Journal of the Canadian Association of Gastroenterology最新文献

Background: Non-alcoholic fatty liver disease (NAFLD) is common, can progress to cirrhosis and hepatic decompensation, and has no approved medical therapy in Canada.

Objective: We conducted a systematic review on whether glucagon-like peptide-1 receptor agonists (GLP-1RA) improve non-alcoholic steatohepatitis (NASH) compared to standard care in NAFLD.

Methods: We searched Medline Ovid, EMBASE(Elsevier), Cochrane CENTRAL, Clinical Trials.gov, and the World Health Organization International Clinical Trials Registry Platform in November 2023 for randomized controlled trials. Inclusion criteria included patients ≥13 years with NAFLD receiving GLP-1RA for ≥6 months compared to standard care/placebo. Cochrane risk-of-bias 2.0 tool was used for each outcome. After screening results in duplicate, we performed meta-analysis and reported odds ratios (OR) for dichotomous and mean difference of change score for continuous outcomes.

Results: Six studies with 478 patients met inclusion criteria; 3 studies reported on the primary endpoint resolution of NASH. GLP-1RA likely leads to resolution of NASH (OR 4.45 (95% CI 1.92, 10.3)) and reduction in liver steatosis on imaging (-5.09% (95% CI -7.49, -2.69), but little to no reduction in liver stiffness on imaging (mean difference -0.17 kPa (95% CI -0.34, 0)).

Interpretation: Treatment with GLP-1RA in NAFLD patients for ≥6 months can probably lead to improvement in NASH on liver biopsy and reduce liver steatosis on imaging. Whether improvements in steatosis on biopsy or imaging results in clinically significant outcomes need to be elucidated as the effects of GLP-1RA on liver fibrosis are unclear; larger ongoing trials may provide more definitive answers. Protocol Registration: PROSPERO-CRD42023472186.

Background: Individuals with ulcerative colitis (UC) are frequently re-hospitalized for persistent or recurrent severe disease flares. Accurate prediction of the risk of early re-hospitalization at the time of discharge could promote targeted outpatient interventions to reduce this risk.

Methods: We conducted a retrospective study in adults with UC admitted to The Ottawa Hospital between 2009 and 2016 for an acute UC-related indication. We ascertained candidate demographic, clinical, and health services predictors through medical records and administrative health databases. We derived and bootstrap validated a multivariable logistic regression model of 90-day UC-related re-hospitalization risk. We chose a probability cut point that maximized Youden's index to differentiate high-risk from low-risk individuals and assessed model performance.

Results: Among 248 UC-related hospitalizations, there were 27 (10.9%) re-hospitalizations within 90 days of discharge. Our multivariable model identified gastroenterologist consultation within the prior year (adjusted odds ratio [aOR] 0.11, 95% confidence interval [CI], 0.04-0.39), male sex (aOR 3.27, 95% CI, 1.33-8.05), length of stay (OR 0.94, 95% CI, 0.88-1.01), and narcotic prescription at discharge (OR 1.96, 95% CI, 0.73-5.27) as significant predictors of 90-day re-hospitalization. The optimism-corrected c-statistic value was 0.78, and the goodness-of-fit test P-value was .09. The chosen probability cut point produced a sensitivity of 77.8%, specificity of 80.9%, positive predictive value (PPV) of 33.0%, and negative predictive value (NPV) of 96.7% in the derivation cohort.

Conclusions: A limited set of variables accessible at the point of hospital discharge can reasonably discriminate re-hospitalization risk among individuals with UC. Future studies are required to validate our findings.

Background and aims: Endoscopic retrograde cholangiopancreatography (ERCP) is performed using anaesthesia or conscious sedation, though the effectiveness, adverse events (AEs), and tolerability of each approach remain unclear. Thus, we compared these approaches prospectively.

Methods: We performed a multi-centre prospective cohort study including patients with native papillae undergoing ERCP for biliary indications between 2018 and 2023. The primary outcome was sedation-related AEs, defined as sustained hypoxaemia or hypotension, unplanned mask ventilation or intubation, vasopressor or reversal agent use, cardiorespiratory arrest, or death. Secondary outcomes included other AEs, technical success measures, and patient-reported tolerability using a validated scale. Multivariable logistic regression was performed in addition to propensity score-matched analyses.

Results: At 8 centres, a total of 3174 first-time biliary ERCPs were performed, 433 (13.6%) employing anaesthesia. Nine sedation-related AEs occurred with conscious sedation (0.3%), while 2 (0.5%) occurred with anaesthesia (odds ratio, OR, 0.35, 0.07-2.37). Only 25 (0.9%) conscious sedation-supported ERCPs were aborted due to the inability to appropriately sedate patients. There were no significant differences in other AE rates, cannulation success, time, or attempts, use of pre-cut or needle-knife access methods, or inadvertent pancreatic duct cannulation. Odds of significant patient-reported intra-procedural awareness and discomfort were both higher with conscious sedation (ORs 16.19, 4.81-54.53, and 21.25, 4.44-101.61, respectively). Propensity score-matched analyses yielded no differences in any outcome compared with primary analyses.

Conclusions: Routine biliary ERCP is equally safe and effective with conscious sedation (vs anaesthesia). Given regional resource limitations, conscious sedation is justified as a primary option for routine biliary ERCP.

Introduction: Women with inflammatory bowel disease (IBD) experience greater delays and misdiagnosis than men. Data from other conditions suggest that sex and/or gender bias in the process of referral to speciality care may contribute.

Methods: We undertook a mixed methods analysis of 120 referral letters to gastroenterology for people ultimately diagnosed with IBD in Calgary, Alberta. Letters were masked for patient sex and gender prior to analysis. Gastroenterologists who were masked to the objective of the study rated the quality of referral letters and triaged letters for urgency. Two study team members performed a Framework analysis to identify agentic (masculine) and commensal (feminine) adjectives, mentions of caregiving and work roles, and psychosocial history. After analysis, letters were unmasked and findings were compared by patient sex.

Results: There were 116 referral letters included in the analysis (n = 59, 50.9% for male patients). There were no differences in letter quality or triage urgency between male and female patients (median quality 4 [IQR 4-7] and 5 out of 10 [IQR 4-6], respectively, higher scores represent better quality; P = .37, and P = .44 for triage category). There was no difference in the use of adjectives and mention of caregiving or work roles, psychiatric history, or social history between letters for female and male patients.

Conclusions: This mixed methods analysis identified no difference in referral letter language, contents, or quality for female and male patients with IBD. Masked letters were triaged similarly to unmasked letters, suggesting an absence of sex and/or gender bias in the gastroenterology triaging process in our setting.

Environmental change is underway and has the potential to adversely affect digestive health. Professional medical organizations have an important role to play in addressing the challenge. An important initial response is the development of a sustainability plan for the medical organization. There are no standardized criteria as to what should be included in such a plan. We have proposed 12 key components that should be contained in sustainability plans for medical organizations. We describe how these were developed for the Canadian Association of Gastroenterology (CAG) and plans for future implementation. We hope that the CAG plan may serve as a template to assist peer medical organizations optimize their response to the climate crisis.

Background: Telemedicine is increasingly common in gastroenterology and may represent an opportunity for improving sustainability in medical care. The purpose of this study was to determine the carbon emissions related to travel for in-person gastroenterology clinic appointments.

Methods: We conducted a cross-sectional analysis evaluating carbon emissions associated with travel to gastroenterology appointments over a 2-week period. We determined the average number of appointments per day and used patient's postal codes to estimate travel distances. We estimated carbon emissions based on these travel distances and completed sensitivity analyses to model methods for emissions reductions.

Results: We assessed 975 clinic appointments, of which 71 were excluded (eg, insufficient data, non-physician appointments), leaving 904 included appointments of which 75% were follow-up (678) and the remainder were new consultations (226). Sixteen different gastroenterologists had an average of 22.7 patients per clinic. The mean return distance travelled per appointment was 57.3 km which translates to 14.9 kg CO₂ per patient visit. An average day at our clinic was equal to burning 146.6 L of gasoline or the annual carbon capture of 15.5 trees. By changing follow-up appointments or those with a travel distance over 100 km to telehealth, emissions were reduced by 77%.

Conclusions: We demonstrate that a relatively modest change in the number of in-person visits can save thousands of litres of gasoline emissions annually from each practicing clinician. While we cannot avoid emissions related to travel for procedure-based appointments, the use of telemedicine is one potential strategy to reduce healthcare-related emissions.

Background: Sexual dysfunction is common in individuals with inflammatory bowel disease (IBD). The aim of this study was to better characterize sexual dysfunction and associated factors among a Canadian cohort of IBD patients.

Methods: A cross-sectional survey study was conducted. The primary outcome was sexual dysfunction as measured by the Female Sexual Dysfunction Scale in females and the Male Sexual Dysfunction Scale in males. Analyses were stratified by sex and multiple linear regression was used to identify associations.

Results: In total, 351 respondents completed the survey. Both females and males were impacted by sexual dysfunction (IBD-FSDS 14.1 [± 13.8] and IBD-MSDS 7.2 [± 9.4, respectively]). Depression was common and strongly associated with sexual dysfunction (β coefficient 0.92 [0.13] for men and 0.84 [0.19] for women, P <.001).

Conclusions: Sexual dysfunction was common and more impactful in women. Depression was strongly associated with sexual dysfunction. This underscores the need for multidisciplinary care in addressing sexual health among individuals living with IBD.