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Background To determine representation of women in gastroenterology (GI) at residency and leadership levels in Canada. Methods The Canadian Resident Matching Service provided data for internal medicine (IM), general surgery (GS), GI and cardiology applicant cycles 2014 to 2018. Z-tests were used to compare proportion of women entering each residency program. An internet search was conducted to calculate percentages of women as GI association presidents, residency program directors, division heads and oral speakers at conferences. Results IM residency had on average of 1789 applicants with 487 matched (49.4% versus 49.5% women). GS residency had on average 357 applicants with 90 matched (41% versus 54.4% women). GI residency had on average 46 applicants with 34 matched (37% versus 35.3% women). Cardiology residency had on average 76 applicants with 54 matched (29% versus 27.8% women). The Canadian Association of Gastroenterology (CAG) has had two out of 47 (4.2%) women presidents. The Ontario Association of Gastroenterology (OAG) has had no women presidents (0/9). The Association des gastro-entérologues du Québec (AGEQ) has had two out of 15 (13%) women presidents. The Alberta Society of Gastroenterology (ASG) has had one out of five (20%) women presidents. From 2018 to 2020, university division heads ranged from 0% to 13.3% women (0 to 2/15). University GI training program directors ranged from 28.6% to 35.7% (4 to 5/14). Women speakers at CAG’s annual conference varied 27% to 42% from 2016 to 2020, averaging 32.7%. Women speakers at OAG’s, AGEQ’s and ASG’s annual conferences averaged 23.3%, 24.1% and 35%, respectively. Conclusion Women gastroenterologists display low representation at multiple levels along the GI career pathway.

Background We aimed to determine the persistence of differential career experiences between male and female gastroenterologists in Canada >20 years after they were first noted in the literature. Methods A 51-question mixed-methods survey was developed focusing on personal, professional and financial characteristics. The survey was disseminated via email and fax to practicing gastroenterologists using provincial college registries and the Canadian Association of Gastroenterology. Numerical data were analyzed using the chi-square test. Qualitative thematic analysis was conducted for short answer responses. Findings There were a total of 114 responses (17% response rate) with 35% female respondents. Mean age was 49 years for males and 41 years for females (P = 0.001). Clinical practice types included general GI (63%), urban (82%) and academic (51%). Males reported more endoscopy time (P = 0.001) versus females who spent more time on research (P < 0.001). Men were more likely to be married (P = 0.011), but women were more likely to be responsible for childcare (P = 0.016). Women were more likely to choose between marriage and career and more chose marriage compared to men (P = 0.045). Males earned >$100,000/year higher income than females even when offset by age and work hours (P = 0.048). A salary >$600,000 was reported by 32% of men, compared to 3% of women. Female gastroenterologists reported less mentorship during GI training, challenging relationships with support staff, reduced promotion opportunity, more difficulty publishing and having their competency challenged. Interpretation Compared to previous data, there has not been significant gender-related progress in the past two decades regarding female gastroenterologists’ clinical practices, remuneration and work-life balance.

Objectives With the increased prevalence of childhood-onset inflammatory bowel disease (IBD), there is a greater need for a planned transition process for adolescents and young adults (AYA). The Canadian IBD Transition Network and Crohn’s and Colitis Canada joined in collaborative efforts to describe a set of care consensus statements to provide a framework for transitioning AYA from pediatric to adult care. Methods Consensus statements were drafted after focus group meetings and literature reviews. An expert panel consisting of 20 IBD physicians, nurses, surgeon, adolescent medicine physician, as well as patient and caregiver representatives met, discussed and systematically voted. The consensus was reached when greater than 75% of members voted in agreement. When greater than 75% of members rated strong support, the statement was rendered a strong recommendation, suggesting that a clinician should implement the statement for all or most of their clinical practice. Results The Canadian expert panel generated 15 consensus statements (9 strong and 6 weak recommendations). Areas of focus of the statements included: transition program implementation, key stakeholders, areas of potential need and gaps in the research. Conclusions These consensus statements provide a framework for the transition process. The quality of evidence for these statements was generally low, highlighting the need for further controlled studies to investigate and better define effective strategies for transition in pediatric to adult IBD care.

Background In patients with inflammatory bowel disease, we strive to achieve mucosal healing, as this has been shown to decrease the risk of disease flares, hospitalization, and surgery. For this reason, we must use objective measures of mucosal healing to inform our clinical decision-making and can no longer rely on patient symptoms alone. Assessment of small bowel Crohn’s disease (SBCD) is particularly challenging given its lack of accessibility via standard endoscopic techniques. Ultrasound (US) represents a readily available, cost-effective, minimally invasive, radiation-free alternative for the assessment of small bowel disease. In this study, we performed a systematic review to determine the accuracy of ultrasound in diagnosing SBCD and its complications as compared with endoscopic visualization, surgery, and/or pathology. Methods We searched MEDLINE, EMBASE, and CENTRAL. Prospective cohort studies published up to March 2017 were reviewed. References meeting all eligibility criteria were assessed at the full-text level by 2 independent reviewers. Sensitivity and specificity were collected where available. Results A total of 2817 unique references were identified. Twenty-two studies were included. All studies were at low–moderate risk of bias based on the Quality Assessment of Diagnostic Accuracy Studies criteria. Transabdominal US (TAUS) yielded moderately high sensitivity and specificity for the diagnosis of SBCD and its postoperative recurrence. Detection was more accurate for severe postoperative recurrence. The diagnostic accuracy of US in stricture and abscess detection was high. Contrast enhancement improved the detection of abscess. Diagnostic detection of fistulas was of moderate accuracy. Entero-enteric fistulization and entero-mesenteric fistulization were most clearly identified. Conclusions Ultrasound can be used to diagnose SBCD in those with known or suspected Crohn’s disease. It can be used to detect postoperative recurrence and can accurately identify abscesses and fistulas, especially with the aid of contrast enhancement.

Prokinetics are recommended for the treatment of functional dyspepsia (FD) but systematic reviews give conflicting results on the efficacy of these agents. We have therefore conducted an updated systematic review to support the 2017 joint ACG/CAG dyspepsia guidelines. Electronic databases, including MEDLINE, EMBASE, and CENTRAL, were searched until September 2017 for randomized controlled trials (RCTs) comparing either prokinetics and placebo or two types of prokinetics to improve FD symptoms. The primary outcome was absence or improvement of dyspeptic symptoms at the end of treatment. Double-blind eligibility assessment and data extraction was performed. Pooled risk ratios of symptoms persisting or adverse events occurring, and standardized mean difference of quality-of-life (QoL) scores with 95% CI, using a random effects model, were calculated. Quality of evidence was assessed using GRADE. The search identified 1388 citations; 38 studies in 35 papers were included. Of these, 29 trials comparing prokinetics with placebo were found. There was a statistically significant effect of prokinetic treatment in reducing global symptoms of FD (RR 0.81, 95% CI 0.74 to 0.89; I2 91%; NNT 7), regardless of FD subtype or ethnicity. When comparing two types of prokinetic, the most commonly used comparator was domperidone. There was no difference in reducing global symptoms (RR 0.94, 95% CI 0.83 to 1.07). QoL was not improved with prokinetic treatment. The adverse events with individual prokinetics were not different from placebo, except for cisapride. The GRADE assessment rated the quality of the evidence in each outcome as very low. From the current evidence, prokinetics may be effective for the treatment in all subtypes of FD, with very low quality of evidence. There was no difference between prokinetics for dyspeptic symptom improvement. High-quality RCTs with large sample sizes of FD patients are needed to verify the efficacy of prokinetics.

Background Women are numerically under-represented in the field of gastroenterology and hepatology. Aims To characterize the gender distribution of first and senior authors and editorial board members of the highest impact factor journals in gastroenterology and hepatology. Methods Using Clarivate Journal Citation Report 2019, the 28 highest ranked journals within gastroenterology and hepatology were selected for review, along with the Journal of the Canadian Association of Gastroenterology. Publications between January 1 to December 31, 2019 were included. Gender of board members and authors was identified using publicly available data. Spearman correlation coefficients were calculated using SPSS to assess for a relationship between editorial board, first author, and senior author gender as well as impact factor. Results Of 29 journals assessed with a median impact factor of 5.55 (IQR 3.72–9.10), 357 journal issues and 8036 articles were reviewed. Three journals were headed by female chief editors, constituting 7.7% of all editors-in-chief (3/39). In total, females made up 17.1% of editorial board members (n=584). Of 8036 first authors, 2547 (31.7%) were female. Of 7335 senior authors, 1390 (19.3%) were female. There were no statistically significant correlations between impact factor and gender. Chief editor gender did not significantly correlate with gender distribution of editorial boards, first or senior authors. There was a significant positive correlation between male-dominated editorial boards and male first and senior authorship, versus a significant negative correlation between male-dominated editorial boards and female first and senior authorship. A positive correlation exists for the same gender between first and senior authors. Conclusions Although gender distribution of female first and senior authorship approaches current distributions in the field of gastroenterology and hepatology, editor-in-chief positions and editorial board membership on journals continue to be occupied by men in higher proportions. Future endeavors such as diversity statements and mentorship may help to balance these distributions in the future. Funding Agencies None

Background Patients diagnosed with inflammatory bowel disease (IBD) during childhood require transfer to an adult gastroenterologist, in Ontario usually just before their 18th birthday. Pediatric onset IBD is a complex phenotype with demonstrated noncompliance risk that may require targeted measures to optimize health care outcomes in the adult care setting. Purpose The purpose of this study was to determine the impact of posttransfer health care setting (academic versus community gastroenterologist) on emergent health resource utilization. Methods This was a population-based retrospective cohort study using health care administrative data from Ontario, Canada. A cohort of patients with Pediatric onset IBD was identified and health resource utilization during a 2-year pretransfer period, transfer of care period and 2-year posttransfer period was analyzed. Posttransfer health care setting was defined as academic (i.e., gastroenterologists providing care in a university affiliated tertiary care center) versus community. A third comparator group, loss to follow-up, was also identified. The primary outcome of this study comprised emergency department utilization. Secondary outcomes included hospitalizations, surgeries, ambulatory visits, endoscopic investigations, and radiological investigations. Results Overall, there were no significant differences found in emergency department use, ambulatory care visits (aside from the expected drop in the lost to follow-up group), hospitalizations, endoscopic procedures, or radiological procedures between exposure groups. Conclusions Posttransfer health care setting does not seem to significantly impact emergent health resource utilization in the posttransfer period.

Background Inflammatory bowel disease (IBD)-related Emergency Department (ED) visits are a costly component to current healthcare expenditures. Patients who are discharged directly from the ED for nonurgent issues (aka “treat and release” ED visits) present an opportunity for quality improvement. Purpose To determine the impact of private insurance on IBD-related treat and release ED visits. The secondary outcome was cost per IBD-related ED visit. Methodology A retrospective cohort study was performed on the 2006 Nationwide Emergency Department Sample (NEDS). Comparisons were made between patients with access to private insurance vs those without. Multivariable survey-weighted logistic and linear regression models with clustering by hospital were created for the primary and secondary outcomes, respectively. Results In total, 19,324 patient encounters were included in the stratified analytic sample. Of these, 9272 (47.98%) patients reported private insurance as their primary payment method. An additional 10,052 (52.02%) patients reported an alternative payment form. The private insurance group was statistically younger, less likely to reside in an urban setting and had more representation within the highest income quartile. The OR of a treat and release ED visit was 1.47 (95% confidence interval 1.34–1.62) for no private insurance compared to private insurance. On average, the cost per ED visit of patients without private insurance was $214.80 ± 48.48, P < 0.001 less than those with private insurance. Conclusions Lack of private insurance is an important predictor of IBD-related treat and release ED visits.

BACKGROUND: The most common extra-intestinal manifestation of inflammatory bowel disease (IBD) is arthritis with a prevalence of 17–39%. Two thirds of patients with seronegative spondyloarthropathies show histologic signs of gut inflammation, and some of these patients go on to develop clinical symptoms of IBD. Though the frequency of bowel and joint symptoms in the respective diseases has been well published there is no data that shows how frequently these symptoms are screened for and the extent of screening. This is important knowledge as the identification of comorbid disease may have a critical impact on initiation of therapy and reduction in disease related morbidity. AIMS: The objective of this study was to determine the frequency and type of screening for bowel and joint symptoms in outpatient rheumatology and gastroenterology (GI) clinics in an academic ambulatory hospital. METHODS: A retrospective cohort study was performed using data from a sample of gastroenterology (n=221) and rheumatology (n=172) patients recorded in the electronic medical record between January 1, 2015 and December 31 2017. Data was extracted between February 1st, 2018 and May 31st, 2018. Data on patient characteristics, disease type, medications and presence and method of screening was manually extracted data from each patient’s electronic chart. Chi-square tests of independence were conducted to assess the distribution of patient and provider baseline characteristics based on screening status. Multivariate logistic regression was used to investigate the likelihood of being screened while adjusting for baseline characteristics. Time to screening from first visit was measured using a Kaplan-Meier survival analysis. RESULTS: In rheumatology, 87.8% of patients were screened for GI symptoms. Age, type of arthritis, and medications did not affect screening rates. Providers who were in practice longer tended to screen less frequently (16.4 vs 13.5 years p value = 0.0003). In GI, only 16.3% of patients were screened for joint symptoms. Age and medications did not affect screening rates, however patients with a history of ulcerative colitis tended to be screened less frequently (77.8% not screened, p value = 0.0059). A history of any extra- intestinal manifestation of IBD increased screening rates (77.8% screened p value < 0.0001) and providers who were in practice longer tended to screen less frequently (9.5 vs 5.1 years, p value < 0.0001). CONCLUSIONS: There exist patient and provider characteristics that predict screening rates for comorbid conditions in GI and rheumatology. This baseline data will be used to develop a quality improvement intervention to improve screening rates in both populations. FUNDING AGENCIES: Department of Medicine, Women’s College Hospital

BACKGROUND: Pediatric-to-adult transition of care in Inflammatory Bowel Disease (IBD) can be challenging for patients between 18–25 and the lack of continuity of care is perceived to be causative in loss to follow-up, treatment disruption and poor clinical outcomes. AIMS: The objective of this study was to determine whether regular email contact with a single IBD nurse could improve health outcomes when delivered during the last 3 months of pediatric care and the first 9 months of adult care. METHODS: Patients were randomized in a 1:1 ratio to the intervention and control groups. Randomization was stratified by center (SickKids, McMaster) and anticipated post-transfer setting (academic vs. community). All individuals enrolled completed a baseline questionnaire (disease phenotype, medications, disease activity (Harvey Bradshaw Index (HBI), Pediatric Ulcerative Colitis Activity Index (PUCAI)), transition readiness (Transition Readiness Assessment Questionnaire (TRAQ), patient satisfaction (CACHE questionnaire), IBD knowledge (Crohn’s and Colitis Knowledge Questionnaire (CCK)). This was repeated every 6 months. MyHealth Passport was distributed twice. The IBD nurse interacted monthly with intervention patients and IBD educational modules were delivered every two months. This study was REB approved. We compared IBDQ, HBI, PUCAI, TRAQ, CACHE, CCK scores between groups. Paired Students t-test or the Wilcoxon ranksum test were used to assess for statistically significance (p-value of

BACKGROUND: Graduating medical school classes in Canada are now 50% or more female. The number of staff gastroenterologists in Canada has been on the rise in the last 20 years but female representation has stayed disproportionately low (30%). AIMS: To determine proportionate female representation in gastroenterology (GI) at residency, attending and leadership levels. METHODS: The Canadian Resident Matching Service (CaRMS) was used to obtain data for residency program applicants and matched trainees by gender from 2014–2018. General internal medicine (GIM), general surgery (GS) were analyzed for the PGY1 match. GI and cardiology were analyzed for the PGY4 match. An internet search was conducted for national and provincial gastroenterology associations to determine presidential history by gender (run date July 31, 2018). Similar searches for university affiliated GI training programs directors and academic university GI division heads by gender were conducted. RESULTS: PGY1 match 2014–2018: In GIM, the average number of annual applicants was 1789 (49.4% female). The average number of matched applicants was 487 (49.5% female). In GS, the average number of annual applicants was 357 (41% female). The average number of matched applicants was 90 (54.4% female). PGY4 match 2014–2018): In GI, the average number of applicants annually was 46 (37% female). The average number of matched applicants was 34, (35.3% female). In cardiology, the average number of annual applicants was 76 (29% female). The average number of matched applicants was 54 (27.8% female). Only one major national GI organization was identified, the Canadian Association of Gastroenterology (CAG). Three provincial organizations were identified (Ontario Association of Gastroenterology (OAG), Alberta Society of Gastroenterology (ASG) and Association of Gastroenterologists of Quebec (AGQ)). A review of complete historical data on past presidents by gender revealed the following: In CAG’s 60-year history, only 2/47 (4%) female presidents have ever been elected. In OAG’s 22-year history, no (0/9) female presidents have ever been elected. In AGQ’s 52-year history, 1/14 (7%) of presidents have been female. In ASG’s 8-year history, 1/4 (25%) of presidents have been female. Only 2018 data was available for academic leadership positions. At the time of the search, university division heads across Canada were 0% female (0/15). University GI training program directors across Canada in 2018 were 27% female (4/15). CONCLUSIONS: Despite gender equivalency in medical school and GIM, women are under-represented in GI (similar to other procedure sub-specialties such as cardiology). They are also under-represented in major GI leadership roles, demonstrating a need for targeted intervention. FUNDING AGENCIES: None

Elderly patients may be at increased risk for poor outcomes after surgery for inflammatory bowel disease (IBD). We investigated postoperative mortality and the incidence of complications in elderly patients with IBD.We identified patients who underwent major IBD-related abdominal surgery using the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files, from 2005 through 2012. We compared mortality and postoperative complications between elderly patients (≥65 years old) and nonelderly patients (65 years old).We identified 15,495 IBD patients who underwent surgery; of these, 1707 (11%) were elderly. Postoperative 30-day mortality was higher among elderly patients with Crohn's disease (CD) (4.2% vs 0.3% in nonelderly patients; P.001) or ulcerative colitis (UC) (6.1% vs 0.7%; P .001). After accounting for potential confounders, the adjusted odds ratio (aOR) of postoperative mortality in patients with CD was 11.67 (95% confidence interval [CI], 5.99-22.74), and in patients with UC was 4.39 (95% CI, 2.49-7.72). Postoperative complications were more common among elderly patients with CD (28.0% vs 19.4% in nonelderly patients; P.001) or UC (39.3% vs 23.6% in elderly patients; P.001). The aOR for any postoperative complication (excluding death) was 1.40 (95% CI, 1.16-1.69) in patients with CD and 1.74 for patients with UC (95% CI, 1.49-2.05). Elderly patients with UC were at increased risk for infectious complications, compared with nonelderly patients (aOR, 1.52; 95% CI, 1.27-1.82). The risk of postoperative venous thromboembolism was higher in elderly patients with CD (aOR, 1.68; 95% CI, 1.04-2.73). A higher proportion of elderly patients was still in the hospital more than 30 days after surgery (5.0% vs 1.8% for nonelderly patients; P.001).Elderly patients with IBD have substantially higher postoperative mortality and more complications than nonelderly patients with IBD. These increased risks should be considered when comparing risks of surgical vs medical therapy in this population.

Pediatric-to-adult transition in chronic disease care is often poorly managed. While there is growing interest in this field, existing reviews of transition models, which are critical in informing the development of best practices and evaluation metrics in transitional care, do not explore the critical design features of models that best improve health outcomes. This systematic review compares existing such models and the design features that positively impact clinical outcomes. Five databases were searched (Medline, CINAHL, EMBASE, PubMed, CENTRAL) until 2018. English-language evaluations (with defined clinical outcomes) of existing models for patients aged 13–28 with a pediatric-onset chronic disease were pulled. Cochrane tools were used for data extraction and risk-of-bias assessment. Twenty-nine studies showed improvements in outcomes for 10 pediatric-onset chronic diseases. A narrative synthesis of findings revealed two broad model types: transition clinics involving single or multiple appointments and/or multidisciplinary team, and transition program facilitators. Both model types included examples of remote (online or telephone) care. Most studies focused on a standardized multidisciplinary transition process that emphasized care coordination. All types resulted in improvements in access to medical care, reduced acute and chronic complications, and increased rates of follow-up. Commonly used strategies in successful programs were patient/family education, transition clinics jointly staffed by pediatric/adult physicians, or clinics dedicated to young adults within adult services. Despite the importance of effective transitional care, there are no commonly agreed upon quality metrics in transition care. Standardized evaluation metrics to compare models across disease types are needed.

Background The number of Canadian gastroenterologists has been on the rise in the last 20 years but female representation has stayed disproportionately low (30%). Gastroenterology has remained a male dominated subspecialty despite research showing as early as 1990’s that systemic gender-based barriers exist. Aims To determine whether GI career profiles differ between male and female gastroenterologists and understand barriers to career advancement related to gender in order to help shape future interventions to counteract these issues. Methods A 51-question survey was disseminated to gastroenterologists practicing in Canada. Using provincial College of Physicians and Surgeons websites, an electronic survey was sent to GIs with email addresses and a paper copy to those with fax numbers. The Canadian Association of Gastroenterology sent our survey link in their September 2019 membership email. The survey included questions pertaining to personal, professional, financial and practice characteristics of participants. Data was analyzed using SAS statistical program, and descriptive analysis with 95% confidence intervals was used to compare proportions of men and women. Nonparametric tests were used for continuous data. Qualitative thematic analysis was applied for short answer responses. Results Total 98 responses received (14.7% response rate) with 35% female respondents. Majority had adult, urban practices (86%) but males reported significantly more endoscopy time (42% v. 30%) vs. females who spent more time on research (23% v. 10%). Men were more likely to be married and have children than females. Women were more likely to not only have to choose between their marriage and their career, but more chose marriage compared to men specifically taking time off for maternity or childcare needs. Men were more likely to leave childcare predominantly to their spouse whereas women were more likely to share responsibility of childcare with spouse and hired help. Even after adjusting for age, males earned a significantly higher income than females (>$100,000 difference). 40% of men reported a salary over $600,000, compared to only 4% of women. Several gender-based biases were cited by females during their staff GI career: receiving less recognition for their work, challenging relationships with senior colleagues and support staff, inferior promotion opportunity, more difficulty publishing research and having their competency challenged by peers. Conclusions This survey shows that there are still many differences in the Canadian GI career pathway experience based on gender. Female GIs are disproportionately negatively affected in their clinical and academic practices, renumeration and work-life balance. Understanding these disparities is the first step towards remedying gender inequality in GI workplace culture. Funding Agencies None

Objectives To evaluate the impact of the transfer from pediatric to adult care on health services use for adolescents with inflammatory bowel disease (IBD). Study design A population-based retrospective cohort study identified all children diagnosed with IBD from 1994 to 2008 and treated by pediatric gastroenterologists in Ontario, Canada, using health administrative data. Self-controlled case series analyses compared health service use in the 2 years before and 2 years after transfer with adult gastroenterologists, with a 6-month washout period at transfer. Outcomes evaluated included IBD-specific and IBD-related hospitalizations, emergency department use, outpatient visits, and laboratory use. The relative incidence (RI) in the post-transfer period was compared with pretransfer periods using Poisson regression analysis controlling for transfer starting age. Analyses were stratified by IBD type: Crohn's disease (CD) and ulcerative colitis (UC). Results There were 536 patients included in the study (388 CD, 148 UC). Emergency department use rate was higher after transfer for both CD (RI, 2.12; 95% CI, 1.53-2.93) and UC (RI, 2.34; 95% CI, 1.09-5.03), as were outpatient visits (CD: RI, 1.56; 95% CI, 1.42-1.72; UC: RI, 1.48; 95% CI, 1.24-1.76), and laboratory investigations (CD: RI, 1.43; 95% CI, 1.26-1.63; UC: 1.38; 95% CI, 1.13-1.68). There was no change in the hospitalization rate (CD: RI, 0.70; 95% CI, 0.42-1.18; UC: RI, 2.41; 95% CI, 0.62-9.40). Conclusions Health services use in Canada increases after transfer from pediatric to adult care for outpatient visits, emergency department use, and laboratory tests, but not hospitalizations. This study has implications for the planning and budgeting of care for adolescents transitioning to adult care.

BACKGROUND: Compliance is critical to the foundation of high quality IBD care. However, many studies rely on self-reported compliance metrics without corroboration. Pediatric to adult transition of care in IBD is a challenging period during which compliance is compromised. AIMS: To determine the impact of transition age (18–25) on non-compliance. METHODS: A retrospective cohort study was performed using data from a sample of gastroenterology patients (n=245) recorded in the electronic medical record between January 1, 2015 and June 30, 2017. Data was extracted between July 1st, 2017 and August 31st, 2017. Data on patient sex, age at last encounter (separated into 4 categories), age of diagnosis, residential address, disease type, comorbidities, medications, substance use, family history of IBD and markers of non-compliance were collected. Single variable logistic regression was used to determine the impact of age category on compliance. Multivariable logistic regression was used to investigate the likelihood of non-compliance depending on age category while adjusting for baseline characteristics. RESULTS: 245 patients were included and separated (18–25 (n=27), 26–45 (n=109), 46–65 (n=84), >65 (n=25)). 49% had Crohn’s Disease (CD), the mean age at last interaction was 43 +/-15, mean age of IBD diagnosis 31 +/-14, 54% were on biologic therapy, 53% had another non-IBD related comorbidity, 50% reported some form of substance use, 33% had a family history of IBD. The 18–25 group was more likely to not show up for a follow-up visit (33% vs 23% vs 11% vs 12%, p=0.002), not show up to a GP appointment (30% vs 29% vs 25% vs 28%, p=0.0081), arrive late to a GI appointment (56% vs 53% vs 45% vs 48%, p=0.001). They were less likely to cancel a GI appointment in advance (56% vs 66% vs 58% vs 56% p=0.002). Patients aged 18–25 were less likely to volunteer self-discontinuation or inconsistent use of medications, as documented in the physician notes (19% vs 42% vs 43% vs 44%, (p=0.002) and were more likely to have no documented non-compliance in the physician notes (59% vs 41% vs 34% vs 44%, p=0.0002). When focusing on no-show, late arrivals or cancelled visits, a multivariable logistic regression model revealed that all other age categories demonstrated less non-compliance compared to the 18–25 age group (26–45 years OR -1.50 [-2.24,-0.75], 46–65 years OR -2.57 [-3.43,-1.72], >65 years OR -2.62 [-3.61,-1.63]. However, when focusing only on physician documented non-compliance, multivariable logistic regression model did not reveal age as a significant predictor. CONCLUSIONS: Transition aged patients 18–25 show more objective forms of non-compliance but are less likely to volunteer their non-compliance in physician interactions, making self-reported compliance metrics unreliable. FUNDING AGENCIES: Department of Medicine, Women’s College Hospital

BACKGROUND: In Canada, the transition from pediatric to adult care occurs between the ages of 12 and 25, with transfer of care occurring at 18. While there is limited literature pertaining to IBD-specific pediatric-to-adult care transition, the needs of pediatric IBD patients are not dissimilar to the needs of pediatric patients with other chronic diseases transitioning to adult care, and so learnings may be translatable across disease types. AIMS: The objective of this systematic review was to evaluate pediatric-to-adult transitional models of care for all pediatric onset chronic diseases. METHODS: We searched MEDLINE, EMBASE, PubMed, CINAHL, Cochrane and CENTRAL for prospective cohort studies published up to June 28, 2018. Title and abstract screening was performed by a single revewer. Articles meeting eligibility criteria then underwent full-text screening by two independent reviewers. Disagreements were adjudicated by the supervising author. RESULTS: The initial search yielded 10,499 articles. After title and abstract screening, 305 articles were obtained. 31 citations were included in this review after deduplication and full-text review, These studies evaluated transitional models of care in 11 different pediatric onset chronic diseases (type 1 diabetes (n=9), juvenile idiopathic arthritis (n=4), cystic fibrosis (n=3), inflammatory bowel disease (n=3), spina bifida (n=2), congenital heart disease (n=2), chronic kidney disease (n=1), congenital adrenal hyperplasia (n=1), sickle cell disease (n=1), HIV (n=1), esophageal atresia (n=1), mix of complex chronic disease (n=1), blood disorders (n=2). Models of care studied included transition clinics involving single or multiple appointments and/or multidisciplinary teams; transition program facilitators (registered nurse or social worker); and remote transition programs, including self-management online education modules and telephone coaching. Metrics for evaluation ranged from disease-specific outcomes (e.g. glycemic control) to self-reported outcomes (transition readiness, quality of life, compliance, etc.) and compliance with care post-transfer (e.g. proportion of patients who completed first appointment with adult specialist). Despite the heterogeneity in disease types, most studies focused on the implementation of a standardized multidisciplinary transition process that emphasized care coordination. However, there was little consensus on the metrics for evaluation, making the comparison of different models challenging. CONCLUSIONS: Models of transition from pediatric to adult care focusing on care coordination through a multi-disciplinary approach have been shown to improve patient outcomes. Future efforts are needed to establish standardized evaluation metrics improving ease of discrimination between models and potential comparison across disease types. FUNDING AGENCIES: Department of Medicine, Women’s College Hospital

AIMS: The authors present an association between bowel preparation induced dehydration and acute cataract worsening. METHODS: This association was identified through a clinical case encountered during routine practice. RESULTS: A 63 year old man was seen for average risk colorectal cancer (CRC) screening. His past medical history was significant for coronary artery disease, dyslipidemia, hypertension, type 2 diabetes, benign prostatic hyperplasia, degenerative disc disease, right cataract surgery. Medications included ASA, atorvastatin, gliclazide, janumet, ramipril, indapamide, ezetimibe, insulin glargine. He had no allergies to medications. He was married, had 2 adult children, was born in Sri Lanka, worked as an auditor and was functionally independent. He was an ex-smoker, and drank 2 alcoholic beverages per night. Family history was unremarkable for gastrointestinal conditions.Colonoscopy was performed for routine CRC screening. Bowel preparation consisted of 4 liters of Go-Lytely the day prior to the procedure. His procedure was conducted as an out-patient within a tertiary care teaching hospital. The colonoscopy was uncomplicated and the examination was normal. He was discharged home and resumed his normal diet and normal medications. Shortly after the colonoscopy, the patient experienced a rapid loss of visual acuity in the left eye, which worsened over the following 48 hours. He presented to the emergency department for evaluation. A CT head was performed showing only scattered white matter changes secondary to mild microangiopathic changes, mild right maxillary fluid but no obvious cerebrovascular accident (CVA). He was referred to ophthalmology who confirmed the acuity loss (the patient was only able to count fingers) and performed fundoscopy after pupillary dilation identifying a dense white cataract. There was low clinical suspicion for giant cell arteritis, no relative afferent pupillary defect to suggest central retinal artery occlusion or central retinal vein occlusion (although fundoscopy was limited due to the cataract itself). The patient was told that that acute worsening of cataracts can occur due to dehydrationand this was likely induced by the bowel preparation. He was also seen by the general internal medicine service who felt the likelihood of CVA, given the absence of focal neurological deficits (aside from the visual acuity loss), was low. The patient underwent successful cataract excision and lens replacement 6 weeks later, with a return to normal left eye vision. CONCLUSIONS: While acute dehydration is a known risk factor for worsening of cataracts, a review of the literature did not demonstrate any reported association between colonoscopy bowel preparation, dehydration and acute cataract worsening. The product monograph for GoLytely does not list this as a potential adverse effect. This is the first case report documenting such an association. FUNDING AGENCIES: None

BACKGROUND: Dyspepsia is a common condition associated with gastrointestinal (GI) disease. Prokinetics are the treatment of choice for functional dyspepsia (FD). However, the role of prokinetics in FD treatment is still controversial. OBJECTIVES: We conducted a systematic review and meta‐analysis of randomised control trials (RCTs) examining the efficacy of prokinetics in the treatment of FD. The primary outcome was overall absence of or improvement of symptoms and symptom scores at the end of treatment. We also evaluated quality of life (QoL) and adverse events as secondary outcomes. SEARCH METHODS: We performed a systematic search of MEDLINE, Embase, the Cochrane Library, and CINAHL, from 1946 until September 2017. RevMan 5.3 was used to calculate pooled risk ratios (RR) of symptoms persisting or without improved QoL or adverse events, mean difference (MD) or standardised mean difference (SMD) of post‐treatment symptoms scores, changes of symptom scores, and QoL, when appropriate with 95% confidence intervals (CI), using a random‐effects model. Quality of evidence was evaluated using GRADE methodology. SELECTION CRITERIA: We included studies that were parallel group RCTs comparing one prokinetic with either placebo or another prokinetic of the same or different class for the treatment of FD. Studies involved adults who presented with dyspepsia symptoms and who had negative or insignificant findings on endoscopy as well as no other organic and metabolic disorders. Studies only including participants with primarily reflux or heartburn symptoms were excluded. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study eligibility, study quality and performed data extraction. MAIN RESULTS: From an initial 1388 citations, we identified 43 studies in 40 papers. Of those, 29 studies with 10,044 participants compared six prokinetics with placebo for the outcome of absence of symptoms or symptom improvement. There was a statistically significant effect of prokinetic treatment in reducing global symptoms of FD (RR of remaining dyspeptic = 0.81, 95% CI 0.74 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) =7, very low‐quality evidence) with considerable heterogeneity; I(2) = 91% (P < 0.00001). After removing cisapride from the analysis, the effect of prokinetics in global symptom improvement still persisted, compared to placebo (RR 0.87, 95% CI 0.80 to 0.94), but was still based on very low‐quality evidence. The result showed persistence of significant improvement in subgroups of studies at unclear or at low risk of bias (RR 0.86, 95% CI 0.80‐0.92), and in subgroups by molecules of cisapride (RR 0.71, 95% CI 0.54 to 0.93; NNTB = 4), acotiamide (RR 0.94, 95% CI 0.91 to 0.98; NNTB = 20) and tegaserod(RR 0.89, 95% CI 0.82 to 0.96; NNTB = 14). Ten studies compared different types of prokinetics with each other and the most commonly used comparator was domperidone, 10 mg three times a day (eight of the 10 studies). There was a significantly better post‐treatment symptom score in other prokinetics, compared to domperidone (SMD ‐0.19, 95% CI ‐0.35 to ‐0.03, very low‐quality evidence), but no difference in reducing global symptom (RR 0.94, 95% CI 0.83 to 1.07), and mean difference symptom scores (SMD ‐0.13, 95% CI ‐0.31 to 0.05). We found five studies that assessed quality of life, but there was no benefit in improving quality of life with prokinetic treatment (SMD 0.11, 95% CI ‐0.10 to 0.33; participants = 1774). The adverse events in individual prokinetics was not different from placebo (RR 1.09, 95% CI 0.95 to 1.25; participants = 3811; studies = 17). However, when we looked at the adverse effects by each prokinetic, there were overall greater adverse effects in the active treatment group with cisapride (RR 1.31, 95% CI 1.03 to 1.65; P = 0.03). The most common side effects were diarrhoea, abdominal discomfort and nausea. The funnel plot was asymmetric (Egger's test, P = 0.02) implying reporting bias or other small‐study effects may be, in part, driving the benefit of prokinetics compared to placebo in this meta‐analysis. The GRADE assessment of the quality of the evidence in each outcome are mostly low or very low due to concerns around risk of bias in study design, unexplained heterogeneity and possible publication bias. AUTHORS' CONCLUSIONS: Due to low, or very low, quality of evidence, we are unable to say whether prokinetics are effective for the treatment of functional dyspepsia . We are uncertain which of the individual prokinetic drugs is the most effective as well as whether prokinetics can improve quality of life. Apart from cisapride, prokinetics are well‐tolerated. Good quality RCTs are needed to verify the efficacy of prokinetics.

Background The transition from pediatric to adult care for inflammatory bowel disease (IBD) is poorly understood. Aims To characterize this transfer of care, health resource utilization was assessed. Methods Patients transferred between 1999 and 2008 were studied. Utilization of health resources one year before transfer and one year after transfer was compared. Resource units assessed included: i) emergency department (ED) visits; ii) hospitalizations; iii) clinic visits; iv) surgical procedures; and v) endoscopies. Secondary outcomes included: i) documentation of patient non-compliance; ii) reason(s) for ED visit; iii) diagnoses most responsible for hospital admission; iv) medications; v) indications for surgery; vi) endoscopic findings; vii) and disease activity. Results 95 subjects were identified (48 female), of whom 69 had Crohn's disease (CD) and 26 had ulcerative colitis (UC). The average age of diagnosis was 12.9 years. Over their adult care interval, subjects had fewer clinic visits (2.56 versus 3.05 (p = 0.01)) and more documented non-compliance (43% versus 29% (p = 0.01)). No differences in ED visits (0.15 versus 0.18 (p = 0.71)), hospitalizations (0.13 versus 0.13 (p = 0.23)), surgical intervention (0.03 versus 0.05 (p = 0.53)) or endoscopies (0.37 versus 0.25 (p = 0.11)) were observed. IBD was active 66.7% of endoscopies under pediatric care versus only 23.8% under adult care (p = 0.003). The average activity of CD was also higher during the last year of pediatric care. Conclusions Understanding the transition process can help to develop strategies needed to support patients and their families.

Background: Medical student rotations in community practice settings are increasingly common within pediatric clerkship curricula yet little evidence exists to support the quality of the educational exposure. Purpose: To assess the impact of clerkship site (community setting vs. exposure to an Academic Health Sciences Center) on the following educational outcomes: 1. Clinical Performance; 2. Examination Performance; 3. Written Assignment Performance; and 4. Successful Matching to a Canadian Pediatric Residency Program. Methods: 340 medical students from the graduating classes of 2007 and 2008 at the University of Toronto, Canada were studied. Rotation performance (clinical assessment, examination mark, and written assignment mark) and acceptance into a Canadian pediatric residency program were assessed in relation to clerkship rotation site. These outcomes were assessed while controlling for the following potential confounders: 1) Pre-clerkship career preference and 2) Pre-rotation site preference as expressed by each medical student. Results: 172 medical students completed rotations that included exposure to an academic health sciences center, while 168 medical students had exclusive exposure to the community setting. Students who completed exclusively community-based pediatric rotations received slightly higher clinical evaluations (p=0.006), but not exam marks (p=0.812) nor written assignment marks (p=0.086). Students who had expressed an interest in paediatrics as a career prior to beginning their clerkship performed better during paediatric clerkship regardless of site (p= .0003) and were more likely to choose a clerkship setting that included exposure to an Academic Health Sciences Center (p=.052). Clerkship setting was not found to impact on successful matching to a Canadian pediatric residency program (p=0.171). Discussion: These results help support the decision of curriculum committees to incorporate the use of community practice settings and inform students and faculty as to the validity of distributed medical education within the field of pediatric medical education.

Agitation, restlessness, and aggression are frequent neurobehavioural sequelae in the early stages of recovery from traumatic brain injury (TBI). These behavioural symptoms disrupt patient care and impede rehabilitation efforts. We review the current literature (1985 onwards) examining the pharmacological management of post-TBI agitation in both acute and post-acute conditions. This article will assess the evidence for the use of selected alkylphenols, benzodiazepines, estrogens, antiandrogens, neuroleptics/antipsychotics, antidepressants, anti-Parkinsonian agents, antipsychotics, anticonvulsants, lithium carbonate, buspirone, beta-blockers, and psychostimulants in agitated TBI survivors. Review of the literature suggests that there is limited evidence to accurately guide clinicians in the management of this patient population.

BACKGROUND: Pediatric onset inflammatory bowel disease (IBD) is a high-risk phenotype that requires transfer to an adult gastroenterologist at age 18. Under-developed emotional and cognitive skills in the transition-aged population can affect adherence rates, especially during periods of remission. A recent study evaluating patients with pediatric onset IBD requiring transfer of care to an adult gastroenterologist identified a relatively large lost to adult gastroenterology (GI) follow-up (LTF) group. AIMS: The purpose of this study was to characterize those patients with pediatric onset IBD who are LTF in the first five years of adult care and identify risk factors for their non-compliance. METHODS: This was a population-based retrospective cohort study using health care administrative data from Ontario, Canada. A cohort of patients with pediatric onset IBD was identified and health resource utilization during a 5-year post-transfer period was analyzed. Patients LTF were compared to those patients actively followed by a gastroenterologist in terms of health resource utilization. The primary outcome of this study comprised Emergency Department (ED) utilization. Secondary outcomes included hospitalizations, surgeries, ambulatory visits, endoscopic and radiological investigations. RESULTS: 2043 patients with pediatric onset IBD were identified. 1696 were followed by an adult GI in the post-transfer period. 306 patients were never seen by an adult GI. 41 patients were never seen by any adult health care provider in the post-transfer period. Patients in the loss to follow-up group were significantly younger, more likely to be male, have ulcerative colitis (UC) and reside in an urban environment. Overall, there were no significant differences found in ED use, total ambulatory care visits (aside from the expected drop amongst GI follow-up), hospitalizations, endoscopic procedures or radiological procedures between exposure groups. Multivariable negative binomial logistic regression revealed that the LTF group was less likely to be seen in the ED and admitted to hospital. CONCLUSIONS: A relatively large LTF group with pediatric onset IBD was characterized in this study. 5-year follow-up reveals no evidence of increased health resource utilization. More work is needed to further define this population, identify barriers to follow-up and whether outcomes such as quality of life, productivity etc. are affected by their non-compliance. FUNDING AGENCIES: CCC

Background & Aims Patients with inflammatory bowel diseases (IBD) are hospitalized frequently. We sought to identify factors associated with risk for IBD-related readmission to the hospital. Methods We performed a retrospective analysis of 26,403 patients hospitalized for IBD from 2004 through 2010 using the Canadian Institute for Health Information Discharge Abstract databases. We examined whether demographic factors, comorbidity, and hospital IBD admission volume were associated with readmission rates, length of stay, bowel resection, and mortality. Results Young, middle-age, and elderly adults were more than twice as likely to undergo surgery during hospitalization than pediatric patients. Elderly patients with IBD had a nearly 40-fold greater in-hospital mortality than pediatric patients (odds ratio, 37.4; 95% confidence interval [CI], 5.17–270.0). In-hospital mortality was lower at hospitals with the highest volume of IBD patients than at those with low volume (odds ratio, 0.20; 95% CI, 0.05–0.97). Rates of readmission were lower for patients with ulcerative colitis than Crohn's disease (hazard ratio, 0.79; 95% CI, 0.72–0.86). The hazard ratios for readmission among young, middle-age, and elderly adults, compared with those of pediatric patients, were 0.79 (95% CI, 0.69–0.90), 0.57 (95% CI, 0.49–0.65), and 0.44 (95% CI, 0.37–0.53), respectively. Rates of readmission were lower at the highest-volume, compared with the lowest-volume, hospitals (hazard ratio, 0.78; 95% CI, 0.64–0.96). Conclusions Based on a retrospective database analysis, pediatric patients with IBD are at greater risk for readmission to the hospital than older patients. Efforts should be made to determine whether factors that contribute to this risk are preventable. The lower risk of readmission at the highest-volume hospitals may reflect optimal management during hospitalization or follow-up evaluation.

Background: Inflammatory bowel disease (IBD) is a chronic inflammatory condition associated with multiple disease-related and treatment-related complications. Population-based, longitudinal data regarding trends of IBD-related complications and rates of bowel resection are lacking in the United States. We aimed to study these temporal trends using a large nationally representative database. Methods: The National Inpatient Sample (NIS) databases (2002-2011), a subset of the Healthcare Cost and Utilization Project by Agency for Healthcare Research and Quality, were utilized for this study. The NIS is the largest all-payer inpatient care database, encompassing approximately 5-8 million hospitalizations from almost 1000 hospitals in the USA. Hospitalizations with diagnosis of IBD were captured by ICD-9 codes (Crohn's disease (CD): 555; Ulcerative colitis (UC): 556). IBD-related complications were identified using various ICD-9 diagnosis codes. Bowel resection was identified using the ICD-9 procedure codes 45.6-45.9. Analyses were performed separately for bowel resection rates for overall IBD, CD and UC. Linear regression was used to assess trends in various complications and resection rates. Analysis was performed using SAS 9.3. Results: Our study sample included 519,459 hospitalizations-related to IBD. The mean age of hospitalizations was 50 years, and the majority of patients were Caucasian (80%) and female (58%). The rate of Clostridium difficile infection increased significantly from 2002 (2.0%) to 2011 (4.04%) (slope 0.222, p

The use of typical neuroleptics has always been the mainstay of treatment for delirium following traumatic brain injury (TBI). Given the recent application of atypical neuroleptics to various psychiatric conditions formerly treated with typical neuroleptics, one questions whether this new class of drugs is superior to its predecessor in treating delirium post-TBI. We present a case of one patient with TBI-induced delirium where in fact the use of the typical mid-potency neuroleptic, loxapine, appeared to have a better clinical effect over the atypical neuroleptic, olanzapine.

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