, specifically related to gender (70% vs. 33%, p = 0.0356). Women described more challenges with support staff compared to their colleagues (36% vs. 0%, p = 0.0105), and stated that gender was the reason. Women were also more likely to report that their clinical competence was challenged compared to their peers (32% vs. 7%, p = 0.0384). Outside of work, women more often felt a work-life misbalance due to coordinating childcare (64% vs. 27%, p = 0.0085). Regarding career aspirations, men more often endorsed wanting a hospital leadership role (67% vs. 32%, p = 0.0201). They also rated renumeration as a driving motivation for applying to a subspecialty more often (47% vs. 12%, p = 0.0085) and rated their desired future personal income to over $70,000 more than women (p = 0.0402).

Conclusions

This study is the first to examine gender-related barriers to advancement in gastroenterology at the crucial internal medicine resident level. Women more often reported training-related challenges with others’ expectations and judgments of their clinical competence, as well as personal challenges with coordinating childcare. A deeper understanding of these differences may shape support interventions to help women meet their career goals.

Funding Agencies

None
A86 INFORMING MODERN CARE FOR CANADIAN IBD PATIENTS: A PROSPECTIVE RANDOMIZED TRIAL ON APPOINTMENT TYPES
Authors: Galts C , Siempelkamp B , Cade K , Wilson L , Loomes D
Published: February 2024

Background

There is now significant data supporting virtual care (telehealth or telephone) as a means to provide care to IBD patients with equivalent outcomes to in-person care. Many studies assessing virtual care lack a control group and suffer from recall bias. Further, there is a lack of understanding individual patient appointment style preferences and the reasons for these preferences.

Aims

We aimed to determine patient’s preferred appointment styles and to inform these preferences by assessing demographic factors and other appointment related factors (e.g. cost, time required, communication, privacy etc). We hypothesize that this information may help to inform decisions regarding choosing the optimal appointment for patients.

Methods

In this single centre randomized trial we assigned IBD patients to in-person, telehealth (with video), or telephone appointments in a sequential manner. To minimize recall bias, surveys were completed after each appointment style. All participants had demographic data collected and survey data was compiled using UBC redcap. Standard regression analyses and T-scores were used for assessment of statistical significance.

Results

After exclusion of surveys with incomplete data, a total of 81 surveys were included, 27 in-person, 28 telephone, and 26 telehealth. The overall scores (out of ten) were 9.1 ±1.0, 7.8 ±2.1, and 8.0 ±2.6 for in-person, telephone and telehealth appointments respectively. With exclusion of telehealth appointments which suffered technical difficulties (n=6) the overall score improved and range was comparable to in-person appointments (8.9 ±1.2). In-person appointments were associated with a higher cost and longer time commitment but had the highest scores across all appointment features (e.g. perceived privacy, physician engagement etc.). Among patients who would have preferred an in-person appointment optimal communication (80.0%) and interaction with care provider (83.3%) were prioritized. Conversely, among participants who would have preferred telehealth appointments, time savings (71.4%) and cost savings (42.9%) were prioritized. Age, gender, number of dependents, and perceived privacy were not associated with any appointment style preference.

Conclusions

This study concludes that all appointment styles have certain benefits and drawbacks that individual patients may variably prioritize. In-person appointments had a higher cost and time requirement but still remained the highest rated appointment style. As virtual care continues to be part of the standard of care for patients with IBD, we suggest that providers individualize the style of patient appointment to their patients and the expected nature of that encounter.

Funding Agencies

None
A87 A SURVEY-BASED ASSESSMENT OF ENDOSCOPY CURRICULUM AND EDUCATION IN CANADIAN TRAINING PROGRAMS
Authors: Gozdzik M , Kundra A , Snelgrove R , Kroeker K
Published: February 2024

Background

Endoscopic training within Canada occurs in programs accredited by the Royal College of Physicians and Surgeons of Canada (RCPSC). Beyond national accreditation, there are no standardized endoscopic training curriculums and each program is responsible for ensuring its trainees achieve competency. There is debate in the literature regarding the minimum number of endoscopic procedures and the role of objective assessment tools in the assessment of trainee competence with no specific recommendations for these by the RCPSC.

Aims

The goal of our study was to characterize endoscopic training curriculums within Canadian training programs while determining the usage and perceived importance of procedure volume tracking and objective assessment tools.

Methods

Online surveys were sent to program directors (PD) and trainees within Adult Gastroenterology, Pediatric Gastroenterology, General Surgery and Colorectal Surgery programs within Canada. Surveys contained questions meant to characterize endoscopy training curriculums and perceived effectiveness of the curriculum while highlighting the factors important for feedback and competency assessment.

Results

Survey responses were obtained from 20 PDs and 83 trainees. Of all programs surveyed 53% (44/83) of trainees reported that they had a formal endoscopy curriculum compared with 75% (15/20) of PDs. PDs assessed endoscopic competence predominantly by EPAs (95%) and verbal feedback (65%) with minimal usage of objective tools (30%). Trainees reported fewer objective tool usage at 2.4% (2/83). When assessed on a 5-point Likert scale, both PDs and trainees felt that verbal feedback was the most important for assessment of competence (3.58 and 4.39 respectively). Seventy-seven percent of trainees report using a procedure log and when asked about procedure volume 37% of trainees expected to complete ampersand:003C250 colonoscopies by the end of their training. Eighty-three percent of PDs felt that all their trainees achieved endoscopic competency with only 50% of adult GI PDs reporting the same. Most PDs and trainees felt that national recommendations for objective tool usage (65% and 57% respectively) and minimum procedure volume (65% and 63% respectively) would be helpful to standardize endoscopic training. Additional results are reported in Figure 1.

Conclusions

Most training programs reported a standardized curriculum with a majority of trainees tracking their procedure volume, but a minority of programs incorporated objective tools. A significant portion of trainees expected to complete ampersand:003C250 colonoscopies by the end of their training and not all PDs felt that all of their trainees reach endoscopic competence. The majority of trainees and PDs felt national recommendations for procedure tracking and objective tools would be helpful, suggesting the need for more formalized endoscopic curriculums in Canada.

Funding Agencies

None
A90 ASSESSING 30-DAY MORTALITY IN PATIENTS UNDERGOING EMERGENT ADD-ON ENDOSCOPIC GI PROCEDURES
Authors: Healey K , Borgaonkar M , McGrath J
Published: February 2024

Background

Gastrointestinal (GI) endoscopic procedures may need to be performed emergently on hospitalized patients. Current short-term mortality rates following emergent GI endoscopic procedures are attributed to their indication and vary by geographic area, ranging from 1.89% to as high as 10%. Recent studies describing clinical outcomes and mortality of non-scheduled GI endoscopic procedures are limited.

Aims

This study aimed to describe the 30-day mortality and clinical outcomes of patients who received endoscopic intervention as an add on, non-scheduled procedure over a 2-month period across 2 tertiary hospitals, in St. John’s, Newfoundland and Labrador.

Methods

We retrospectively reviewed the charts for all patients between July 1, 2021, and August 31, 2021, who received an esophagogastroduodenoscopy (EGD), colonoscopy, sigmoidoscopy, and percutaneous gastrostomy (PEG) across 2 tertiary hospitals in St. John’s, Newfoundland and Labrador. Endoscopic procedures on hospitalized patients that were added to the emergency endoscopy list were included. Procedures were done during working hours on weekdays or outside working hours at night-time, and during the weekend. Data on demographics, endoscopic findings, treatment outcomes, and 30-day mortality, were collected through electronic chart review. Descriptive statistics were conducted for data analysis.

Results

Of the 258 add on procedures performed on 213 patients, 17 patients (8.0%) died within 30 days of having had the procedure. The most frequently performed procedure was EGD, and the mortality associated with it was 9.4% (12/127), followed by sigmoidoscopy (1/29, 3.4%), colonoscopy (0/18, 0%), PEG (3/9; 33.3%). One patient who died had both EGD and colonoscopy (1/25, 4%). No patients died from both EGD and sigmoidoscopy (0/5, 0%). The median time between the procedure and death was 15 days. The median age was 72 years old. Most patients received endoscopic intervention for suspected bleeding. The major causes of death were cardiac, GI, malignancy, respiratory, and other.

Conclusions

Hospitalized patients are a distinct cohort with competing risks that need to be considered when planning endoscopic procedures. Further investigation is necessary with a larger patient cohort over multiple years.

Funding Agencies

Summer Undergraduate Research Award (Memorial University of Newfoundland)
A93 AN ANALYSIS OF POST-ENDOSCOPY EXPERIENCES WITHIN AN EARLY ADULT IBD PATIENT POPULATION AT A NATIONAL IBD CENTRE
Authors: Hu M , Mohmand Z , Wu W , Bollegala N
Published: February 2024

Background

Up to 25% of IBD patients are diagnosed before the age of 18, necessitating a process of transition from pediatric to early adult care. Poor endoscopy experiences have been described to jeopardize the overall patient experience with the healthcare system. There is a paucity of literature evaluating the endoscopy experiences of IBD patients during this pivotal point in their disease management.

Aims

The aim of this study is to describe the reported post-endoscopy experiences of early adult IBD patients (18 to 25 years old) compared to those in an adult model of care (26 years old, or above).

Methods

A retrospective analysis of patients with IBD treated at Mount Sinai Hospital from January 1st, 2017 to December 31st, 2021 who underwent an outpatient colonoscopy was performed. Qualitative and quantitative data were longitudinally collected from endoscopy records. The first phase of the study consisted of a comparison of outcomes between early adults (18 to 25 years) and adults (26 years, or above). The second phase consisted of a comparison of outcomes between sedation types (deep versus conscious). T-test was used to compare differences for continuous variables and Fisher exact test was used for categorical variables.

Results

In this initial pilot study of 171 patients, 12.9% of early adults underwent deep sedation compared to 11.4% of adults. Patients who underwent deep sedation were more likely to have Crohn’s disease compared to Ulcerative Colitis (95.2%, 57.7%, pampersand:003C0.01). There were no differences in mean procedure lengths in minutes (18.3, 18.6, p=0.80). Early adults who underwent conscious sedation required additional sedative medications during the procedure in 48.9% of cases compared to 32.3% in the adult cohort (p=0.04), however the mean total of conscious sedation medication used had no differences between the two groups (p=0.59). Nursing post-procedure subjective scoring measuring pain and nausea showed no significant difference (p=0.29). Physician narrative note descriptions of subjective procedural tolerance also showed no significant differences (p=0.78).

Conclusions

Patients with Crohn’s disease are more likely to require deep sedation for their adult colonoscopies compared to patients with Ulcerative Colitis. Gastroenterologists are not adequately prepared to gauge the amount of conscious sedation an early adult patient will require, necessitating top-up amounts peri-procedure more frequently. Current tools in the forms of subjective scoring and narrative documentation utilized by healthcare providers to measure procedural experience and tolerance are poor markers of actual patient experience. Future efforts should be focused on better understanding the endoscopic experience of the early adult IBD patient population and utilizing an innovative and collaborative approach.

Funding Agencies

Division of Gastroenterology, University of Toronto Faculty of Medicine Resident Research Grant
A97 INTERNAL MEDICINE RESIDENT AND STAFF PERCEPTIONS OF GASTROENTEROLOGY ROTATION
Authors: Klemm N K , Jayakumar S
Published: February 2024

Background

The choice of subspecialty by internal medicine residents is partially influenced by their experience with that service. Challenges exist between internal medicine and the high acuity, procedurally-heavy, gastroenterology (GI) service. Negative perceptions may limit the number of residents rotating through a gastroenterology elective, impacting knowledge and comfort managing common GI conditions.

Aims

To identify misperceptions of the GI service at a tertiary hospital, and evaluate resident and new staff comfort in managing common GI conditions.

Methods

Twenty-question survey sent to internal medicine residents during 2022-2023 and 13-question survey sent to staff that completed training from 2020-2022; both anonymous, and using Qualtrics software.

Results

The survey was completed by 18% (30/166) of residents and 20% (13/65) of staff. Most staff (62%) practiced in a community setting. Both cohorts cited overnight cross-coverage consults during (56%) and negative word-of mouth (38%), as reasons they avoided a GI elective. Most participants reported a little (33%) or moderate (47%) amount of GI teaching on medicine service and were unaware of formal lectures (79%) during a GI rotation. Residents and staff were most comfortable managing pancreatitis (98%) and ALF (74%). Staff wished for more experience managing pancreatic and liver masses and outpatient IBD flares; however both groups (86%) were unaware of the ambulatory week during the GI rotation.

Conclusions

Misperception and unawareness of a GI elective persist amongst internal medicine residents and has implications for new staff managing GI conditions. This study has led to action items that address these concerns.

Table 1: Resident & staff awareness, perceptions & knowledge of GI

Funding Agencies

None
A98 EFFECT OF A PROLONGED MULTIVITMAIN SHORTAGE ON HOME PARENTERAL NUTRITION PATIENTS: SINGLE CENTRE EXPERIENCE
Authors: Lam N C , Wang C , Schwenger K , Arca-Juico C , Chin K , Macgillivray A , Yuen C , Pang I , Allard J
Published: February 2024

Background

Multivitamin shortages in home parenteral nutrition (HPN) are scarce but have a significant impact on patient morbidity. Recently, Ontario, Canada experienced a HPN intravenous multivitamin shortage that lasted over 3 months. As per the American Society of Parenteral and Enteral Nutrition (ASPEN) guidelines, patients were instructed to use an over-the-counter multivitamin supplement during the shortage. However, due to the nature of HPN patients, the risk for malnutrition related complications remains high, specifically thiamine deficiency.

Aims

This study aims to assess the relationship between the multivitamin shortage and thiamine deficiency. We conducted an analysis before and after the intravenous multivitamin shortage in HPN patients and compared anthropometric, biochemical and clinical outcomes in those who followed the oral multivitamin recommendation versus those who did not.

Methods

This retrospective descriptive study included HPN patients in a single-centre program in Toronto, Canada who required HPN ≥ 5 days/week. These patients were followed throughout the multivitamin shortage which lasted from February - June 2023. Patients were categorized into two groups: those who consumed an oral multivitamin and those who did not. Clinical and biochemical data were collected pre and post-multivitamin shortage. Data was collected on compliance with taking oral multivitamins. The primary outcome was the presence of any adverse clinical outcome related to a micronutrient deficiency.

Results

Twenty-five HPN patients were included. 56% (n=14) of patients were compliant with oral multivitamin usage and met the ASPEN recommendations for supplementation. Compliant patients were significantly older and were on significantly longer duration of HPN. Two patients were diagnosed with WE and had brief hospitalizations. Both patients experienced complete resolution of their symptoms after treatment with high-dose thiamine. Hence, compliance with oral multivitamins did not correlate to developing WE. The median time from the shortage to the development of WE was 2 months. Though not statistically significant, those who developed WE were more likely to be female, utilized a venting gastrostomy tube, and utilized HPN for longer.

Conclusions

Complications related to micronutrient deficiency are rare in the HPN population but shortages in intravenous multivitamins can increase the risk of conditions such as WE. In our study, compliance with oral multivitamins did not guarantee protection from developing adverse outcomes, likely due to limitations in absorption due to altered gastrointestinal anatomy. A regimented protocol for screening should be implemented in HPN patients, especially during long shortages of key HPN components like multivitamins.

Funding Agencies

None
A101 TRENDS IN MEDICAID SPENDING FOR HEPATITIS C TREATMENT FROM 2012-2021
Authors: Malik G , Tsai C H , Congly S E
Published: February 2024

Background

Hepatitis C virus (HCV) infection is a pervasive disease that reduces quality and quantity of life. Medicaid is the largest health insurance program in the United States that provides coverage to individuals with low income including children, pregnant individuals, and people with disabilities. Due to the impact of HCV on individuals and the world goal for elimination of HCV by 2030, an analysis of healthcare costs attributed to hepatitis C medications is imperative to guide further policy and coverage changes.

Aims

To analyze Medicaid spending and utilization for hepatitis C treatment from 2012 to 2021 and provide a reflection on the impact it has on healthcare costs in the USA.

Methods

The Centers for Medicare & Medicaid Services public database was accessed to obtain Medicaid spending on Hepatitis C medications from 2012-2021. Data extracted included brand and generic drugs to treat HCV, total annual spending, total dosage units prescribed, total number of claims, and average spending per dosage unit and claim. Microsoft Excel was used for data analysis and creation of graphs.

Results

A total of 20 oral medications were included in this study. Total spending on all medications per year increased from $184 million in 2012 and peaked in 2016 at $3.3 billion. In 2021, the highest amount of Medicaid spending was on Mavyret ($658 million) followed by generic sofosbuvir-velpatasvir ($389 million) and Epclusa ($262 million). The total number of claims decreased from 135,542 in 2012 to 121,101 in 2021 with a peak in 2016 at 159,826. During the same time, the average spending per claim increased from 2012 ($6,518) to 2021 ($146,792). In 2021, the highest average spending per claim was seen with Harvoni ($30,941) followed by Sovaldi ($27,247), Vosevi ($23,877), and Epclusa ($22,917). In the same year, Mavyret had the greatest number of claims at 51,500 followed by generic sofosbuvir-velpatasvir (50,115), Epclusa (11,437), and Vosevi (2,177).

Conclusions

Despite the number of claims declining from 2012 to 2021, the average spending has increased due to the significant cost of HCV medications on Medicaid spending. The highest spending was noted to be with originator medications while generic formulations had the highest number of claims. Understanding the trends in spending on HCV medications can help guide insurance coverage changes for those depending on Medicaid. Lastly, shifting policies towards increased use of generic medications can help with increasing access and reducing costs to the population.

Figure 1. Total annual spending per year in billions ($ USD, blue bars) and total number of claims (orange line) per year from 2012 to 2021.

Funding Agencies

None
A102 EUS-GUIDED GASTROENTEROSTOMY IS COST-EFFECTIVE COMPARED TO SURGICAL GASTROJEJUNOSTOMY AND ENTERAL STENTING FOR PALLIATION OF MALIGNANT GASTRIC OUTLET OBSTRUCTION
Authors: Miller C , Rostamianmoghaddam Y , Khakban A , Barkun A , Chen Y
Published: February 2024

Background

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is an emerging modality for the treatment of malignant gastric outlet obstruction (GOO), which combines the benefits of the traditional treatments by providing a robust bypass using a minimally invasive, endoscopic approach. The health economic aspects of this new treatment compared to the traditional treatment approaches are not known.

Aims

To conduct a cost-consequence analysis to compare the costs and benefits of using EUS-GE, surgical gastrojejunostomy (SGJ) and enteral stenting (ES) for the management of malignant GOO.

Methods

A decision analytical model, comprising a decision tree and a time-dependent state-transition model with three health states (no recurrent GOO, recurrent GOO, and death), was designed. The costs and benefits of the first month are included in the decision tree, after which, simulated patients enter the time-dependent state-transition model and the costs and consequences of each intervention are estimated for each monthly cycle until the end of a twelve-month time horizon. To address uncertainty around parameters, the expected values of costs and other outcomes were obtained through probabilistic analysis. The model parameters were assigned probability distributions and 10,000 Monte Carlo simulations were conducted using randomly sampled values drawn from these distributions. The outcomes were the estimated total cost and the probability of recurrent GOO in the follow-up time. We compared the incremental cost of avoiding recurrent GOO between these three strategies. A willingness-to-pay threshold of $50,000 to avoid recurrent GOO was established a priori.

Results

The total estimated costs for EUS-GE, SGJ, and ES, were $82,575 (SD, $16,240), $149,731 (SD, $27,254), and $77,324 (SD, $14,529), respectively. SGJ (6.84% [SD, 1.34]) had a lower GOO recurrence rate compared to EUS-GE (8.70% [SD, 1.64] and ES (23.37% [SD, 3.82]; however, when comparing SGJ with EUS-GE and ES, the incremental cost to avoid GOO recurrence was $ 3,611,345 and $37,854, respectively. The cost of avoiding GOO recurrence using EUS-GE compared to ES was $35,774.

Conclusions

EUS-GE has emerged as a cost-effective option in treating patients with malignant GOO. It is associated with a much lower cost per avoided recurrent GOO when compared to SGJ, and it is more effective in preventing recurrent GOO than ES at a cost that is well below the pre-set willingness-to-pay threshold of $50,000.

Cumulative rate of GOO recurrence for EUS-GE, SGJ and ES

Funding Agencies

None
A103 A COMPREHENSIVE REVIEW OF ENTEROLITH ILEUS SECONDARY TO COMPLICATIONS OF ILEAL DIVERTICULA AND INVESTIGATIONS INTO OPTIMAL MANAGEMENT
Authors: Miranda C J , Aijaz A , Carlson A M , Hossein-Javaheri N , Ali M H , Ismail M
Published: February 2024

Background

Acquired ileal diverticula are rarely found in adults and are only apparent in 1.9% of small bowel contrast studies. Even more rarely, these diverticula can lead to enterolith formation which can obstruct the bowel, a term coined “enterolith ileus”. Both surgical and non-surgical approaches have been espoused in tackling this complication but definitive literature on optimal management is lacking and is limited to scattered case reports and case series. With this phenomenon carrying significant morbidity and mortality, we have conducted a comprehensive review of all available case reports to summarize our understanding of enterolith ileus secondary to ileal diverticula.

Aims

To understand the varying clinical presentations of enterolith ileus from ileal diverticula complications and understanding optimal management for the pathology.

Methods

A comprehensive search of PubMed, OVID, CINAHL, and Cochrane databases up to February 2023 was conducted to identify all studies reporting clinical information on enterolith formation in ileal diverticula leading to small bowel obstruction. Relevant data were extracted from selected studies to determine clinical courses and optimal management.

Results

Our literature review identified 61 case reports of enterolith ileus secondary to complications of ileal diverticula. The mean age of the patients was 51.64 years (SD 20.9), with 27% of them being female. The most common symptoms reported were abdominal pain (87%), nausea, and vomiting (51%), followed by constipation (18%) and melena (5%). Notably, localized abdominal tenderness was a common finding, observed in 74% of cases across 29 out of 34 studies reporting physical examination findings. Diagnostic investigations, including abdominal X-rays and CT scans, consistently revealed dilated bowel loops and signs of bowel obstruction. Surgical intervention was eventually required for almost all patients (97%), with diverticulectomy performed in 47%, enterectomy in 12%, and surgical resection of the bowel in 32% of cases respectively. These surgical interventions demonstrated high success rates, effectively resolving the condition in most cases. Complications, such as wound infection (2 cases), postoperative ileus (3 cases), anastomotic leak, and wound dehiscence (1 case each) were observed in a limited number of patients.

Conclusions

Our findings highlight the critical importance of prompt diagnosis and management of enterolith ileus secondary to complications of ileal diverticula. We recommend avoidance of initial conservative management as surgical intervention has proven almost always necessary and is highly successful in tackling this pathology. Early recognition and intervention can help minimize the risk of morbidity and mortality associated with this condition.

Funding Agencies

None
A104 ATYPICAL PRESENTATION OF HSD3B7 DEFICIENCY
Authors: Morrissey M , Kawada P
Published: February 2024

Background

Bile acid synthesis disorders are the result of deficient activity of one of 17 enzymes required for conversion of cholesterol into bile acids. One such bile acid synthesis disorder is 3β-hydroxy-Δ5-C27-steroid oxidoreductase (HSD3B7) deficiency, an autosomal recessive inherited disorder caused by a defect in 3β-hydroxy-Δ5-C27-steroid dehydrogenase (C27 3β-HSD) enzyme. Ultimately, this bile acid synthesis disorder is due to a HSD3B7 gene mutation. With only 53 cases reported between 1993 and 2015, HSD3B7 deficiency is rare. Additionally, the existing literature is primarily in the form of case reports, with the majority of patients with HSD3B7 deficiency presenting in the neonatal period, often with cholestatic jaundice.

Aims

To showcase an atypical presentation of HSD3B7 deficiency, in an 11 year old male with recurrent epistaxis and a coagulopathy of vitamin K deficiency. Additionally, to complete a review of the literature available on HSD3B7 deficiency.

Methods

Case report, chart review, and literature review.

Results

11 year old male who initially presented to Pediatric Hematology with prolonged PTT and INR in the context of recurrent epistaxis and easy bruising. Upon further work up, the patient was found to have low levels of vitamin K dependent factors, as well as low vitamin levels of A, D, and E. Additionally, the patient had elevation of AST, ALT, GGT, ALP, and total bilirubin. Normalization of the INR and PTT were achieved with vitamin K supplementation. Genetic testing was sent to work up the abnormal liver enzymes and revealed HSD3B7 deficiency. Fast atom bombardment ionization was subsequently completed and confirmed the diagnosis.

Conclusions

There is limited clinical data available regarding HSD3B7 deficiency. The classic presentation of this bile acid synthesis disorder is in a neonate with cholestatic jaundice, hepatomegaly, fat-soluble vitamin deficiencies, and lipid malabsorption. Therefore, the initial presentation of an 11 year old with recurrent epistaxis and prolonged INR and PTT is thus an atypical presentation of HSD3B7 deficiency. This case report demonstrates that there is diversity in the age of presentation and accompanying signs and symptoms in HSD3B7 deficiency.

Funding Agencies

None
A105 PILOT STUDY ON THE ACCURACY OF CHATGPT IN ARTICLE SCREENING FOR SYSTEMATIC REVIEWS IN GASTROENTEROLOGY
Authors: Na C B , Sinanian G , Gimpaya N , Mokhtar A , Chopra D , Scaffidi M , Yeung E , Grover S
Published: February 2024

Background

Systematic reviews synthesize extant research to answer a research question in a way that minimizes bias. After articles for potential inclusion are identified by sensitive searches, screening requires human expert review, which may be time-consuming and subjective. Large language models such as ChatGPT may have potential for this application.

Aims

This pilot study aims to assess the accuracy of ChatGPT 3.5 in screening of articles for systematic reviews in gastroenterology by (1) identifying if articles were correctly included and (2) excluding articles reported by authors as difficult to assess.

Methods

We searched the Cochrane Library for gastroenterology systematic reviews (January 1, 2022 to May 31, 2023) and selected the 10 most cited studies. The test set used to determine the accuracy of Open AI’s ChatGPT 3.5 model for included studies was the final list of included studies for each Cochrane review. The test set used for studies challenging to assess was the “excluded studies” list as defined in the Cochrane Handbook. Figure 1 shows the prompt used for the screening query. Articles were omitted if they did not have digital sources, abstracts or methods. Each article was screened 10 times to account for variability within ChatGPT’s outputs. Articles with ≥5 inclusion results were counted as an included study.

Results

ChatGPT correctly identified included studies at rates ranging from 60% to 100%. ChatGPT correctly identified exlcuded studies at rates ranging from 0% to 50% (Table 1). A total of 265 articles were screened.

Conclusions

In this pilot study, we demonstrated that ChatGPT is accurate in identifying articles screened for inclusion in Cochrane reviews; however, it is inaccurate in excluding articles described by the authors as being difficult to assess. We hypothesize that the GPT 3.5 model can read for keywords and broad interventions but is unable to reason cognitively, as an expert would, as to why a study may be excluded. We aim to review reasons for exclusion in future work.

Table 1. Screening Results of ChatGPT

Figure 1. ChatGPT Screening Prompt

Funding Agencies

None