Journal of the Canadian Association of Gastroenterology最新文献

Background: IBD-related psychological distress (IBD-PD) refers to the emotional impact of IBD and is associated with increased IBD activity. The inability to provide high-quality, person-centred care for IBD-PD that is proportional to clinical need is a significant healthcare gap in the Canadian healthcare system. The aim of this study was to generate stakeholder-derived data about patient experiences with IBD-PD in Nova Scotia, Canada.

Methods: Virtual semi-structured interviews took place between October 2021 and March 2022. The interview script was developed iteratively with researchers, IBD care providers, and patient research partners. Questions were designed to assess perceptions and experiences with IBD-PD. Adult IBD patients were recruited from IBD clinics. Using thematic analysis, codes were generated to identify themes.

Results: Nineteen individuals were approached to participate. The total number of participants recruited and enrolled was 14. The mean participant age was 37.6 years (range 23-57) with 57.1% as female (8/14). The following themes emerged: (1) There are specific triggers for IBD-PD such as hospital settings, social isolation, and stress (2) Times in a patients journey that are psychologically distressing include: initial diagnosis, transitions to new medication or new treatment, and surgery (3) some participants achieved psychological wellbeing while living with IBD and reported their experience gave them new perspective on life and more empathy and compassion.

Conclusions: There are many triggers for IBD-PD and timepoints associated with IBD-PD throughout a patient's disease course. It is important to understand IBD-PD from the patient perspective, so that future interventions meet patient-specific needs.

Background: Increasing incidence rates of colorectal cancer (CRC) diagnosed before age 50 have been reported in Canada and other Western countries. Several organizations have lowered their recommended starting age for CRC screening. We aimed to analyze CRC rates in Canada and model the impacts of lowering the age to start faecal immunochemical test (FIT)-based screening in Canada.

Methods: We evaluated the differences in absolute and relative incidence rates between age groups over time using the Canadian Cancer Registry data. Additionally, we used the OncoSim-Colorectal microsimulation model to examine starting FIT screening at 45 years of age over a lifetime time horizon. We estimated changes in CRC cases, deaths, potential years of life gained, and costs.

Results: Absolute CRC incidence increased among groups below 50 years of age, with recent birth cohorts experiencing the greatest relative increases. Microsimulation results suggest that screening at 45 would result in fewer CRC cases (15 070) and CRC deaths (6100) in Canada between 2025 and 2071. For every additional 100 colonoscopies, 3.5 fewer CRC cases and 1.4 fewer CRC deaths are expected. Modelling suggests this may lead to an overall cost savings of $233 million CAD over the lifespan of eligible cohorts.

Conclusion: Our results indicate that as CRC incidence in younger age groups has continued to increase, lowering the age to start FIT screening to 45 would result in overall population benefit through reduced CRC incidence and mortality. However, given resource considerations, provincial decision makers must evaluate changes in their programs to ensure proper implementation.

Background: Early cholecystectomy is recommended for patients with gallstone pancreatitis to reduce recurrent gallstone-related adverse events. However, the management of patients with gallstone pancreatitis in British Columbia (BC) is not known. This study aims to determine the prevalence of early cholecystectomy and outcomes among patients admitted in BC with mild gallstone pancreatitis.

Methods: A retrospective multicentre cohort of patients with gallstone pancreatitis admitted from 2018 to 2023 to 4 BC hospitals. Exclusion criteria included prior cholecystectomy, pancreatic cancer, and patients with moderate or severe pancreatitis. Patients receiving a cholecystectomy in ≤30 days were labelled early and compared to late cholecystectomy (>30 days) or no cholecystectomy. The primary outcome was recurrent biliary events, including cholecystitis, choledocholithiasis, and pancreatitis.

Results: In total, 260 patients were included in the analysis and 35.0% had early cholecystectomy. Early cholecystectomy was associated with younger age (53.0 years vs 65.4 years, P < .001) and fewer comorbidities (Charlson Comorbidity Index 1.6 vs 3.3, P < .001) in univariate analysis. Multivariate analysis identified nonsurgical admission to gastroenterology (OR, 0.16; 95% CI, 0.06-0.44; P < .001) or other services (OR, 0.07; 95% CI, 0.028-0.17; P < .001) as less likely to result in early cholecystectomy. Patients who received late cholecystectomy were more likely to experience recurrent biliary events in univariate (HR, 3.16; 95% CI, 1.93-5.20; P < .001) and multivariate Cox-regression analysis (HR, 4.36; 95% CI, 1.9-10.1).

Conclusions: Early cholecystectomy reduces recurrent biliary events. Admission under surgery is associated with early cholecystectomy and may be important in achieving higher rates of index admission cholecystectomy.

Background: There is limited evidence to support optimal concentrations for therapeutic drug monitoring in patients with Crohn's disease (CD) who experience a loss of response (LOR) to tumour necrosis factor antagonists. This study aimed to determine the threshold trough adalimumab concentration beyond which patients with LOR are unable to recapture a response after dose escalation.

Methods: Enrolled patients had responded to adalimumab therapy after ≥16 weeks and subsequently experienced a secondary LOR, defined as a C-reactive protein (CRP) level ≥5 mg/L and/or a fecal calprotectin (FC) level ≥250 µg/g. Dosing was escalated from biweekly to weekly. Patients were then assessed for 12 weeks to determine their ability to recapture a response, defined as a CRP response (≥50% CRP decrease and/or CRP <5 mg/L) and/or FC response (≥50% FC decrease and/or FC <150 µg/g). The relationship between baseline trough concentration and non-recapture of biochemical response was evaluated using logistic regression.

Results: Of 97 enrolled patients, 49 (50.5%) did not recapture a response to adalimumab after dose escalation. Baseline trough concentration was not associated with non-recapture of biochemical response (odds ratio, 0.98; 95% CI: 0.91-1.06; P = .626). There was no threshold trough concentration identified that was predictive of non-recapture of biochemical response. No new adalimumab safety signals were identified.

Conclusions: No association was observed between trough adalimumab concentration and non-recapture of biochemical response after dose escalation for secondary LOR in CD. The threshold concentration above which dose escalation is ineffective remains unclear. ClinicalTrials.gov identifier: NCT02896985.

Background: Tissue transglutaminase antibodies (tTG-IgA) are the primary tool for celiac disease (CeD) screening, can be incorporated into a formal diagnosis of CeD without the need for biopsy-confirmation, and are recommended for subsequent monitoring of disease status. However, it remains understudied how frequently children are further tested after an initial positive result.

Methods: Administrative data from Alberta, Canada were utilized to identify children with their first positive tTG-IgA result between 2016 and 2023. Children were stratified according to baseline result: low (1.0-2.9× the upper limit of normal [ULN]), medium (3.0-9.9× the ULN), and high (≥10× the ULN). Mean cumulative functions were estimated to determine the average number of repeated tTG-IgA tests across time. Further differences were evaluated by sex, age, urban-rural status, and socioeconomic status.

Results: Among 4405 children with incident CeD autoimmunity, almost half (49.1%) had high baseline values at index positivity. These children also had the most overall and positive follow-up tests, on average. For example, within 5 years, those with baseline tTG-IgA ≥10× the ULN had, on average, 3.7 overall (95% CI, 3.6-3.9) and 2.5 positive (95% CI, 2.4-2.6) repeat tests, respectively, compared to 2.1 overall (95% CI, 2.0-2.2) and 0.8 positive (95% CI, 0.7-0.8) among those with 1.0-2.9× the ULN. Significant differences were also present across the urban-rural spectrum and the socioeconomic gradient (eg, highest in metropolitan centres).

Conclusion: These findings showcase notable variation in follow-up tTG-IgA testing among children with incident CeD autoimmunity in Alberta, Canada.

Background: Patients with pancreatic ductal adenocarcinoma (PDAC) experience debilitating symptoms, yet factors associated with symptom burden and severity are not well described.

Methods: This population-based cohort study included patients diagnosed with PDAC and who completed Edmonton Symptom Assessment System (ESAS) between 1 month before and 2 months after diagnosis between January 1, 2007 and December 31, 2020 in Ontario, Canada. The ESAS contains 9 symptoms on a scale from 0 to 10. The primary outcome was moderate to severe (ESAS scores ≥4) symptoms (pain, tiredness, nausea, depression, anxiety, drowsiness, loss of appetite, well-being, and shortness of breath) 2-6 months after diagnosis. We used multivariable logistic regression models to evaluate associations between the primary outcome and baseline demographic and clinical variables, cancer-specific factors, and baseline symptom scores.

Results: We included 4918 patients (mean age 68 years, 52% male). Near the time of diagnosis, 13.8% (nausea) to 38.5% (well-being) of patients reported moderate to severe symptoms. At 2-6 months after diagnosis, 23.0% (dyspnea) to 57.5% (poor well-being) reported moderate to severe symptoms. A range of baseline demographic, clinical, and cancer-specific risk factors were identified for reporting of moderate to severe symptoms. The presence of baseline symptoms for each of the 9 included symptoms was associated with reporting of the same symptom with moderate to high severity 2-6 months after diagnosis.

Conclusions: Patients with PDAC face a high symptom burden following diagnosis. Universal physician symptom screening for patients diagnosed with PDAC may enable improved symptom identification and management.

Objectives: Inflammatory bowel disease (IBD) is associated with a range of extraintestinal manifestations, including renal complications. While chronic kidney disease in IBD is well described, the risk of acute kidney injury (AKI) remains less well quantified. We aimed to evaluate the risk of AKI among hospitalized patients with IBD compared to non-IBD populations, and to assess this risk across clinical subgroups.

Methods: We conducted a systematic review and meta-analysis in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and registered the protocol with PROSPERO. A comprehensive search of PubMed, MEDLINE, Embase, Scopus, and Cochrane CENTRAL was conducted from inception to June 2025. Eligible studies included cohort, case-control, and randomized control trials reporting on AKI outcomes in IBD versus non-IBD comparators. Meta-analyses were performed using random-effects models. Subgroup analyses were conducted by surgical status, infection, acute coronary syndrome, and general hospitalization.

Results: Seventeen retrospective cohort studies involving 20 127 976 patients (140 482 with IBD) were included. IBD was associated with significantly increased odds of AKI (pooled odds ratio [OR]: 1.87; 95% confidence interval [CI], 1.53-2.29). The association was especially prominent in surgical patients (OR: 2.17; 95% CI, 1.73-2.73), including orthopedic (OR: 2.22; 95% CI, 1.50-3.30) and spinal (OR: 2.15; 95% CI, 1.66-2.78) subgroups. Associations in acute coronary syndrome and infection subgroups were less consistent. ROBINS-E (Risk Of Bias In Non-randomized Studies-of Exposures) assessments revealed a moderate risk of bias.

Conclusions: A diagnosis of IBD is potentially associated with the development of AKI, particularly in surgical settings. Routine renal monitoring could be considered, especially during hospitalizations and perioperative care.

Background: Inflammatory bowel disease (IBD) is influenced by genetic and environmental factors, including diet and physical activity (PA). IBD patients who engage in more PA report improvements in quality of life, symptom management, and fatigue levels. This report aims to characterize habitual PA collected using wearable technology in patients with mild-to-moderate Crohn's disease (CD) and provide insight into the feasibility of wearable technology in IBD.

Methods: This study is part of a larger multicenter, randomized controlled trial at the University of Calgary and the University of Alberta. Patients (n = 59) were randomized to receive a CD therapeutic dietary intervention + conventional management or conventional management alone for 13 weeks. PA data, collected using wearables, included habitual PA metrics (daily step count, daily time spent sitting, daily sit to stand transitions [n = 31]), and exercise metrics (daily light PA minutes, daily moderate to vigorous PA (MVPA) minutes [n = 23]). Baseline data were pooled across groups and used to investigate habitual PA.

Results: Participants were restricted to nonstricturing, nonpenetrating, colonic or ileocolonic, mild-to-moderate CD. The average daily step count for this cohort was approximately 6700 steps, with time spent sitting (hours) averaging 8.2 ± 2.1 daily. Additionally, pooled average daily light PA and daily MVPA measured 60.0 ± 32.4 and 18.5 ± 13.0 minutes, respectively.

Future directions: Studies detailing objective assessment of daily PA using wearable technology in IBD are limited. These gaps in the literature provide future direction for researchers to investigate current PA trends and barriers to PA uptake.

Background: Patients are referred for colonoscopy for symptom assessment, screening, and surveillance. Public health measures to mitigate the spread of the COVID-19 pandemic disrupted services and increased patient delays for colonoscopy services. The differential impact of these interruptions by colonoscopy indication is largely unknown. We aimed to understand the effects of the pandemic on colonoscopy services and patient wait times in Montreal, Canada.

Study: Using 2018-2022 retrospective clinical data from 2 high-volume Montreal endoscopy centres and provincial administrative data, we characterized changes in colonoscopy wait times and the proportion of wait-listed patients who were delayed (wait time exceeded provincial guidelines) by procedure indication and demographics. We used regression to examine patient characteristics associated with delayed procedures during pre- and intraCOVID-19 periods. We used time series analysis to characterize trends in the proportion of wait-listed patients delayed.

Results: The COVID-19-related public health measures resulted in record-high delays (median increase in wait times of 34%-159% across indications). While older patients experienced longer wait times pre-pandemic, intra-COVID-19 wait times increased disproportionately for patients younger than 50. The proportion of wait-listed patients delayed peaked in mid-2020 (56.9% for screening; 56.0% for symptom assessment patients). By early 2022, the proportion delayed had fallen to 37.3% for screening patients but remained at 53.8% for symptom assessment patients.

Conclusions: Pandemic service disruptions disproportionately impacted symptom assessment procedures and younger patients, resulting in lasting effects. Systematic monitoring of procedures and wait times could facilitate timely detection and intervention to prevent disparities in patient access to care.

Background: The COVID-19 pandemic led to a significant decrease in endoscopic procedure volumes, resulting in a backlog of patients awaiting investigation. Our study thus aimed to develop a machine learning-based scheduling tool to improve resource utilization, enhance system efficiency, and increase patient throughput, ultimately reducing procedural delays.

Methods: In the first phase, machine learning methods were applied to historical data to predict procedure duration based on patient characteristics and environmental factors. In the second phase, a scheduling module was built using a greedy heuristic and a Mixed Integer Programming (MIP) model to optimize resource utilization.

Results: We showed that among the tested models, an XGBoost regression model was selected with a mean absolute error of 5.67 minutes on the test set. The simulation results demonstrated that MIP increased the number of patients scheduled by 5.9% while reducing mean waiting time from 19.5 days to 17.3 days over a waiting list of 1,000 patients, evaluated within a 2-week period (10 working days). Simulations using real patient data showed that the MIP scheduled 8 more patients than the baseline. Numerical results confirmed higher resource utilization rates in adaptive schedules.

Conclusions: Our study highlights the potential of a machine learning-based scheduling tool to enhance resource allocation, thus helping address backlogs in endoscopic procedures. Real-world clinical validation is now necessary to substantiate the tool's effectiveness. Future work should prioritize prospective data collection to refine the predictive model and seamlessly integrate the tool into clinical workflows, ensuring its practical utility and success.