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Background and Aims: Since the onset of the Coronavirus disease 2019 (COVID-19) pandemic, there has been a significant opportunity to leverage virtual platforms for communication and dissemination of knowledge. An online survey was conducted to examine the viewpoints of World Gastroenterology Organization (WGO) leaders concerning the necessity, primary priority areas, and implementation strategies for a virtual global gastroenterology educational program., Methods: We conducted a survey of leaders of WGO member societies to assess their opinions on creating opportunities for global education using virtual platforms, identifying practical implementation steps and priority educational areas., Results: Responses were obtained from 57/117 (48.7%) contacted leaders with 56/57 (98.2%) identifying such a need. Five mutually exclusive priority educational topics were proposed in the survey: clinical gastroenterology, endoscopy, nutritional support, research methodology, and professional development. Overall, most participants prioritized clinical gastroenterology (45/57; 78.9%) and endoscopy/hand skills (27/57; 47.3%) as educational topics to be addressed by the virtual global gastroenterology educational program. A majority of WGO member society leaders surveyed favored monthly teaching activities (33/57; 57.8%), ideally carried out between 1500-2100 local time (31/57; 54.3%), ideally with no administrative fees (47/57; 82.4%)., Conclusions: This truly global survey of WGO member societies achieved a good response rate and provides important insights into the need for and scope of future virtual education programs under the aegis of the WGO.

The environment is changing rapidly under pressure from 3 related drivers: climate change, pollution, and biodiversity loss. These environmental changes are affecting digestive health and disease in multiple ways. Heat extremes can cause intestinal and hepatic dysfunction. Access to adequate amounts of food of high nutritional content and to clean water is under threat. Extreme weather is associated with flooding and enteric infections and affects the delivery of care through infrastructure loss. Air, water, and soil pollution from chemicals and plastics are emerging as risk factors for a variety of intestinal diseases including eosinophilic esophagitis, metabolic dysfunction associated fatty liver disease, digestive tract cancers, inflammatory bowel disease, and functional bowel disease. Migration of populations to cities and between countries poses a special challenge to the delivery of digestive care. The response to the threat of environmental change is well underway in the global digestive health community, especially with regard to understanding and reducing the environmental impact of endoscopy. Individuals, and peer societies, are becoming more engaged, and have an important role to play in meeting the challenge., (© 2024 The Authors.)

Background and study aims Adequacy of endoscope disinfection in resource-limited settings is unknown. Adenosine triphosphate (ATP) testing is useful for evaluation of endoscope reprocessing, and ATP <200 relative light units (RLUs) after manual endoscope cleaning has been associated with adequacy of endoscope disinfection. Methods Consecutive endoscopes undergoing reprocessing at five World Gastroenterology Organisation (WGO) training centers underwent ATP testing before and after an on-site educational intervention designed to optimize reprocessing practices. Results A total of 343 reprocessing cycles of 65 endoscopes were studied. Mean endoscope age was 5.3 years (range 1-13 years). Educational interventions, based on direct observation of endoscope reprocessing practices at each site, included refinements in pre-cleaning, manual cleaning, high-level disinfection, and endoscope drying and storage. The percentage of reprocessing cycles with post-manual cleaning ATP ≧200 decreased from 21.4% prior to educational intervention to 14.8% post-intervention ( P =0.11). In multivariable logistic modelling, gastroscopes were significantly less likely (odds ratio [OR] 0.04, 95% confidence interval [CI] 0.01-0.19; P <0.001) than colonoscopes to achieve post-manual cleaning ATP < 200. No other factor (educational intervention, study site, endoscope age) was significantly associated with improved outcomes. Endoscope ID was not significantly associated with ATP values, and sites that performed manual versus automated HLD did not have significantly different likelihood of post-manual cleaning ATP <200 (OR 1.18, 95% CI 0.56-2.50; P =0.67). Conclusions In resource-limited settings, approximately 20% of endoscope reprocessing cycles may result in inadequate disinfection. This was not significantly improved by a comprehensive educational intervention. Alternative approaches to endoscope reprocessing are needed., Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Competing Interests: Competing interests: None declared. BO, DL, G Metz, AMV, G Macedo and MLP are members of the steering committee that developed the WGO Climate Course for Global Gastroenterology. EEO commissioned the commentary series as the editor-in-chief of Gut.

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Global warming and climate change are important worldwide issues which are a major human health threat. Climate change can affect the gastrointestinal (GI) system in many ways. Increased rainfall events and flooding may be associated with increased GI infections and hepatitis. Climate change could cause changes in gut microbiota, which may impact the pattern of GI diseases. The stress of access to essential needs such as clean water and food, the effects of forced migration, and natural disasters could increase brain-gut axis disorders. The association between air pollution and GI disorders is another challenging issue. There is a lot to do personally and professionally as gastroenterologists regarding climate change., Competing Interests: Competing Interests The authors declare no conflict of interest related to this work., (© 2023 Middle East Journal of Digestive Diseases.)

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Background: The University of Limerick Cancer network (ULCaN) was established in 2019 with funding from the Health Research Institute at the University of Limerick in order to build a network between individuals in academia, primary and secondary care and the general public so that cancer services can be coordinated and more effective. The aim of this paper is to outline our experience of engaging with stakeholders to identify gaps in the cancer journey locally., Methods: Four focus group discussions were conducted with patients; their carers; members of the public; and healthcare providers with 2 main aims: 1) to investigate gaps in cancer services; 2) to identify knowledge, attitudes and opportunities available to promote cancer research. The focus groups were audio recorded, transcribed and thematically analysed., Results: 15 themes within the topics of cancer care, palliation, communication, clinical trials, diet and exercise and public and patient involvement in research and advocacy were identified. These include directing people to reliable information and navigating misinformation and stigma linked with cancer, promoting awareness of clinical trials and palliative care services and improving communication when multiple healthcare providers are involved., Conclusion: The need to make more coherent, efficient and integrated cancer research amongst local stakeholders was evident. Embedding patients and members of the public into ULCaN is an important deliverable for collaborative research., Competing Interests: Declaration of Competing Interest The authors are involved in cancer research., (Copyright © 2021. Published by Elsevier B.V.)

Climate change has been described as the greatest public health threat of the 21st century. It has significant implications for digestive health. A multinational team with representation from all continents, excluding Antarctica and covering 18 countries, has formulated a commentary which outlines both the implications for digestive health and ways in which this challenge can be faced., (Copyright © 2021 by Wolters Kluwer, the American Gastroenterological Association, the British Society of Gastroenterology and BMJ Publishing Group, the World Gastroenterology Association.)

Objectives: We estimated and compared the travel related carbon emissions of the annual meeting of the Canadian Association of Gastroenterology between the two most common geographical locations of the meeting., Methods: We modelled the car, train and flight travel journey of each registrant to two annual meetings. One was held in Toronto, close to where the majority of Gastroenterogists live, the other in Banff in the west of the country. We used validated carbon emission outputs per kilometer of travel., Results: The average per capita distance travelled to the Toronto meeting was 2845 km, resulting in 0.540 tonnes (t) of CO 2 equivalent (CO 2 e) emitted per person. When the meeting was held in Banff emissions were 41% higher than those in Toronto with an average distance travelled of 3949 km and 0.760t of CO 2 e emitted per person. Almost all of the travel related carbon emissions for both meetings were generated by flying., Conclusions: Even when held close to the largest population centre, there is a large environmental impact from travel to annual meetings. Importantly, choice of meeting location has a very big impact on difference in carbon emissions. Societies need to consider the site of meetings and reduce the number of in-person attendees if they wish to reduce their carbon footprint. Hybrid models participants should be considered. Our analysis also suggests, other medical societies who wish to model their annual meetings can use a simplified model, using flying distance only, to estimate travel-related emissions., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology.)

Competing Interests: Intérêts concurrents: Christen Shoesmith, Aaron Izenberg, Wendy Johnston, Colleen O’Connell, Kerri Schellenberg et Lorne Zinman ont été membres d’un comité consultatif scientifique sur Radicava (édaravone; Mitsubishi Tanabe Pharma Canada). Christen Shoesmith signale avoir été investigatrice principale d’un site pour plusieurs essais cliniques multicentriques sur la sclérose latérale amyotrophique (SLA). Au cours des 36 derniers mois, la Dre Shoesmith a participé à des essais cliniques commandités par Biogen, Cytokinetics, ALS Pharma et Orphazyme. Marvin Chum signale avoir reçu une bourse de recherche clinique sur la SLA du programme Bernice Ramsay, indépendamment des travaux soumis. Aaron Izenberg signale avoir reçu des honoraires personnels de Biogen, Roche, Alnylam, Genzyme, Takeda et Mitsubishi Tanabe Pharma, indépendamment des travaux soumis. Aucun autre intérêt concurrent n’a été déclaré.

Competing Interests: Competing interests: Christen Shoesmith, Aaron Izenberg, Wendy Johnston, Colleen O’Connell, Kerri Schellenberg and Lorne Zinman were members of a scientific advisory committee for Radicava (edaravone; Mitsubishi Tanabe Pharma Canada). Christen Shoesmith reports being a site principal investigator for several multicentre amyotrophic lateral sclerosis (ALS) clinical trials. In the last 36 months, Dr. Shoesmith has participated in clinical trials sponsored by Biogen, Cytokinetics, ALS Pharma and Orphazyme. Marvin Chum reports receiving a grant from Bernice Ramsay ALS Clinical Research Fellowship, outside the submitted work. Aaron Izenberg reports receiving personal fees from Biogen, Roche, Alnylam, Genzyme, Takeda and Mitsubishi Tanabe Pharma, outside the submitted work. No other competing interests were declared.

Performance of endoscopic procedures is associated with a risk of infection from COVID-19. This risk can be reduced by the use of personal protective equipment (PPE). However, shortage of PPE has emerged as an important issue in managing the pandemic in both traditionally high and low-resource areas. A group of clinicians and researchers from thirteen countries representing low, middle, and high-income areas has developed recommendations for optimal utilization of PPE before, during, and after gastrointestinal endoscopy with particular reference to low-resource situations. We determined that there is limited flexibility with regard to the utilization of PPE between ideal and low-resource settings. Some compromises are possible, especially with regard to PPE use, during endoscopic procedures. We have, therefore, also stressed the need to prevent transmission of COVID-19 by measures other than PPE and to conserve PPE by reduction of patient volume, limiting procedures to urgent or emergent, and reducing the number of staff and trainees involved in procedures. This guidance aims to optimize utilization of PPE and protection of health care providers.

Background: It is necessary for health planners, educators and physician and patient organizations to be aware of trends in gastroenterologist (GI) numbers in order to ensure that patients have timely access to care., Methods: The number of GIs in practice and the number of trainees in the specialty was determined for 2018 using three national databases compared with previous years., Results: In 2018, there were 787 GIs in Canada, which equated to 2.1 GIs per 100,000 population. There are marked differences between provinces with numbers ranging from 1.1 to 2.9 per 100,000. There are 53 GIs specializing in pediatric GI care. Forty-six per cent of practitioners under the age of 35 years are female. Seventy-two residents are training in adult GI and six in pediatrics. Approximately 75% of fellows in adult and pediatric GI are training on temporary visas. The number of adult GIs is decreasing despite increasing national population growth and service demand. The numbers of trainees in both adult and pediatric GI are lower than in 2010. If these trends continue, wait times for GI care, which are already poor, will likely increase further., Conclusions: Continued monitoring of human resource numbers, patient access to care and validation of current data is required.The purpose of this report is to present the number of gastroenterologists (GIs), both in practice and in training, in Canada for 2018. We also wished to examine the 2018 numbers by province and gender, compare the 2018 numbers with those of previous years and describe the practice settings and organization., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology.)

The earth's atmosphere has warmed by about 1°C compared with preindustrial temperature. This is producing changes in the earth's climate and weather which have implications for gastrointestinal health and disease. Climate change will exacerbate current challenges with regard to provision of adequate nutrition and access to clean water. An increase in high rainfall events, flooding and droughts will be associated with an increase in enteric infections and hepatitis. Changes in habitat may result in altered distribution of gastrointestinal illness such as Vibrio cholera. Climate change will force migration between countries, and within countries, and will drive relocation from rural to urban areas, further straining sanitation and clean water provision. The infrastructure required to the delivery of gastrointestinal care is vulnerable to extreme weather events which will become more frequent. The Gastroenterology community needs to join the debate on climate change by organizing, educating, advocating, and supporting our political leaders as they face the enormous challenges posed by global warming.

Pathology is the study of disease and is an important component in medical education. However, with medical curriculum reform, its role and contribution to medical courses is under potential threat. We surveyed the status of pathology in all six Irish medical schools. Information was received from five direct undergraduate and four graduate entry programmes. Pathology was recognisable as a core subject in all but one of the medical schools, was generally taught in years two or three, and the greatest contact hours were for histopathology (44-102 hours). Lectures were the most common teaching modality, and all used single best or extended matching answer multiple-choice questions as part of assessments. Currently, pathology is very visible in Irish medical education but needs to remain relevant with the move to theme and case-based teaching. There is heavy reliance on lectures and on non-academic/full-time hospital staff to deliver teaching, which may not be sustainable., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To review and summarize the recently developed Canadian Association of Gastroenterology screening recommendations for patients with a family history of colorectal cancer (CRC) or adenoma from a family medicine perspective., Quality of Evidence: A systematic review and meta-analysis was performed to synthesize knowledge regarding family history and CRC. The Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE were searched with the following MeSH terms: colorectal cancers or neoplasms, screen or screening or surveillance, and family or family history. Known hereditary syndromes were excluded. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to establish certainty in reviewed evidence. Most recommendations are conditional recommendations with very low-quality evidence., Main Message: Individuals who have 1 first-degree relative (FDR) with CRC or an advanced adenoma diagnosed at any age are recommended to undergo colonoscopy every 5 to 10 years starting at age 40 to 50 years or 10 years younger than the age at diagnosis of the FDR, although fecal immunochemical testing at an interval of every 1 to 2 years can be used. Individuals with FDRs with non-advanced adenomas or a history of CRC in second-degree relatives should be screened according to average-risk guidelines. Lifestyle modification can statistically significantly decrease risk of CRC and should be considered in all patients., Conclusion: These guidelines acknowledge the many factors that can increase an individual's risk of developing CRC and allow for judgment to be employed depending on the clinical scenario. Lifestyle advice already given to patients for weight, blood pressure, and heart disease management will reduce the risk of CRC if implemented, and this combined with more targeted screening for higher-risk individuals will hopefully be successful in decreasing CRC mortality in Canada., (Copyright© the College of Family Physicians of Canada.)

Background & Aims: Inflammatory bowel diseases (IBDs) exist worldwide, with high prevalence in North America. IBD is complex and costly, and its increasing prevalence places a greater stress on health care systems. We aimed to determine the past current, and future prevalences of IBD in Canada., Methods: We performed a retrospective cohort study using population-based health administrative data from Alberta (2002-2015), British Columbia (1997-2014), Manitoba (1990-2013), Nova Scotia (1996-2009), Ontario (1999-2014), Quebec (2001-2008), and Saskatchewan (1998-2016). Autoregressive integrated moving average regression was applied, and prevalence, with 95% prediction intervals (PIs), was forecasted to 2030. Average annual percentage change, with 95% confidence intervals, was assessed with log binomial regression., Results: In 2018, the prevalence of IBD in Canada was estimated at 725 per 100,000 (95% PI 716-735) and annual average percent change was estimated at 2.86% (95% confidence interval 2.80%-2.92%). The prevalence in 2030 was forecasted to be 981 per 100,000 (95% PI 963-999): 159 per 100,000 (95% PI 133-185) in children, 1118 per 100,000 (95% PI 1069-1168) in adults, and 1370 per 100,000 (95% PI 1312-1429) in the elderly. In 2018, 267,983 Canadians (95% PI 264,579-271,387) were estimated to be living with IBD, which was forecasted to increase to 402,853 (95% PI 395,466-410,240) by 2030., Conclusion: Forecasting prevalence will allow health policy makers to develop policy that is necessary to address the challenges faced by health systems in providing high-quality and cost-effective care., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Canada's large geographic area and low population density pose challenges in access to specialized health care for remote and rural residents. We compared health services use, surgical rate, and specialist gastroenterologist care in rural and urban inflammatory bowel disease (IBD) patients in Canada., Methods: We used validated algorithms that were applied to population-based health administrative data to identify all people living with the following three Canadian provinces: Alberta, Manitoba, and Ontario (ON). We compared rural residents with urban residents for time to diagnosis, hospitalizations, outpatient visits, emergency department (ED) use, surgical rate, and gastroenterologist care. Multivariable regression compared the outcomes in rural/urban patients, controlling for confounders. Provincial results were meta-analyzed using random-effects models to produce overall estimates., Results: A total of 36,656 urban and 5,223 rural residents with incident IBD were included. Outpatient physician visit rate was similar in rural and urban patients. IBD-specific and IBD-related hospitalization rates were higher in rural patients (incidence rate ratio [IRR] 1.17, 95% CI 1.02-1.34, and IRR 1.27, 95% CI 1.04-1.56, respectively). The rate of ED visits in ON were similarly elevated for rural patients (IRR 1.53, 95% CI 1.42-1.65, and IRR 1.33, 95% CI 1.25-1.40). There were no differences in surgical rates or prediagnosis lag time between rural and urban patients. Rural patients had fewer IBD-specific gastroenterologist visits (IRR 0.79, 95% CI 0.73-0.84) and a smaller proportion of their IBD-specific care was provided by gastroenterologists (28.3% vs 55.2%, P <0.0001). This was less pronounced in children <10 years at diagnosis (59.3% vs 65.0%, P <0.0001), and the gap was widest in patients >65 years (33.0% vs 59.2%, P <0.0001)., Conclusion: There were lower rates of gastroenterologist physician visits, more hospitalizations, and greater rates of ED visits in rural IBD patients. These disparities in health services use result in costlier care for rural patients. Innovative methods of delivering gastroenterology care to rural IBD patients (such as telehealth, online support, and remote clinics) should be explored, especially for communities lacking easy access to gastroenterologists., Competing Interests: Disclosure Eric I Benchimol and Geoffrey C Nguyen were supported by New Investigator Awards from CIHR, Crohn’s and Colitis Canada, and the Canadian Association of Gastroenterology. Eric I Benchimol was also supported by the Career Enhancement Program from the Canadian Child Health Clinician Scientist Program. M Ellen Kuenzig was supported by a Post-Doctoral Fellowship Award from CIHR, Crohn’s and Colitis Canada, and the Canadian Association of Gastroenterology. Charles N Bernstein was supported in part by the Bingham Chair in Gastroenterology. Geoffrey C Nguyen and Gilaad G Kaplan were CIHR Embedded Clinician Research Chairs. Astrid Guttmann was supported by a CIHR Applied Chair in Reproductive and Child Health Services and Policy Research. Lisa M Lix was supported by a Canada Research Chair (Tier I). The authors report no other conflicts of interest in this work.

Background & Aims: A family history (FH) of colorectal cancer (CRC) increases the risk of developing CRC. These consensus recommendations developed by the Canadian Association of Gastroenterology and endorsed by the American Gastroenterological Association, aim to provide guidance on screening these high-risk individuals., Methods: Multiple parallel systematic review streams, informed by 10 literature searches, assembled evidence on 5 principal questions around the effect of an FH of CRC or adenomas on the risk of CRC, the age to initiate screening, and the optimal tests and testing intervals. The GRADE (Grading of Recommendation Assessment, Development and Evaluation) approach was used to develop the recommendations., Results: Based on the evidence, the Consensus Group was able to strongly recommend CRC screening for all individuals with an FH of CRC or documented adenoma. However, because most of the evidence was very-low quality, the majority of the remaining statements were conditional ("we suggest"). Colonoscopy is suggested (recommended in individuals with ≥2 first-degree relatives [FDRs]), with fecal immunochemical test as an alternative. The elevated risk associated with an FH of ≥1 FDRs with CRC or documented advanced adenoma suggests initiating screening at a younger age (eg, 40-50 years or 10 years younger than age of diagnosis of FDR). In addition, a shorter interval of every 5 years between screening tests was suggested for individuals with ≥2 FDRs, and every 5-10 years for those with FH of 1 FDR with CRC or documented advanced adenoma compared to average-risk individuals. Choosing screening parameters for an individual patient should consider the age of the affected FDR and local resources. It is suggested that individuals with an FH of ≥1 second-degree relatives only, or of nonadvanced adenoma or polyp of unknown histology, be screened according to average-risk guidelines., Conclusions: The increased risk of CRC associated with an FH of CRC or advanced adenoma warrants more intense screening for CRC. Well-designed prospective studies are needed in order to make definitive evidence-based recommendations about the age to commence screening and appropriate interval between screening tests., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Although the incidence of inflammatory bowel diseases (IBDs) varies with age, few studies have examined variations between the sexes. We therefore used population data from established cohorts to analyze sex differences in IBD incidence according to age at diagnosis., Methods: We identified population-based cohorts of patients with IBD for which incidence and age data were available (17 distinct cohorts from 16 regions of Europe, North America, Australia, and New Zealand). We collected data through December 2016 on 95,605 incident cases of Crohn's disease (CD) (42,831 male and 52,774 female) and 112,004 incident cases of ulcerative colitis (UC) (61,672 male and 50,332 female). We pooled incidence rate ratios of CD and UC for the combined cohort and compared differences according to sex using random effects meta-analysis., Results: Female patients had a lower risk of CD during childhood, until the age range of 10-14 years (incidence rate ratio, 0.70; 95% CI, 0.53-0.93), but they had a higher risk of CD thereafter, which was statistically significant for the age groups of 25-29 years and older than 35 years. The incidence of UC did not differ significantly for female vs male patients (except for the age group of 5-9 years) until age 45 years; thereafter, men had a significantly higher incidence of ulcerative colitis than women., Conclusions: In a pooled analysis of population-based studies, we found age at IBD onset to vary with sex. Further studies are needed to investigate mechanisms of sex differences in IBD incidence., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Several databases track gastroenterology (GI) human resource (HR) numbers in Canada. They differ in the data which they collect and, hence, in their estimates of GI HR. The two most likely to reflect current HR are the Canadian Institute of Health Research (CIHI) and Canadian Medical Association (CMA) databases. The estimates of GI's generated by each of the databases correlate closely with each other. Approximately 50 trainees enter the adult GI workforce per year, and approximately five enter the pediatric group. We estimate that Canada as a whole has between 782 and 848 GIs or 2.14 GIs per 100,000 population in 2016. Six of the 10 provinces have fewer than two GIs per 100,000 population. National GI numbers are increasing by 6% per year. Validation studies are required.

Objectives: To determine the association between inflammatory bowel disease (IBD) and rural/urban household at the time of diagnosis, or within the first 5 years (y) of life., Methods: Population-based cohorts of residents of four Canadian provinces were created using health administrative data. Rural/urban status was derived from postal codes based on population density and distance to metropolitan areas. Validated algorithms identified all incident IBD cases from administrative data (Alberta: 1999-2008, Manitoba and Ontario: 1999-2010, and Nova Scotia: 2000-2008). We determined sex-standardized incidence (per 100,000 patient-years) and incident rate ratios (IRR) using Poisson regression. A birth cohort was created of children in whom full administrative data were available from birth (Alberta 1996-2010, Manitoba 1988-2010, and Ontario 1991-2010). IRR was calculated for residents who lived continuously in rural/urban households during each of the first 5 years of life., Results: There were 6,662 rural residents and 38,905 urban residents with IBD. Incidence of IBD per 100,000 was 33.16 (95% CI 27.24-39.08) in urban residents, and 30.72 (95% CI 23.81-37.64) in rural residents (IRR 0.90, 95% CI 0.81-0.99). The protective association was strongest in children <10 years (IRR 0.58, 95% CI 0.43-0.73) and 10-17.9 years (IRR 0.72, 95% CI 0.64-0.81). In the birth cohort, comprising 331 rural and 2,302 urban residents, rurality in the first 1-5 years of life was associated with lower risk of IBD (IRR 0.75-0.78)., Conclusions: People living in rural households had lower risk of developing IBD. This association is strongest in young children and adolescents, and in children exposed to the rural environment early in life.

Objectives: The incidence of pediatric-onset inflammatory bowel disease (IBD) is increasing worldwide. We used population-based health administrative data to determine national Canadian IBD incidence, prevalence, and trends over time of childhood-onset IBD., Methods: We identified children <16 years (y) diagnosed with IBD 1999-2010 from health administrative data in five provinces (Alberta, Manitoba, Nova Scotia, Ontario, Quebec), comprising 79.2% of the Canadian population. Standardized incidence and prevalence were calculated per 100,000 children. Annual percentage change (APC) in incidence and prevalence were determined using Poisson regression analysis. Provincial estimates were meta-analyzed using random-effects models to produce national estimates., Results: 5,214 incident cases were diagnosed during the study period (3,462 Crohn's disease, 1,382 ulcerative colitis, 279 type unclassifiable). The incidence in Canada was 9.68 (95% CI 9.11 to 10.25) per 100,000 children. Incidence was similar amongst most provinces, but higher in Nova Scotia. APC in incidence did not significantly change over the study period in the overall cohort (+2.06%, 95% CI -0.64% to +4.76%). However, incidence significantly increased in children aged 0-5y (+7.19%, 95% +2.82% to +11.56%). Prevalence at the end of the study period in Canada was 38.25 (95% CI 35.78 to 40.73) per 100,000 children. Prevalence increased significantly over time, APC +4.56% (95% CI +3.71% to +5.42%)., Conclusions: Canada has amongst the highest incidence of childhood-onset IBD in the world. Prevalence significantly increased over time. Incidence was not statistically changed with the exception of a rapid increase in incidence in the youngest group of children.

Summary: Dalhousie University, with the help of the other Maritime universities formed and sent a hospital to Europe during the First World War (WWI). They served from January 1916 to April 1919. There is no comprehensive account of the treatment of German wounded by Canadian Medical Services in WWI; however, there is direct photographic and written evidence from the No. 7 Canadian Stationary Hospital that the relationship was one of mutual trust, more characteristic of that between a health care provider and patient than between combatants. The activities of the No. 7 in treating German wounded from the Western Front provide insight into this undocumented aspect of the medical services in WWI. A previously unrecognized painting by Sir William Orpen, one of the leading artists of the 20th century, of the unit at work in France is described. An appendix to this commentary is available at canjsurg.ca.

Background: Amyotrophic lateral sclerosis (ALS) is a rapidly progressing degenerative motor neuron disease that results in significant muscle weakness. Defects in energy metabolism and difficulties in swallowing eventually lead to a reduction in body mass. Weight loss exacerbates symptoms and serves as an independent negative prognostic factor. Percutaneous endoscopic gastrostomy (PEG) is often inserted in patients with ALS to either supplement or replace oral feeding. However, the criteria for PEG placement and timing of insertion are important clinical decisions that have not been fully studied. Given the absence of guiding evidence, the aim of this project was to better understand how Canadian ALS clinics make decisions regarding gastrostomy feeding., Methods: ALS clinical directors across Canada were asked if they had written guidelines for timing of PEG insertion and if not, what criteria they use to make this decision. Responses from 10 of 17 centres contacted were received., Results: The approach to supplemental nutrition management in Canadian clinics varies in the absence of formal guidelines. Only one centre has a written set of centre-specific protocols in place. Most clinics considered some combination of respiratory decline, weight loss, dysphagia and/or patient readiness when reaching a decision. However, the absolute threshold and mechanism of measuring the individual criteria differed between clinics., Conclusions: Practices generally reflect international published recommendations but vary on the emphasis of specific criteria. Further research is required to determine the optimal timing and criteria to place gastrostomy feeding tubes in the ALS population.

Background: Television watching is obesogenic due to its sedentary nature and programming content, which influences children. Few studies have examined exercise placement within children-specific programming. This study aimed to investigate the frequency and type of exercise placement in children-specific television broadcasts and to compare placements on the UK and Irish television channels., Methods: Content analysis for five weekdays' worth of children-specific television broadcasting totaling 82.5 hours on both the UK (British Broadcasting Corporation) and Irish (Radió Teilifís Éireann) television channels was performed. For the purposes of comparing the UK and Irish placements, analysis was restricted to programming broadcast between 6 am and 11.30 am. Exercise placements were coded based on type of activity, activity context, activity motivating factors and outcome, and characters involved., Results: A total of 780 cues were recorded during the total recording period. A wide variety of sports were depicted, but dancing-related cues were most commonly seen (n=163, 23.3%), with the majority of cues being of mild (n=365, 65.9%) or moderate (n=172, 31.0%) intensity. The majority of cues were associated with a positive outcome (n=404, 61.4%), and social motivations were most commonly seen (n=289, 30.3%). The Irish and the UK portrayals were broadly similar., Conclusion: This study highlights the wide variety of sports portrayed and the active effort undertaken by television stations to depict physical exercise and recreation in a positive light.

Background: Levels of endoscopic demand and capacity in West Africa are unclear., Objectives: This paper aims to: 1. describe the current labor and endoscopic capacity, 2. quantify the impact of a mixed-methods endoscopy course on healthcare professionals in West Africa, and 3. quantify the types of diagnoses encountered., Methods: In a three-day course, healthcare professionals were surveyed on endoscopic resources and capacity and were taught through active observation of live cases, case discussion, simulator experience and didactics. Before and after didactics, multiple-choice exams as well as questionnaires were administered to assess for course efficacy. Also, a case series of 23 patients needing upper GI endoscopy was done., Results: In surveying physicians, less than half had resources to perform an EGD and none could perform an ERCP, while waiting time for emergency endoscopy in urban populations was at least one day. In assessing improvement in medical knowledge among participants after didactics, objective data paired with subjective responses was more useful than either alone. Of 23 patients who received endoscopy, 7 required endoscopic intervention with 6 having gastric or esophageal varices. Currently the endoscopic capacity in West Africa is not sufficient. A formal GI course with simulation and didactics improves gastrointestinal knowledge amongst participants.

Objective: The link between childhood obesity and both television viewing and television advertising have previously been examined. We sought to investigate the frequency and type of food and beverage placements in children-specific television broadcasts and, in particular, differences between programme genres., Method: Content of five weekdays of children-specific television broadcasting on both UK (BBC) and Irish (RTE) television channels was summarized. Food and beverage placements were coded based on type of product, product placement, product use and characters involved. A comparison was made between different programme genres: animated, cartoon, child-specific, film, quiz, tween and young persons' programming., Results: A total of 1155 (BBC=450; RTE=705) cues were recorded giving a cue every 4·2 min, an average of 12·3 s/cue. The genre with most cues recorded was cartoon programming (30·8%). For the majority of genres, cues related to sweet snacks (range 1·8-23·3%) and sweets/candy (range 3·6-25·8%) featured highly. Fast-food (18·0%) and sugar-sweetened beverage (42·3%) cues were observed in a high proportion of tween programming. Celebratory/social motivation factors (range 10-40 %) were most common across all genres while there were low proportions of cues based on reward, punishment or health-related motivating factors., Conclusions: The study provides evidence for the prominence of energy-dense/nutrient-poor foods and beverages in children's programming. Of particular interest is the high prevalence of fast-food and sugar-sweetened beverage cues associated with tween programming. These results further emphasize the need for programme makers to provide a healthier image of foods and beverages in children's television.

Background & Aims: Probiotic formulations of single species of bacteria have not been effective in preventing the recurrence of Crohn's disease after surgery. We investigated the ability of VSL#3, a mixture of 8 different bacterial probiotic species, to prevent Crohn's disease recurrence after surgery in a multicenter, randomized, double-blind, placebo-controlled trial., Methods: Within 30 days of ileocolonic resection and re-anastomosis, patients with Crohn's disease were randomly assigned to groups given 1 sachet of VSL#3 (900 billion viable bacteria, comprising 4 strains of Lactobacillus, 3 strains of Bifidobacterium, and 1 strain of Streptococcus salivarius subspecies thermophilus) (n = 59) or matching placebo (n = 60). Colonoscopy was performed at days 90 and 365 to evaluate the neoterminal ileum for disease recurrence and obtain mucosal biopsies for cytokine analysis. Patients from both groups with either no or mild endoscopic recurrence at day 90 received VSL#3 until day 365. The primary outcome was the proportion of patients with severe endoscopic recurrence at day 90., Results: At day 90, the proportion of patients with severe endoscopic lesions did not differ significantly between VSL#3 (9.3%) and placebo (15.7%, P = .19). The proportions of patients with non-severe lesions at day 90 who had severe endoscopic recurrence at day 365 were 10.0% in the early VSL#3 group (given VSL#3 for the entire 365 days) and 26.7% in the late VSL#3 group (given VSL#3 from days 90 through 365) (P = .09). Aggregate rates of severe recurrence (on days 90 and 365) were not statistically different, 20.5% of subjects in the early VSL#3 group and 42.1% in the late VSL#3 group. Patients receiving VSL#3 had reduced mucosal inflammatory cytokine levels compared with placebo at day 90 (P < .05). Crohn's disease activity index and inflammatory bowel disease quality of life scores were similar in the 2 groups., Conclusions: There were no statistical differences in endoscopic recurrence rates at day 90 between patients who received VSL#3 and patients who received placebo. Lower mucosal levels of inflammatory cytokines and a lower rate of recurrence among patients who received early VSL#3 (for the entire 365 days) indicate that this probiotic should be further investigated for prevention of Crohn's disease recurrence. Clinical trials.gov number: NCT00175292., (Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Increasing prevalence of overweight and obese children in developed countries poses a substantial threat to long-term health. One well-described factor is the amount of time spent watching television, with exposure to food advertising a known influence on food preferences and consumption patterns., Aims: Following recent formulation of new rules regarding advertising of food during children's programming, we sought to examine the advertising content in children-specific television broadcasts on Irish television., Methods: Advertisement content analysis for 5 weekdays of children-specific television broadcasting from 0700 to 1700 hours on Irish television was performed. Data were coded and transferred to SPSS for analyses. Food and beverage advertisements were coded based on type of product, nutritional content, intended age group and outcome., Results: 322 advertisements were broadcast during the recording period. 31 % (n = 101) of advertisements related to food or beverage products with 66.3 % (n = 68) of food advertisements being for foods that should be eaten in moderation. The most frequently recorded food advertisement was for fast food products (27.3 %, n = 24), followed by sweets/candy (21.6 %, n = 19) and dairy products (17.0 %, n = 15). The most frequently recorded beverage advertisement was for natural orange juices (46.2 %, n = 6). 54.7 % (n = 176) of advertisements were adult specific with 27.3 % (n = 88) being children specific. All food and beverage advertisements were associated with a positive outcome (n = 322)., Conclusions: These results demonstrate that food and beverages depicted in advertisements during children's programming are predominantly unhealthy foods with high salt and sugar contents. The findings from this study again highlight the ongoing need for new rules regarding food advertising in children's programming.

Objectives: Increased time in which children spend watching television is a well-described contributor to paediatric obesity. This study investigated the frequency and type of food and beverage placement in children-specific television broadcasts and compared data from UK (UK) and Irish television stations., Design: Content analysis, totalling 82.5 h, reflecting 5 weekdays of children-specific television broadcasting on UK and Irish television channels was performed. To allow comparison between UK and Irish food and beverage cues, only broadcasts between 06.00 and 11.30 were analysed. Data were coded separately by two analysts and transferred to SPSS for analyses. Food and beverage cues were coded based on type of product, product placement, product use, motivation, outcome and characters involved., Results: A total of 1155 food and beverage cues were recorded. Sweet snacks were the most frequent food cue (13.3%), followed by sweets/candy (11.4%). Tea/coffee was the most frequent beverage cue (13.5%), followed by sugar-sweetened beverages (13.0%). The outcome of the cue was positive in 32.6%, negative in 19.8%, and neutral in 47.5% of cases. The most common motivating factor associated with each cue was celebratory/social (25.2%), followed by hunger/thirst (25.0%). Comparison of UK and Irish placements showed both to portray high levels of unhealthy food cues. However, placements for sugar-sweetened beverages were relatively low on both channels., Conclusions: This study provides further evidence of the prominence of unhealthy foods in children's programming. These data may provide guidance for healthcare professionals, regulators and programme makers in planning for a healthier portrayal of food and beverage in children's television., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Nova Scotia has one of the highest incidences of inflammatory bowel disease (IBD) in the world. We wished to determine trends of IBD over time., Methods: All Provincial residents have government provided health insurance and all interactions with the hospital, and physician billing systems, are captured on an administrative database. We used a validated measure to define incident cases of Crohn's (CD), ulcerative colitis (UC) and undifferentiated IBD (IBDU). Incidence rates of these diseases for the years 1996-2009 were calculated., Results: Over the study period, 7,153 new cases of IBD were observed of which 3,046 cases were categorized as CD (42.6%), 2,960 as UC (41.4%) and 1,147 as IBDU (16.0%). Annual age standardized incidence rates were very high but have declined for CD from 27.4 to 17.7/100,000 population and for UC from 21.4 to 16.7/100,000. The decline was seen in all age groups and both genders. The decrease was not explained by a small increase in IBDU., Conclusion: The incidence of CD and UC are decreasing in Nova Scotia. If replicated elsewhere this indicates a reversal after a long period of increasing occurrence of IBD. This has implications for both epidemiology and health planning.

The Internet provides patients and their families with ready access to on-line health related information. However, this information is not always accurate, understandable or provided by health professionals or advocacy groups. One hundred children with Type 1 diabetes mellitus, or their parents, attending a paediatric diabetes clinic during September to November 2011 were invited sequentially to participate in this questionnaire-based survey of Internet use in searching for diabetes-related information. Sixty-seven (67%) returned completed anonymised questionnaires: 36/67 (53%) were categorised as socio-economic groups C1/C2. Of the 67 families who returned completed questionnaires, 64 (96%) had a home computer and 62 (93%) had home Internet access; 27 (40%) rarely, and 40 (60%) frequently, searched on-line for diabetes-related information. Key search terms were not provided by respondents. There appears to be considerable internet use in seeking health related information for children with Type 1 diabetes mellitus. Clinicians should make efforts to direct patients and their families to websites that present accurate and current information.

The inflammatory bowel diseases, Crohn's and ulcerative colitis, are common and a significant cause of morbidity. They were rare before the 1930's but the incidence has been increasing in both developed and developing countries. We have recently reported that the incidence in Nova Scotia, the area with one of the highest reported burden globally, is decreasing since 1997. We postulate that this decrease may be due to the addition of folate to cereals. This was mandated in 1998 but the process of fortification began in 1997. There is circumstantial evidence from epidemiology studies that a diet deficient in folate may have contributed to the global rise in these diseases. This hypothesis, if proven to be correct, has important implications for the prevention and treatment of these diseases., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Differences between American (United States [US]) and European guidelines for colonoscopy surveillance may create confusion for the practicing clinician. Under- or overutilization of surveillance colonoscopy can impact patient care., Methods: The Canadian Association of Gastroenterology (CAG) convened a working group (CAG-WG) to review available guidelines and provide unified guidance to Canadian clinicians regarding appropriate follow-up for colorectal cancer (CRC) surveillance after index colonoscopy. A literature search was conducted for relevant data that postdated the published guidelines., Results: The CAG-WG chose the 2012 US Multi-Society Task Force (MSTF) on Colorectal Cancer to serve as the basis for the Canadian position, primarily because the US approach was the simplest and comprehensively addressed the issue of serrated polyps. Aspects of other guidelines were incorporated where relevant. The CAG-WG recommendations differed from the US MSTF guidelines in three main areas: patients with negative index colonoscopy should be followed-up at 10 years using any of the appropriate screening tests, including colonoscopy, for average-risk individuals; among patients with >10 adenomas, a one-year interval for subsequent colonoscopy is recommended; and for long-term follow-up, patients with low-risk adenomas on both the index and first follow-up procedures can undergo second follow-up colonoscopy at an interval of five to 10 years., Discussion: The CAG-WG adapted the US MSTF guidelines for colonoscopy surveillance to the Canadian health care environment with a few modifications. It is anticipated that the present article will provide unified guidance that will enhance physician acceptance and encourage appropriate utilization of recommended surveillance intervals.

Background: Periodically surveying wait times for specialist health services in Canada captures current data and enables comparisons with previous surveys to identify changes over time., Methods: During one week in April 2012, Canadian gastroenterologists were asked to complete a questionnaire (online or by fax) recording demographics, reason for referral, and dates of referral and specialist visits for at least 10 consecutive new patients (five consultations and five procedures) who had not been seen previously for the same indication. Wait times were determined for 18 indications and compared with those from similar surveys conducted in 2008 and 2005., Results: Data regarding adult patients were provided by 173 gastroenterologists for 1374 consultations, 540 procedures and 293 same-day consultations and procedures. Nationally, the median wait times were 92 days (95% CI 85 days to 100 days) from referral to consultation, 55 days (95% CI 50 days to 61 days) from consultation to procedure and 155 days (95% CI 142 days to 175 days) (total) from referral to procedure. Overall, wait times were longer in 2012 than in 2005 (P<0.05); the wait time to same-day consultation and procedure was shorter in 2012 than in 2008 (78 days versus 101 days; P<0.05), but continued to be longer than in 2005 (P<0.05). The total wait time remained longest for screening colonoscopy, increasing from 201 days in 2008 to 279 days in 2012 (P<0.05)., Discussion: Wait times for gastroenterology services continue to exceed recommended targets, remain unchanged since 2008 and exceed wait times reported in 2005.

Unlabelled: Overweight and obesity is a growing problem in Ireland. Many parents are unaware when their child is overweight or obese. Our objectives were to examine parents' perceptions of a healthy diet and their children's BMI; and to evaluate the food offered to children in our paediatric in-patient unit., Findings: A retrospective questionnaire was distributed to 95 patients and their families admitted over one month. Seventy-eight had BMI values calculated (42 males, 36 females). Twenty-one children (26.9%) were overweight/obese: 14/21 parents (66.7%) thought their child had a normal weight. Sixty percent of children served dinner in the hospital were given fried potatoes. Four had fruit/vegetables. Forty-six parents brought food into hospital, of these 14 brought purchased food., Conclusions: This study highlights the problem of child obesity in Ireland and parental underestimation of this problem. The nutritional value of food served to children in hospital needs to be improved and hospital admissions used as opportunities to promote healthy eating habits.