Abstract Objectives Acute severe colitis (ASC) occurs in up to 15 percent of children with ulcerative colitis, with a high index of morbidity and mortality. Treatment includes high-dose steroids, infliximab, and salvage therapies. Unfortunately, up to 20 percent of patients may need an urgent colectomy due to treatment failure. We report our experience using tofacitinib for the treatment of six patients. Methods A retrospective review of our medical electronic records was conducted. We included every patient with ASC and treatment failure, in whom tofacitinib was used as a salvage therapy. Response, complications, and disease course were noted. Results Six patients were included with Pediatric Ulcerative Colitis Activity Index (PUCAI) scores ranging from 65 to 85 on admission, and 35 to 85 before tofacitinib was started (P 0.07). Median response time was 72 h. A median decrease of 40 points in PUCAI was noted (P 0.00001). Mean length of stay was 18 days with discharge 9 days after tofacitinib introduction. Haemoglobin, albumin, fecal calprotectin, and CRP improved after tofacitinib (P 0.02, P 0.02, P 0.025, and P 0.01, respectively). The mean follow-up was 8.5 months, four patients achieved complete remission and only one had a recrudescence of symptoms (P 0.01). One patient had a systemic Epstein-Barr virus infection prior to tofacitinib therapy, which resolved with rituximab treatment. No other complications were noted. Conclusions Tofacitinib response is rapid and impressive in children suffering from ASC, and the safety profile appears comparable to or better than other available treatments. In the future, tofacitinib should be integrated into pediatric protocols.
{"title":"The Role of Tofacitinib in the Treatment of Acute Severe Colitis in Children","authors":"Guillermo Alejandro Costaguta, Chloé Girard, Véronique Groleau, Kelly Grzywacz, Martha Heather Dirks, Colette Deslandres","doi":"10.1093/jcag/gwad042","DOIUrl":"https://doi.org/10.1093/jcag/gwad042","url":null,"abstract":"Abstract Objectives Acute severe colitis (ASC) occurs in up to 15 percent of children with ulcerative colitis, with a high index of morbidity and mortality. Treatment includes high-dose steroids, infliximab, and salvage therapies. Unfortunately, up to 20 percent of patients may need an urgent colectomy due to treatment failure. We report our experience using tofacitinib for the treatment of six patients. Methods A retrospective review of our medical electronic records was conducted. We included every patient with ASC and treatment failure, in whom tofacitinib was used as a salvage therapy. Response, complications, and disease course were noted. Results Six patients were included with Pediatric Ulcerative Colitis Activity Index (PUCAI) scores ranging from 65 to 85 on admission, and 35 to 85 before tofacitinib was started (P 0.07). Median response time was 72 h. A median decrease of 40 points in PUCAI was noted (P 0.00001). Mean length of stay was 18 days with discharge 9 days after tofacitinib introduction. Haemoglobin, albumin, fecal calprotectin, and CRP improved after tofacitinib (P 0.02, P 0.02, P 0.025, and P 0.01, respectively). The mean follow-up was 8.5 months, four patients achieved complete remission and only one had a recrudescence of symptoms (P 0.01). One patient had a systemic Epstein-Barr virus infection prior to tofacitinib therapy, which resolved with rituximab treatment. No other complications were noted. Conclusions Tofacitinib response is rapid and impressive in children suffering from ASC, and the safety profile appears comparable to or better than other available treatments. In the future, tofacitinib should be integrated into pediatric protocols.","PeriodicalId":17263,"journal":{"name":"Journal of the Canadian Association of Gastroenterology","volume":"288 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135685222","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Correction to: The 2023 Impact of Inflammatory Bowel Disease in Canada: Epidemiology of IBD","authors":"","doi":"10.1093/jcag/gwad043","DOIUrl":"https://doi.org/10.1093/jcag/gwad043","url":null,"abstract":"","PeriodicalId":17263,"journal":{"name":"Journal of the Canadian Association of Gastroenterology","volume":"39 7","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135455137","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Susanna Meade, Elizabeth Squirell, Thomas Tam Hoang, James Chow, Gregory Rosenfeld
Abstract Background Biological medications for inflammatory bowel disease (IBD) account for a significant burden on provincial budgets. In an effort to curb these rising costs, nationwide switching to biosimilars is expected to be complete in Canada before the end of 2023. Biosimilar products do not require the same rigor for licensing as the originator and therefore there has been appropriate scepticism as to how biosimilars will perform in real-world practice. Methods We have performed a systematic review including real-world observational studies of adult patients with IBD. The primary outcome was clinical effectiveness and/or safety in patients who had switched from originator to biosimilar anti-TNF. Secondary outcomes included loss of response (LOR), treatment persistence or cessation and immunogenicity. Results We included 43 studies (7,462 patients [70 percent Crohn’s disease: 30 percent ulcerative colitis]; 32 infliximab studies, and 11 adalimumab studies). For infliximab, 75 percent patients were in clinical remission at the time of switch and 75 percent maintained clinical remission beyond 12 months, compared to 78 percent of patients who continued originator. For adalimumab, 86 percent patients were in remission at the time of switch with 82 percent maintaining remission at 6 months follow-up. Injection site pain was higher in patients who switched to a citrate containing adalimumab biosimilar, compared with those who continued originator. All other outcomes (LOR, treatment cessation or persistence and serious adverse events) were similar to patients who continued originator (in comparator cohorts or the available literature). Conclusion Whilst ongoing vigilance is required, these data are reassuring to both patients and clinicians and will significantly help to reduce health-care costs across Canada.
{"title":"An Update On Anti-TNF Biosimilar Switching—Real-World Clinical Effectiveness and Safety","authors":"Susanna Meade, Elizabeth Squirell, Thomas Tam Hoang, James Chow, Gregory Rosenfeld","doi":"10.1093/jcag/gwad027","DOIUrl":"https://doi.org/10.1093/jcag/gwad027","url":null,"abstract":"Abstract Background Biological medications for inflammatory bowel disease (IBD) account for a significant burden on provincial budgets. In an effort to curb these rising costs, nationwide switching to biosimilars is expected to be complete in Canada before the end of 2023. Biosimilar products do not require the same rigor for licensing as the originator and therefore there has been appropriate scepticism as to how biosimilars will perform in real-world practice. Methods We have performed a systematic review including real-world observational studies of adult patients with IBD. The primary outcome was clinical effectiveness and/or safety in patients who had switched from originator to biosimilar anti-TNF. Secondary outcomes included loss of response (LOR), treatment persistence or cessation and immunogenicity. Results We included 43 studies (7,462 patients [70 percent Crohn’s disease: 30 percent ulcerative colitis]; 32 infliximab studies, and 11 adalimumab studies). For infliximab, 75 percent patients were in clinical remission at the time of switch and 75 percent maintained clinical remission beyond 12 months, compared to 78 percent of patients who continued originator. For adalimumab, 86 percent patients were in remission at the time of switch with 82 percent maintaining remission at 6 months follow-up. Injection site pain was higher in patients who switched to a citrate containing adalimumab biosimilar, compared with those who continued originator. All other outcomes (LOR, treatment cessation or persistence and serious adverse events) were similar to patients who continued originator (in comparator cohorts or the available literature). Conclusion Whilst ongoing vigilance is required, these data are reassuring to both patients and clinicians and will significantly help to reduce health-care costs across Canada.","PeriodicalId":17263,"journal":{"name":"Journal of the Canadian Association of Gastroenterology","volume":"35 3","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134973491","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Lisa Zhang, Kelly Brennan, Jennifer A Flemming, Sulaiman Nanji, Maya Djerboua, Shaila J Merchant, Antonio Caycedo-Marulanda, Sunil V Patel
Abstract Background Those with cirrhosis who require emergency colorectal surgery are at risk for poor outcomes. Although risk predictions models exists, these tools are not specific to colorectal surgery, nor were they developed in a contemporary setting. Thus, the objective of this study was to assess the outcomes in this population and determine whether cirrhosis etiology and/or the Model for End Stage Liver Disease (MELD-Na) is associated with mortality. Methods This population-based study included those with cirrhosis undergoing emergent colorectal surgery between 2009 and 2017. All eligible individuals in Ontario were identified using administrative databases. The primary outcome was 90-day mortality. Results Nine hundred and twenty-seven individuals (57%) (male) were included. The most common cirrhosis etiology was non-alcoholic fatty liver disease (NAFLD) (50%) and alcohol related (32%). Overall 90-day mortality was 32%. Multivariable survival analysis demonstrated those with alcohol-related disease were at increased risk of 90-day mortality (hazards ratio [HR] 1.53, 95% confidence interval [CI] 1.2–2.0 vs. NAFLD [ref]). Surgery for colorectal cancer was associated with better survival (HR 0.27, 95%CI 0.16–0.47). In the subgroup analysis of those with an available MELD-Na score (n = 348/927, 38%), there was a strong association between increasing MELD-Na and mortality (score 20+ HR 6.6, 95%CI 3.9–10.9; score 10–19 HR 1.8, 95%CI 1.1–3.0; score <10 [ref]). Conclusion Individuals with cirrhosis who require emergent colorectal surgery have a high risk of postoperative complications, including mortality. Increasing MELD-Na score is associated with mortality and can be used to risk stratify individuals.
{"title":"Emergency Colorectal Surgery in Those with Cirrhosis: A Population-based Study Assessing Practice Patterns, Outcomes and Predictors of Mortality","authors":"Lisa Zhang, Kelly Brennan, Jennifer A Flemming, Sulaiman Nanji, Maya Djerboua, Shaila J Merchant, Antonio Caycedo-Marulanda, Sunil V Patel","doi":"10.1093/jcag/gwad040","DOIUrl":"https://doi.org/10.1093/jcag/gwad040","url":null,"abstract":"Abstract Background Those with cirrhosis who require emergency colorectal surgery are at risk for poor outcomes. Although risk predictions models exists, these tools are not specific to colorectal surgery, nor were they developed in a contemporary setting. Thus, the objective of this study was to assess the outcomes in this population and determine whether cirrhosis etiology and/or the Model for End Stage Liver Disease (MELD-Na) is associated with mortality. Methods This population-based study included those with cirrhosis undergoing emergent colorectal surgery between 2009 and 2017. All eligible individuals in Ontario were identified using administrative databases. The primary outcome was 90-day mortality. Results Nine hundred and twenty-seven individuals (57%) (male) were included. The most common cirrhosis etiology was non-alcoholic fatty liver disease (NAFLD) (50%) and alcohol related (32%). Overall 90-day mortality was 32%. Multivariable survival analysis demonstrated those with alcohol-related disease were at increased risk of 90-day mortality (hazards ratio [HR] 1.53, 95% confidence interval [CI] 1.2–2.0 vs. NAFLD [ref]). Surgery for colorectal cancer was associated with better survival (HR 0.27, 95%CI 0.16–0.47). In the subgroup analysis of those with an available MELD-Na score (n = 348/927, 38%), there was a strong association between increasing MELD-Na and mortality (score 20+ HR 6.6, 95%CI 3.9–10.9; score 10–19 HR 1.8, 95%CI 1.1–3.0; score &lt;10 [ref]). Conclusion Individuals with cirrhosis who require emergent colorectal surgery have a high risk of postoperative complications, including mortality. Increasing MELD-Na score is associated with mortality and can be used to risk stratify individuals.","PeriodicalId":17263,"journal":{"name":"Journal of the Canadian Association of Gastroenterology","volume":"17 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135617934","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sarang Gupta, Sam Seleq, Nikko Gimpaya, Rishad Khan, Michael A Scaffidi, Rishi Bansal, Samir C Grover
Abstract Background and study aims The Paris classification characterizes the morphology of superficial gastrointestinal tract neoplasms. This system has been shown to predict the risk of submucosal invasion in certain subtypes of lesions. There is limited data that assesses its agreement amongst endoscopists. We performed a systematic review to summarize the available literature on the interobserver reliability (IOR) of the Paris classification. Methods We conducted a search through December 2020 for studies reporting IOR of the Paris classification. Studies were included if they quantitatively evaluated the IOR of the Paris classification with at least five participating endoscopists. Two authors independently screened studies and abstracted data using an a priori-designed data collection form. Evaluation of study quality and risk of bias was performed using an adapted version of the Guidelines for Reporting Reliability and Agreement Studies. Results Of the 1,541 studies retrieved, 5 were included in the review. All studies were observational cohort studies published between 2014 and 2020. The IOR of the Paris classification was moderate amongst all four studies evaluating colorectal neoplasms (range, κ = 0.42 to κ = 0.54) and substantial in one study that evaluated gastric neoplasms (κw = 0.65). An educational intervention was conducted by three studies with variable methodology and no significant change in IOR. Conclusions IOR of the Paris classification is moderate for superficial colonic neoplasms. Further study is needed to determine the reliability of this system for superficial gastric lesions. Standardized training programs are required to investigate the impact of educational intervention on the Paris classification amongst endoscopists.
{"title":"Interobserver Reliability of the Paris Classification for Superficial Gastrointestinal Tract Neoplasms: A Systematic Review","authors":"Sarang Gupta, Sam Seleq, Nikko Gimpaya, Rishad Khan, Michael A Scaffidi, Rishi Bansal, Samir C Grover","doi":"10.1093/jcag/gwad039","DOIUrl":"https://doi.org/10.1093/jcag/gwad039","url":null,"abstract":"Abstract Background and study aims The Paris classification characterizes the morphology of superficial gastrointestinal tract neoplasms. This system has been shown to predict the risk of submucosal invasion in certain subtypes of lesions. There is limited data that assesses its agreement amongst endoscopists. We performed a systematic review to summarize the available literature on the interobserver reliability (IOR) of the Paris classification. Methods We conducted a search through December 2020 for studies reporting IOR of the Paris classification. Studies were included if they quantitatively evaluated the IOR of the Paris classification with at least five participating endoscopists. Two authors independently screened studies and abstracted data using an a priori-designed data collection form. Evaluation of study quality and risk of bias was performed using an adapted version of the Guidelines for Reporting Reliability and Agreement Studies. Results Of the 1,541 studies retrieved, 5 were included in the review. All studies were observational cohort studies published between 2014 and 2020. The IOR of the Paris classification was moderate amongst all four studies evaluating colorectal neoplasms (range, κ = 0.42 to κ = 0.54) and substantial in one study that evaluated gastric neoplasms (κw = 0.65). An educational intervention was conducted by three studies with variable methodology and no significant change in IOR. Conclusions IOR of the Paris classification is moderate for superficial colonic neoplasms. Further study is needed to determine the reliability of this system for superficial gastric lesions. Standardized training programs are required to investigate the impact of educational intervention on the Paris classification amongst endoscopists.","PeriodicalId":17263,"journal":{"name":"Journal of the Canadian Association of Gastroenterology","volume":"215 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136292345","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract The coronavirus disease pandemic globally affected public health and the world economy, leading to an increase in mental health symptoms, thought to be due in part to periods of quarantining, restrictions, and other interventions used to curb ongoing transmission of the virus. It is well established that persons with inflammatory bowel disease (IBD) have significantly higher rates of depression and anxiety than the general population and that mental health symptoms can exacerbate disease severity. For persons with IBD, psychological distress was correlated with challenges in accessing medical care. In the early stages of the pandemic, endoscopy suites were closed, leading to fewer colonoscopies, although this rebounded the following year. This likely led to fewer diagnoses of IBD initially as people avoided the health care system, and also a reduction in IBD-related dysplasia being detected during colonoscopy. Many hospitals and health care clinics adjusted by delivering telemedicine for ambulatory care. Persons with IBD had increased stress about accessing both their health care provider and gastroenterologist during the pandemic, although many had increased satisfaction with the level of care they received virtually. Telemedicine is now being used in most clinics in conjunction with in-person care, to help deliver care, and can be cost-effective. Additional research is needed to assess whether heightened levels of mental health symptoms have led to worsening disease activity, and further, if a delay in health care access including colonoscopies and surgeries, or the perceived decreased access to health care professionals for some will have detrimentally affected the disease course for persons with IBD.
{"title":"How Did COVID-19 Affect Mental Health and Access to Care in Persons With Inflammatory Bowel Disease","authors":"Seth R Shaffer","doi":"10.1093/jcag/gwad033","DOIUrl":"https://doi.org/10.1093/jcag/gwad033","url":null,"abstract":"Abstract The coronavirus disease pandemic globally affected public health and the world economy, leading to an increase in mental health symptoms, thought to be due in part to periods of quarantining, restrictions, and other interventions used to curb ongoing transmission of the virus. It is well established that persons with inflammatory bowel disease (IBD) have significantly higher rates of depression and anxiety than the general population and that mental health symptoms can exacerbate disease severity. For persons with IBD, psychological distress was correlated with challenges in accessing medical care. In the early stages of the pandemic, endoscopy suites were closed, leading to fewer colonoscopies, although this rebounded the following year. This likely led to fewer diagnoses of IBD initially as people avoided the health care system, and also a reduction in IBD-related dysplasia being detected during colonoscopy. Many hospitals and health care clinics adjusted by delivering telemedicine for ambulatory care. Persons with IBD had increased stress about accessing both their health care provider and gastroenterologist during the pandemic, although many had increased satisfaction with the level of care they received virtually. Telemedicine is now being used in most clinics in conjunction with in-person care, to help deliver care, and can be cost-effective. Additional research is needed to assess whether heightened levels of mental health symptoms have led to worsening disease activity, and further, if a delay in health care access including colonoscopies and surgeries, or the perceived decreased access to health care professionals for some will have detrimentally affected the disease course for persons with IBD.","PeriodicalId":17263,"journal":{"name":"Journal of the Canadian Association of Gastroenterology","volume":"43 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136292619","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Grant Greaves, Kaitlyn G Harding, Brent Parker, Vu C Nguyen, Azim Ahmed, Belinda Yee, Joël Perren, Mathew Norman, Morgan Grey, Rafael Perini, Fahd Jowhari, Adrian Bak
Abstract Background Endoscopic retrograde cholangiopancreatography (ERCP) is used to diagnose and treat pancreatic and biliary disease. The current standard is to conduct ERCP under conscious sedation (CS). Patient movement and agitation during ERCP under CS can result in procedure failure and complications. Aiming to reduce procedure failure rates and complications, Kelowna General Hospital (KGH) in British Columbia, Canada transitioned to performing ERCP under general anesthesia (GA) as the practice standard. Objective To determine if conducting ERCP under GA compared to CS decreases procedure complications, particularly post-ERCP pancreatitis (PEP). Methods The charts of 2,198 patients who underwent ERCP at KGH between 2015 and 2020 were reviewed. Before September 17, 2017, ERCP was performed under CS (n = 1,316). Afterwards, ERCP was conducted under GA (n = 882). Demographic, clinical, and procedural data were extracted. The data were analyzed using univariate and multivariate statistical analysis. Results Procedure failure rates (CS = 9 percent, GA = 3 percent, P < 0.001) decreased in the GA cohort after adjusting for age, sex, and co-morbidities. Thirty-day mortality, intensive care unit (ICU) transfer, returns post-discharge, PEP, and cholangitis rates were similar between cohorts. Conclusion Performing ERCP under GA compared to CS resulted in an increase in procedural success rates. Other complication rates were similar between groups.
背景内镜逆行胰胆管造影(ERCP)用于胰腺和胆道疾病的诊断和治疗。目前的标准是在意识镇静(CS)下进行ERCP。在CS下进行ERCP时，患者的运动和躁动可能导致手术失败和并发症。为了降低手术失败率和并发症，加拿大不列颠哥伦比亚省的Kelowna总医院(KGH)将在全身麻醉(GA)下实施ERCP作为实践标准。目的探讨与CS相比，GA下进行ERCP是否能减少手术并发症，特别是ERCP后胰腺炎(PEP)。方法回顾2015年至2020年在KGH接受ERCP治疗的2198例患者的病历。2017年9月17日前，在CS下行ERCP (n = 1316)。然后在GA下进行ERCP (n = 882)。提取了人口学、临床和手术数据。采用单因素和多因素统计分析对数据进行分析。结果手术失败率(CS = 9%， GA = 3%， P <0.001)，在调整了年龄、性别和合并症后，GA队列中下降。30天死亡率、重症监护病房(ICU)转院、出院后复诊、PEP和胆管炎发生率在队列之间相似。结论在GA下行ERCP比CS下行ERCP成功率高。两组间其他并发症发生率相似。
{"title":"Endoscopic Retrograde Cholangiopancreatography Under General Anesthesia Compared to Conscious Sedation Study","authors":"Grant Greaves, Kaitlyn G Harding, Brent Parker, Vu C Nguyen, Azim Ahmed, Belinda Yee, Joël Perren, Mathew Norman, Morgan Grey, Rafael Perini, Fahd Jowhari, Adrian Bak","doi":"10.1093/jcag/gwad037","DOIUrl":"https://doi.org/10.1093/jcag/gwad037","url":null,"abstract":"Abstract Background Endoscopic retrograde cholangiopancreatography (ERCP) is used to diagnose and treat pancreatic and biliary disease. The current standard is to conduct ERCP under conscious sedation (CS). Patient movement and agitation during ERCP under CS can result in procedure failure and complications. Aiming to reduce procedure failure rates and complications, Kelowna General Hospital (KGH) in British Columbia, Canada transitioned to performing ERCP under general anesthesia (GA) as the practice standard. Objective To determine if conducting ERCP under GA compared to CS decreases procedure complications, particularly post-ERCP pancreatitis (PEP). Methods The charts of 2,198 patients who underwent ERCP at KGH between 2015 and 2020 were reviewed. Before September 17, 2017, ERCP was performed under CS (n = 1,316). Afterwards, ERCP was conducted under GA (n = 882). Demographic, clinical, and procedural data were extracted. The data were analyzed using univariate and multivariate statistical analysis. Results Procedure failure rates (CS = 9 percent, GA = 3 percent, P &lt; 0.001) decreased in the GA cohort after adjusting for age, sex, and co-morbidities. Thirty-day mortality, intensive care unit (ICU) transfer, returns post-discharge, PEP, and cholangitis rates were similar between cohorts. Conclusion Performing ERCP under GA compared to CS resulted in an increase in procedural success rates. Other complication rates were similar between groups.","PeriodicalId":17263,"journal":{"name":"Journal of the Canadian Association of Gastroenterology","volume":"23 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135738897","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Kevin L Kecskemeti, Mark Borgaonkar, Jerry McGrath
Abstract Objective There have been concerns about the widespread usage of proton pump inhibitors (PPIs), leading to recommendations to deprescribe PPIs in certain patients. This study aims to determine if PPI deprescription in patients with symptomatic esophageal strictures was consistent with published guidelines and to compare the rate of PPI deprescription between two-time points. Methods All patients from two gastroenterology practices who received endoscopic dilation to treat symptomatic strictures between the years of 2015–2017 and 2019–2021 were identified using physician billing codes. We defined inappropriate PPI deprescription as: a patient who was deprescribed their PPI with a past medical history of esophageal stricture, Barrett’s esophagus, grade C/D esophagitis, or who had experienced symptom recurrence after PPI deprescription. Furthermore, we analyzed the rate of PPI deprescription between two time periods 2015–2017 (group 1) and 2019–2021 (group 2). Results Two hundred twenty-three esophageal dilations were analyzed. Twenty-six patients in the sample were deprescribed their PPI, with the majority (57 percent) meeting the criteria for inappropriate PPI deprescription. There was a trend towards more inappropriate deprescription in the second time period. (71 percent vs. 33 percent; P = 0.06). Patients in group 2 had a higher rate of PPI deprescription (23.9 percent) than group 1 (6.0 percent; P < 0.001). Conclusions PPI deprescription in patients treated for symptomatic esophageal strictures appears to be more common in the second time period. Most patients were defined as inappropriate deprescription. Physicians must apply guidelines carefully when considering deprescribing PPIs.
{"title":"Assessing Frequency and Appropriateness of Proton Pump Inhibitor Deprescription in Patients Requiring Endoscopic Therapy for Esophageal Strictures","authors":"Kevin L Kecskemeti, Mark Borgaonkar, Jerry McGrath","doi":"10.1093/jcag/gwad036","DOIUrl":"https://doi.org/10.1093/jcag/gwad036","url":null,"abstract":"Abstract Objective There have been concerns about the widespread usage of proton pump inhibitors (PPIs), leading to recommendations to deprescribe PPIs in certain patients. This study aims to determine if PPI deprescription in patients with symptomatic esophageal strictures was consistent with published guidelines and to compare the rate of PPI deprescription between two-time points. Methods All patients from two gastroenterology practices who received endoscopic dilation to treat symptomatic strictures between the years of 2015–2017 and 2019–2021 were identified using physician billing codes. We defined inappropriate PPI deprescription as: a patient who was deprescribed their PPI with a past medical history of esophageal stricture, Barrett’s esophagus, grade C/D esophagitis, or who had experienced symptom recurrence after PPI deprescription. Furthermore, we analyzed the rate of PPI deprescription between two time periods 2015–2017 (group 1) and 2019–2021 (group 2). Results Two hundred twenty-three esophageal dilations were analyzed. Twenty-six patients in the sample were deprescribed their PPI, with the majority (57 percent) meeting the criteria for inappropriate PPI deprescription. There was a trend towards more inappropriate deprescription in the second time period. (71 percent vs. 33 percent; P = 0.06). Patients in group 2 had a higher rate of PPI deprescription (23.9 percent) than group 1 (6.0 percent; P &lt; 0.001). Conclusions PPI deprescription in patients treated for symptomatic esophageal strictures appears to be more common in the second time period. Most patients were defined as inappropriate deprescription. Physicians must apply guidelines carefully when considering deprescribing PPIs.","PeriodicalId":17263,"journal":{"name":"Journal of the Canadian Association of Gastroenterology","volume":"34 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136341873","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ganive Bhinder, Javier M Meza-Cardona, Alan Low, Guy Aumais, Gail P Attara, James R Gray
Abstract Objectives Irritable bowel syndrome (IBS) is a chronic, debilitating, functional gastrointestinal disorder with symptoms of abdominal pain, bloating, and altered bowel behaviours of constipation (IBS-C), diarrhea (IBS-D), or a mixture of both (IBS-M). There is limited information published on the impact of symptoms on everyday life in the Canadian population. Methods An online survey was conducted with individuals diagnosed with IBS to capture the severity and frequency of patient-reported symptoms, including impact on productivity, quality of life, healthcare utilization, treatment access, and corresponding symptom relief. Responses from the three subtypes of IBS were categorized to illustrate differences among these. Results There were 2,470 qualified respondents (filtered from 2,981, which included nonspecific IBS). IBS-M was the most common subtype, at 44 percent. Most individuals from all three IBS subtypes reported experiencing moderate to severe abdominal pain (63–70 percent) and bloating (59–75 percent) over the previous 3 months. Persons living with IBS-C reported severe bloating (32 percent), straining (72 percent), and tenesmus (78 percent) whereas those with IBS-D experienced severe urgency (63 percent) and incontinence (29 percent). Symptoms interfered in daily life, sometimes in 46 percent and often in 23 percent of respondents. Patients reported mood and anxiety disorders as common comorbidities with IBS (mood disorders: 30–34 percent; anxiety disorders: 25–30 percent). Conclusions This study focuses on the differences among the IBS subtypes. IBS impacts productivity and healthcare utilization, which requires further investigation on approaches to improve treatment. The frequency and severity of symptoms in IBS are high and only a few respondents reported that their symptoms are under control.
{"title":"Irritable Bowel Syndrome Patient Experience: A Survey of Patient-Reported Symptoms by Irritable Bowel Syndrome Subtype and Impact on Quality of Life","authors":"Ganive Bhinder, Javier M Meza-Cardona, Alan Low, Guy Aumais, Gail P Attara, James R Gray","doi":"10.1093/jcag/gwad028","DOIUrl":"https://doi.org/10.1093/jcag/gwad028","url":null,"abstract":"Abstract Objectives Irritable bowel syndrome (IBS) is a chronic, debilitating, functional gastrointestinal disorder with symptoms of abdominal pain, bloating, and altered bowel behaviours of constipation (IBS-C), diarrhea (IBS-D), or a mixture of both (IBS-M). There is limited information published on the impact of symptoms on everyday life in the Canadian population. Methods An online survey was conducted with individuals diagnosed with IBS to capture the severity and frequency of patient-reported symptoms, including impact on productivity, quality of life, healthcare utilization, treatment access, and corresponding symptom relief. Responses from the three subtypes of IBS were categorized to illustrate differences among these. Results There were 2,470 qualified respondents (filtered from 2,981, which included nonspecific IBS). IBS-M was the most common subtype, at 44 percent. Most individuals from all three IBS subtypes reported experiencing moderate to severe abdominal pain (63–70 percent) and bloating (59–75 percent) over the previous 3 months. Persons living with IBS-C reported severe bloating (32 percent), straining (72 percent), and tenesmus (78 percent) whereas those with IBS-D experienced severe urgency (63 percent) and incontinence (29 percent). Symptoms interfered in daily life, sometimes in 46 percent and often in 23 percent of respondents. Patients reported mood and anxiety disorders as common comorbidities with IBS (mood disorders: 30–34 percent; anxiety disorders: 25–30 percent). Conclusions This study focuses on the differences among the IBS subtypes. IBS impacts productivity and healthcare utilization, which requires further investigation on approaches to improve treatment. The frequency and severity of symptoms in IBS are high and only a few respondents reported that their symptoms are under control.","PeriodicalId":17263,"journal":{"name":"Journal of the Canadian Association of Gastroenterology","volume":"49 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135132987","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Tanya Barber, Katelynn Crick, Lynn Toon, Jordan Tate, Karen Kelm, Kerri Novak, Rose O Yeung, Puneeta Tandon, Daniel C Sadowski, Sander Veldhuyzen van Zanten, Denise Campbell-Scherer
Abstract Background Gastroscopy to investigate dyspepsia without alarm symptoms rarely results in clinically actionable findings or sustained health-related quality-of-life improvements among patients aged 18–60 years and is, therefore, not recommended. Despite this, referrals for and performance of gastroscopy among this patient population remain high. The purpose of this study was to understand family physicians’ and gastroenterologists’ mental models of dyspepsia and the drivers behind referring or performing gastroscopy. Methods Cognitive task analysis routine critical decision method interviews with family physicians (n = 8) and gastroenterologists (n = 4). Results Family physicians and gastroenterologists hold rich mental models of dyspepsia that rely on sensemaking; however, gaps in information continuity affect their ability to plan and coordinate patient care. Drivers behind decisions to refer or perform gastroscopy were: eliminating risk for serious pathology, providing reassurance, perceived preference by patients to receive information and reassurance from gastroenterologists, maintaining relationships with patients, and saving costs to the health system. Conclusions Family physicians refer for dyspepsia when they are seeking support from gastroenterologists, they believe that alternative factors may be impacting the patient’s health or view it as a cost-saving measure. Likewise, gastroenterologists perform gastroscopy for dyspepsia when they perceive it as a cost-saving measure, they want to support their primary care colleagues and provide their colleagues and patients with reassurance. An improved degree of communication between speciality and primary care could allow for continuity in the transfer of information about patients and reduce referrals for dyspepsia.
{"title":"Gastroscopy for dyspepsia: Understanding primary care and gastroenterologist mental models of practice: A cognitive task analysis approach","authors":"Tanya Barber, Katelynn Crick, Lynn Toon, Jordan Tate, Karen Kelm, Kerri Novak, Rose O Yeung, Puneeta Tandon, Daniel C Sadowski, Sander Veldhuyzen van Zanten, Denise Campbell-Scherer","doi":"10.1093/jcag/gwad035","DOIUrl":"https://doi.org/10.1093/jcag/gwad035","url":null,"abstract":"Abstract Background Gastroscopy to investigate dyspepsia without alarm symptoms rarely results in clinically actionable findings or sustained health-related quality-of-life improvements among patients aged 18–60 years and is, therefore, not recommended. Despite this, referrals for and performance of gastroscopy among this patient population remain high. The purpose of this study was to understand family physicians’ and gastroenterologists’ mental models of dyspepsia and the drivers behind referring or performing gastroscopy. Methods Cognitive task analysis routine critical decision method interviews with family physicians (n = 8) and gastroenterologists (n = 4). Results Family physicians and gastroenterologists hold rich mental models of dyspepsia that rely on sensemaking; however, gaps in information continuity affect their ability to plan and coordinate patient care. Drivers behind decisions to refer or perform gastroscopy were: eliminating risk for serious pathology, providing reassurance, perceived preference by patients to receive information and reassurance from gastroenterologists, maintaining relationships with patients, and saving costs to the health system. Conclusions Family physicians refer for dyspepsia when they are seeking support from gastroenterologists, they believe that alternative factors may be impacting the patient’s health or view it as a cost-saving measure. Likewise, gastroenterologists perform gastroscopy for dyspepsia when they perceive it as a cost-saving measure, they want to support their primary care colleagues and provide their colleagues and patients with reassurance. An improved degree of communication between speciality and primary care could allow for continuity in the transfer of information about patients and reduce referrals for dyspepsia.","PeriodicalId":17263,"journal":{"name":"Journal of the Canadian Association of Gastroenterology","volume":"75 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135477850","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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