Journal of the Canadian Association of Gastroenterology最新文献

Aims: Electrosurgical units (ESUs) are essential for tissue dissection hemostasis during ESD. The ERBE VIO 3, enables rapid setting changes, facilitating the swift application of vessel sealing current. Additionally, features such as PreciseSect mode allow dynamic modulation frequency adjustment, making it suitable for submucosal dissection and vessel management. Our comparison of the ERBE VIO3 and 300d aims to assess whether these functionalities enhance the ESD experience.

Methods: From 2021 to 2024, 88 patients undergoing ESD for colorectal lesions were identified from a prospectively maintained database. Lesions were categorized based on the ESU utilized.

Results: Eighty-eight procedures were identified. Forty-four (50.0%) procedures were performed using VIO 3 and 44 (50.0%) using VIO 300d. 40 (45.5%) lesions were colonic and 48 (54.5%) rectal. Median lesion diameter was 4.5 cm. Lesions in the VIO3 group were significantly larger (P = 0.027). All ESDs were completed en bloc. Use of the VIO3 resulted in a significantly fewer uses of coagulation graspers overall (28 vs 23, P < 0.001), fewer uses of coagulation graspers for arterial bleeding (1 vs 2, P < 0.001), fewer uses of coagulation graspers per cm² (0.17 vs 0.58, P < 0.001), and fewer uses of coagulation graspers per minute (0.011 vs 0.066, P < 0.001). This led to a non-significant trend in increased efficiency with use of the VIO3 (4.6 vs 5.1 min/cm², P = 0.667).

Conclusions: The VIO 3 significantly decreased reliance on coagulation graspers, particularly in addressing arterial bleeding. This holds the potential to enhance procedural efficiency, reduce bleeding, and lower costs associated with coagulation graspers usage.

Background: Acute severe ulcerative colitis (ASUC) is associated with significant morbidity. In patients with ulcerative colitis (UC), the estimated lifetime risk of developing severe colitis is 25%. Several gastrointestinal societies have provided recommendations on pathways of care for managing ASUC. The degree to which they are adhered to in different care settings remains unclear.

Methods: We conducted a retrospective review using data from 7 acute-care hospitals collected through the general medicine inpatient initiative (GEMINI), a hospital research collaborative that collects administrative and clinical data from hospital information systems. We identified all patients with the most responsible inpatient discharge diagnosis of ulcerative colitis between April 2015 and December 2019. The primary outcome was the difference in hospital length of stay of patients admitted with ASUC based on hospital-type; community, academic, or inflammatory bowel disease (IBD)-focussed sites.

Results: 765 eligible patients were identified between April 2015 and December 2019. The mean hospital length of stay was 9.21 days for the academic sites, 6.94 days for the community sites, and 8.03 for the IBD specialty centre (P = .094). Adverse events were uncommon overall. In our multiple logistic regression analysis, we identified that admission to an IBD-focussed centre compared to an academic centre, carried an odds ratio of 2.07 (95% CI, 1.16-3.78) for the outcome of inpatient-colectomy.

Conclusions: The processes of care for patients with ASUC varied on the basis of the type of hospital they were admitted to, with the IBD specialty centre providing the most guideline adherent care. Low-cost interventions should be utilized to promote adherence to clinical practice recommendations.

Objectives: Despite rapidly rising rates of pediatric inflammatory bowel disease (IBD), literature exploring the financial burden on families of children with IBD remains limited. This study sought to better understand the socioeconomic burden of pediatric IBD on families at our institution and compare IBD provider practices and perceptions across the country.

Methods: Two separate electronic surveys exploring demographics, financial impacts of an IBD diagnosis, and perceptions around IBD care were developed for patient families and IBD providers respectively. Descriptive statistics and regression analysis took place to assess survey responses. Thematic analysis was also undertaken to qualitatively assess family survey comments.

Results: Patient survey results (N = 69) indicated missed time off work and school and dietary therapy costs as considerable burdens on families. Nearly 60% of respondents also reported significant mental health impacts on the family. Provider data (N = 18) suggests some variability in clinical practice, allied health support, and financial support for families. However, providers almost universally recognize the financial, mental health, and employment impacts on families as significant socioeconomic burdens on families.

Conclusions: This is the first study in Canada to directly explore national provider practices and the socioeconomic burden on families of children with IBD. Results indicate a good correlation between provider awareness and the increased financial burden on families but suggest ongoing care gaps to address impacts on employment, mental health, and out-of-pocket costs. This data suggests that various quality improvement opportunities for research and advocacy exist to better support families, both locally and beyond.

Background/aims: Among Crohn's disease patients with loss of response or non-response to ustekinumab (UST), there remains no clear strategy for dose escalation. Moreover, clinical associations and the role of therapeutic drug monitoring (TDM) are poorly understood. This study assessed response to escalation of UST therapy via increased dosing frequency or re-induction, as well as assessed associations of response.

Methods: A single-centre retrospective cohort study was performed. Adults who underwent dose escalation to every 4 weeks or reinduction of UST were included. The primary outcome was clinical and biochemical remission which was defined as a Harvey Bradshaw Index (HBI) of <5 and a C-reactive protein (CRP) level within the normal limit or a Fecal Calprotectin (FCP) level <250 ug/g. Partial response to treatment was defined as a 50% decrease from baseline HBI, CRP, or FCP.

Results: Thirty-nine patients were included. Clinical outcomes were assessed at a median of 17 weeks (IQR 12-21). Clinical and biochemical remission was achieved in 30.8% of patients (n = 12). Remission was found to be more likely among patients with lower baseline HBI (5.2 vs 9.0 P = .044) and younger patients (29.8 years vs 37.7 P = .046). No association was observed between baseline TDM values in the remission vs the non-remission group (3.32 ug/mL vs 2.91 ug/mL p=0.77). No severe adverse events were recorded.

Conclusion: UST dose escalation, in the form of reinduction or increased frequency to every 4 weeks may be effective among patients with loss of response or partial response, though predictors of response and strategy of escalation remain unclear.

Background: First Nations (FN) people in Canada are commonly diagnosed with colorectal cancers. Although Canada has treaty responsibilities to ensure FNs people have equitable access to quality health services, access to colorectal cancer screening in Canada by FNs people has not been fully assessed.

Methods: The objectives of our retrospective population-level study that linked multiple administrative databases were to investigate differences in colorectal cancer screening rates: participation, retention, positivity, follow-up colonoscopy, and invasive colorectal cancer detection, as well as wait times to follow-up colonoscopy, and stages at diagnosis between FNs and non-FNs people in Alberta. All Alberta residents eligible for colorectal cancer screening (aged 50-74) between 2012 and 2018 were included. The study and descriptive methods adhered to FNs principles of ownership, control, access, and possession.

Results: FNs people were less likely to participate in colorectal cancer screening (lower by 15.9% among women, P < 0.00001, and 17.0% among men; P = 0.0007), and less likely to be retained in the screening program (lower by 11.6%, P = 0.0013, among women and 9.9% %, P = 0.034, among men). They were more likely to screen positive (average difference of 7.0% among women and 7.3%, among men, both P < 0.0002). Invasive colorectal cancer detection rates were higher (3.2/1000) versus (2.3/1000) as were late-stage diagnoses (61% versus 43%, P = P = 0.004) among FNs people than non-FNs people, respectively.

Conclusions: Higher invasive colorectal cancer detection rates and more late-stage diagnoses in FNs people can be due to lower participation and retention in colorectal cancer screening programs. Understanding and addressing the reasons for these inequities are needed to improve these outcomes for FNs people.

Background: Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder which can respond to proton-pump inhibitors (PPIs). Genetic variation in the CYP2C19 metabolism gene influences PPI efficacy and adverse effects. Pharmacogenetic testing (PGx) can predict PPI response by analyzing genetic variation, particularly identifying patients categorized as CYP2C19 rapid or ultra-rapid metabolizers who might benefit from PPI dosage increases or changes to pharmacotherapy. Although PGx clinical practice guidelines have been established for PPI use, routine clinical implementation has been slow.

Methods: We conducted a non-interventional prospective cohort study of patients followed by a paediatric EoE clinic between 2020 and 2023. Eligible patients underwent CYP2C19 PGx testing, with results correlated to PPI use and histological outcomes assessed via endoscopic biopsies.

Results: Sixty-nine patients underwent PGx testing; 20 (29%) and 5 (7%) were determined to be rapid and ultra-rapid metabolizers, respectively. PGx-based management changes were made in 44 (64%) patients. Forty-three (62%) patients completed reassessment endoscopy, of which 21 (49%) demonstrated histological remission; 17 (40%) of these patients achieved remission after PGx-guided drug changes.

Conclusions: This study demonstrates that PPI non-response in patients with EoE may partly be due to inadequate PPI dosing in those with rapid or ultra-rapid CYP2C19 metabolizer status. Identifying CYP2C19 metabolizer status in pediatric patients with EoE for first-generation PPIs leads to therapeutic management changes and can improve histological remission rates. Clinicians treating EoE patients should consider routine PGx testing in combination with monitoring clinical factors to guide individualized PPI therapy and optimize dosing.

Introduction: Patient comfort is an important predictor of patient satisfaction and a quality indicator in endoscopy. The St. Paul's Endoscopy Comfort Score (SPECS), previously validated for colonoscopy, was assessed for measuring patient comfort during esophagogastroduodenoscopy (EGD).

Methods: In this prospective cohort study, 3 groups of assessors (gastroenterologists, nurses, and observers) used SPECS and the modified Gloucester Comfort Scale (GS) to measure patients' comfort during outpatient EGD. Patient-reported outcomes were measured using a visual analogue scale (VAS) and satisfaction survey. Descriptive statistics and inter-rater reliability were calculated across the 3 groups for both tools. The correlation between SPECS, GS, and VAS was calculated.

Results: Three hundred subjects were included. The mean age was 56.7 years (SD 14.7 years) and 160 (53.3%) were male. Overall, 89.0% (N=267) of subjects received conscious sedation with intravenous midazolam and fentanyl at a mean dose of 3.3 mg (SD 1.6 mg) and 51.4 mcg (SD 29.7 mcg), respectively. The mean total SPECS for physicians, nurses, and observers were 1.3 (SD 1.6), 1.4 (SD 1.7), and 1.7 (SD 1.9), respectively. Amongst the 3 assessors (9 physicians, 5 nurses, and 4 observers), SPECS and GS demonstrated good inter-rater reliability with an intraclass coefficient of 0.71 (95% CI, 0.66-0.76) and 0.64 (95% CI, 0.58-0.69), respectively. SPECS and GS had a mild correlation with VAS.

Conclusions: SPECS is a reliable assessment tool to measure patient comfort during EGD. SPECS may be used to audit patient comfort at a facility and physician level.

Background and aims: The role of artificial intelligence (AI) in hepatology is rapidly expanding. However, the ability of AI chat models such as ChatGPT to accurately answer clinical questions remains unclear. This study aims to determine the ability of large language models (LLMs) to answer questions in hepatology, as well as compare the accuracy and quality of responses provided by different LLMs.

Methods: Hepatology questions from the Digestive Diseases Self-Education Platform were entered into three LLMs (OpenAI's ChatGPT-4, Microsoft's Bing, and Google's Bard) between September 7 and 13, 2023. Questions were posed with and without multiple-choice answers. Generated responses were assessed based on accuracy and number of correct answers. Statistical analysis was performed to determine the number of correct responses per LLM per category.

Results: A total of 144 questions were used to query the AI models. ChatGPT-4's accuracy was 62.3%, Bing's accuracy was 53.5%, and Bard's accuracy was 38.2% (P < .001) for multiple-choice questions. For open-ended questions, ChatGPT-4's accuracy was 44.4%, Bing's was 28.5%, and Bard's was 21.4% (P < .001). ChatGPT-4 and Bing attempted to answer 100% of the questions, whereas Bard was unable to answer 11.8% of the questions. All 3 LLMs provided a rationale in addition to an answer, as well as counselling where appropriate.

Conclusions: LLMs demonstrate variable accuracy when answering clinical questions related to hepatology, though show comparable efficacy when presented with questions in an open-ended versus multiple choice (MCQ) format. Further research is required to investigate the optimal use of LLMs in clinical and educational contexts.