Contrast Enhanced CT Versus MRI for Accurate Diagnosis of Wall-thickening Type Gallbladder Cancer

Introduction

Diagnosis of wall-thickening type gallbladder cancer (GBC) is challenging. Computed tomography (CT) and magnetic resonance imaging (MRI) are commonly utilized to evaluate gallbladder wall thickening. However, there is a lack of data comparing the performance of CT and MRI for the detection of wall-thickening type GBC.

Aim

We aim to compare the diagnostic accuracy of CT and MRI in diagnosis of wall-thickening type GBC.

Materials and methods

This prospective study comprised consecutive patients suspected of wall-thickening type GBC who underwent preoperative contrast-enhanced CT and MRI. The final diagnosis was based on the histopathology of the resected gallbladder lesion. Two radiologists independently reviewed the characteristics of gallbladder wall thickening at CT and MRI. The association of CT and MRI findings with histological diagnosis and the interobserver agreement of CT and MRI findings were assessed.

Results

Thirty-three patients (malignancy, 13 and benign, 20) were included. None of the CT findings were significantly associated with GBC. However, at MRI, heterogeneous enhancement, indistinct interface with the liver, and diffusion restriction were significantly associated with malignancy (P = 0.006, <0.001, and 0.005, respectively), and intramural cysts were significantly associated with benign lesions (P = 0.012). For all MRI findings, the interobserver agreement was substantial to perfect (kappa = 0.697-1.000). At CT, the interobserver agreement was substantial to perfect (k = 0.631-1.000).

Conclusion

These findings suggest that MRI may be preferred over CT in patients with suspected wall thickening type GBC. However, larger multicenter studies must confirm our findings.

Incidentally Detected Gallbladder Carcinoma: Can F-18 FDG PET/CT Aid in Staging and Prognostication?

Purpose

Incidental gallbladder carcinoma (IGBC) is diagnosed in post-cholecystectomy specimens for benign indications, where the role of 2-fluro-2-deoxyglucose positron emission tomography/computed tomography(FDG-PET/CT) is not clearly defined. The present study aimed to assess the benefits of staging and prognosticating with FDG-PET/CT in IGBC.

Materials and Methods

A retrospective observational study from a tertiary-care center from January 2010 to July 2020 was performed. The demographic, clinical, histopathological, and treatment-related histories were collected. FDG-PET/CT-image findings were compared with survival outcomes through telephonic follow-up. The chi-square test was used for comparing frequencies. The univariate and multivariate survival estimates were analyzed using the Kaplan-Meier analysis and the Cox-proportional hazard model, respectively. Log-rank test was used to compare the Kaplan-Meier curves.

Results

The study included 280 postcholecystectomy participants (mean age: 52 ± 11 years; women: 227) of whom 52.1% had open surgery(146/280). Residual disease in the gallbladder fossa (54.8% vs. 36.6%, p = 0.002) and liver infiltration (32.9% vs. 22.4%, p = 0.05) were seen more frequently in open surgery compared to laparoscopic surgery, while anterior abdominal wall deposits were more common in laparoscopy(35.1% vs. 24%,p = 0.041). FDG-PET/CT changed the management in 10% (n = 28) of patients compared to contrast-enhanced CT. The median survival was 14 months (95%CI-10.3-17.7). A higher stage of the disease on the FDG-PET/CT (loco-regional disease-HR 4.86, p = 0.006; metastatic disease-HR 7.53, p < 0.001) and the presence of liver infiltration (HR-1.92, p = 0.003) were independent predictors of poor survival outcomes.

Conclusion

FDG-PET/CT detects residual and metastatic disease in patients with IGBC, enabling the institution of appropriate management and acting as a tool for prognostication of survival.

Outcomes of Self-expandable Metal Stents in Patients With Unresectable Gallbladder Cancer Undergoing Percutaneous Biliary Drainage

Background

Biliary obstruction in gallbladder cancer (GBC) is associated with worse prognosis and needs drainage. In patients with biliary confluence involvement, percutaneous biliary drainage (PBD) is preferred over endoscopic drainage. However, PBD catheters are associated with higher complications compared to endoscopic drainage. PBD with self-expandable metal stents (SEMS) is desirable for palliation. However, the data in patients with unresectable GBC is lacking.

Materials and methods

This retrospective study comprised consecutive patients with proven GBC who underwent PBD-SEMS insertion between January 2021 and December 2022. Technical success, post-procedural complications, clinical success, duration of stent patency, and biliary reinterventions were recorded. Clinical follow-up data was analysed at 30 days and 180 days of SEMS insertion and mortality was recorded.

Results

Of the 416 patients with unresectable GBC, who underwent PBD, 28 (median age, 50 years; 16 females) with PBD-SEMS insertion were included. All SEMS placement procedures were technically successful. There were no immediate/early post-procedural complications/deaths. The procedures were clinically successful in 63.6% of the patients with hyperbilirubinemia (n = 11). Biliary re-interventions were done in 6 (21.4%). The survival rate was 89.3 % (25/28) at 30 days and 50% at 180 days. The median follow-up duration was 80 days (range, 8-438 days).

Conclusion

PBD-SEMS has moderate clinical success and 6-months patency in almost half of the patients with metastatic GBC and must be considered for palliation.

Impact of comorbidities in severely injured patients with blunt chest injury: A population-based retrospective cohort study

INTRODUCTION

Blunt chest injuries result in up to 10 % of major trauma admissions. Comorbidities can complicate recovery and increase the mortality rate in this patient cohort. A better understanding of the association between comorbidities and patient outcomes will facilitate enhanced models of care for particularly vulnerable groups of patients, such as older adults.

AIMS

i) compare the characteristics of severely injured patients with blunt chest injury with and without comorbidities and ii) examine the relationship between comorbidities and key patient outcomes: prolonged length of stay, re-admission within 28 days, and mortality within 30 days in a cohort of patients with blunt chest injury admitted after severe trauma.

METHODS

A retrospective cohort study using linked data from the NSW Trauma Registry and NSW mortality and hospitalisation records between 1st of January 2012 and 31st of December 2019.

RESULTS

After adjusting for potential confounding factors, patients with severe injuries, chest injuries, and comorbidities were found to have a 34 % increased likelihood of having a prolonged length of stay (OR = 1.34, 95 %I = 1.17-1.53) compared to patients with no comorbidities. There was no difference in 30-day mortality for patients with a severe chest injury who did or did not have comorbidities (OR = 1.05, 95 %CI = 0.80-1.39). No significant association was found between comorbidities and re-admission within 28 days.

CONCLUSION

Severely injured patients with blunt chest injury and comorbidities are at risk of prolonged length of stay.

Proposal for a new morphological "combined type" of gallbladder cancer: description of radiopathological characteristics and comparison with other morphological types

OBJECTIVE

To describe the radiopathological characteristics of a new morphological "combined type" of gallbladder cancer (GBC) and compare it with the mass replacing gallbladder and thickening types of GBC.

MATERIALS AND METHODS

The imaging and pathological details of consecutive patients with GBC between August 2020 and December 2022 were retrospectively reviewed. Two radiologists reviewed computed tomography/magnetic resonance imaging in consensus for the morphological type of GBC. The radiologists classified GBC as mass replacing gallbladder, wall thickening, and combined type. The combined type was defined as a mass arising from the thickened wall of an adequately distended gallbladder that extended exophytically into the adjacent liver parenchyma. The presence of calculi, site, and size of lesion, biliary/portal vein involvement, liver, lymph node, and omental metastases was compared among the various types. The pathological characteristics were also compared.

RESULTS

Of the 481 patients (median age 55 years, 63.2% females) included in the study, mass replacing gallbladder, wall thickening, and combined-type GBC were seen in 42.8% (206/481), 40.5% (195/481), and 16.6% (80/481) of patients, respectively. In the combined type of GBC, biliary/portal vein involvement was seen in 63.7% (51/80) and 7.5% (6/80) of patients. Liver, lymph node, and omental metastases were seen in 67.5% (54/80), 40% (32/80), and 41.2% (33/80) patients, respectively. Liver metastases were significantly more common in the combined type (p = 0.002). There were no significant differences in pathological characteristics among the various types.

CONCLUSION

Combined-type GBC is less common than the mass replacing gallbladder and thickening types and is associated with a higher risk of liver metastases.

Autoimmune disorders of the gastrointestinal tract: Review of radiological appearances

Autoimmune gastrointestinal (GI) disorders comprise a heterogeneous group of diseases with non-specific clinical manifestations. These are divided into primary and secondary. A high index of clinical suspicion complemented with endoscopic and radiological imaging may allow early diagnosis. Due to the relatively low incidence of autoimmune disorder, the imaging literature is sparse. In this review, we outline the pathogenesis, classification, and imaging appearances of autoimmune GI disorders.

Exploring Scientific Validation of Millets in Contemporary Healthcare: A Traditional Food Supplement

Millets, small-seeded grasses, are gaining interest for their nutrition and health benefits. This abstract provides a comprehensive overview of millets' pharmacological activities, highlighting their rich bioactive compounds. These compounds, including phenolic compounds, flavonoids, and dietary fibers, contribute to antioxidant effects, safeguarding against chronic diseases. Millets also possess anti-inflammatory properties, potentially alleviating conditions, like arthritis and asthma. They show anti-carcinogenic potential, possibly preventing various cancers' development through mechanisms, like apoptosis induction and inhibiting tumor growth. Moreover, millets offer hypolipidemic and hypoglycemic effects, beneficial for managing conditions, such as dyslipidemia and diabetes. Their high dietary fiber and resistant starch content regulate blood lipids and glucose, reducing the cardiovascular risk. Additionally, millets act as antimicrobials, inhibiting pathogens and serving as natural alternatives to synthetic antimicrobials. They exhibit immunomodulatory effects, enhancing immune function and response. Overall, millets' pharmacological properties, including antioxidant, antiinflammatory, anti-carcinogenic, hypolipidemic, hypoglycemic, antimicrobial, and immunomodulatory traits, position them as functional foods with varied health benefits. Further research can integrate millets into preventive and therapeutic approaches for diverse diseases.

Sarcopenia is common in ulcerative colitis and correlates with disease activity

Background/Aims

Association of sarcopenia with disease severity in ulcerative colitis (UC) is not clearly defined. We planned to estimate the prevalence of sarcopenia in patients with UC as per the revised definition and its relation with the disease severity.

Methods

A cross-sectional assessment of sarcopenia in patients with UC was performed. Disease activity was graded according to complete Mayo score. Hand grip strength was assessed with Jamar hand dynamometer, muscle mass using a dual energy X-ray absorptiometry scan, and physical performance with 4-m walk test. Sarcopenia was defined as a reduction of both muscle mass and strength. Severe sarcopenia was defined as reduced gait speed in presence of sarcopenia.

Results

Of 114 patients (62 males, mean age: 36.49±12.41 years), 32 (28%) were in remission, 46 (40.4%) had mild-moderate activity, and 36 (31.6%) had severe UC. Forty-three patients (37.7%) had probable sarcopenia, 25 (21.9%) had sarcopenia, and 14 (12.2%) had severe sarcopenia. Prevalence of sarcopenia was higher in active disease (2 in remission, 6 in active, and 17 in severe, P<0.001). Of 14 with severe sarcopenia, 13 had severe UC while 1 had moderate UC. On multivariate analysis, lower body mass index and higher Mayo score were associated with sarcopenia. Of 37 patients with acute severe colitis, 16 had sarcopenia. Requirement of second-line therapy was similar between patients with and without sarcopenia. On follow-up (median: 18 months), there was a non-significant higher rate of major adverse events in those with sarcopenia (47.4% vs. 33.8%, P=0.273).

Conclusions

Sarcopenia and severe sarcopenia in UC correlate with the disease activity.

Simultaneous Integrated Boost (SIB) Versus Sequential Boost in Anal Cancer Patients: A Single-Center Experience

PURPOSE

Concurrent chemoradiation is the standard of care for the treatment of anal cancer. Radiation can be delivered by sequential or simultaneous integrated boost (SIB) approach. The present study was conducted to compare the treatment outcomes and toxicity profile of patients with anal cancer treated with sequential boost and SIB approach.

METHODS

A single-institution retrospective analysis of patients with squamous cell carcinoma of the anal canal treated between 2019 and 2022 with radical chemoradiation was performed. The sequential boost schedule consisted of 45 Gy in 25 fractions (1.8 Gy daily) to the gross tumor, nodes, and elective nodal volume, followed by a 9 Gy in five fractions boost to the gross disease. Patients receiving SIB were treated as per RTOG 0529 protocol. In both the groups, patients were treated with volumetric modulated arc therapy (VMAT). The two groups were compared in terms of overall survival (OS), colostomy-free survival (CFS), relapse-free survival (RFS), and acute toxicity profile. p-values < 0.05 were considered statistically significant.

RESULTS

The patient and disease characteristics in both treatment arms were comparable. The only difference was a significantly longer overall treatment time of ≥ 50 days in the sequential arm (77.8% vs 43.8%, p = 0.04). The median follow-up was 18 months. The 2-year CFS was 80% in sequential vs 87.5% at 2 years for the SIB arm, 2-year OS 83.3% vs 58.6%, and 2-year RFS was 38.9% vs 41.7%, respectively. A total of 14 (77.8%) in sequential and 8 (50%) in the SIB arm had disease relapse. On univariate analysis, the involved pelvic lymph node significantly affected OS (HR 10.45, p = 0.03) while inguinal lymph node involvement adversely affected RFS (HR 6.16, p = 0.02). The most common acute toxicity was radiation-induced dermatitis, 15 (83.4%; 5 grade II, 10 grade III) in sequential vs 7 (43.8%; 3 each grade II and III) in the SIB group followed by hematological (61.1% vs 68.75%). However, the incidence of overall acute toxicities was significantly less in the SIB arm (p = 0.006).

CONCLUSION

Our study showed that concurrent chemoradiation with the SIB-VMAT approach is well tolerated in patients of anal carcinoma and resulted in lesser treatment interruptions and comparable outcomes as compared to the sequential approach. Our results warrant further evaluation in a prospective study.

Proteomic-miRNA Biomics Profile Reveals 2D Cultures of Human iPSC-Derived Neural Progenitor Cells More Sensitive than 3D Spheroid System Against the Experimental Exposure to Arsenic

The iPSC-derived 3D models are considered to be a connective link between 2D culture and in vivo studies. However, the sensitivity of such 3D models is yet to be established. We assessed the sensitivity of the hiPSC-derived 3D spheroids against 2D cultures of neural progenitor cells. The sub-toxic dose of Sodium Arsenite (SA) was used to investigate the alterations in miRNA-proteins in both systems. Though SA exposure induced significant alterations in the proteins in both 2D and 3D systems, these proteins were uncommon except for 20 proteins. The number and magnitude of altered proteins were higher in the 2D system compared to 3D. The association of dysregulated miRNAs with the target proteins showed their involvement primarily in mitochondrial bioenergetics, oxidative and ER stress, transcription and translation mechanism, cytostructure, etc., in both culture systems. Further, the impact of dysregulated miRNAs and associated proteins on these functions and ultrastructural changes was compared in both culture systems. The ultrastructural studies revealed a similar pattern of mitochondrial damage, while the cellular bioenergetics studies confirm a significantly higher energy failure in the 2D system than to 3D. Such a higher magnitude of changes could be correlated with a higher amount of internalization of SA in 2D cultures than in 3D spheroids. Our findings demonstrate that a 2D culture system seems better responsive than a 3D spheroid system against SA exposure.

ITPA polymorphisms do not predict additional risk beyond TPMT and NUDT15 for thiopurine-induced cytopenia in inflammatory bowel disease

INTRODUCTION AND AIM

Thiopurine-related leukopenia is associated with polymorphisms in the thiopurine methyltransferase (TPMT) and nucleoside diphosphate-linked moiety X type motif 15 (NUDT15) genes. However, those polymorphisms explain only a fraction of thiopurine-related leukopenia. Our aim was to study the role of an inosine triphosphate pyrophosphatase (ITPA) polymorphism in patients with inflammatory bowel disease (IBD) and thiopurine-related leukopenia that was unexplained by the TPMT and NUDT15 polymorphisms.

MATERIAL AND METHODS

We enrolled consecutive IBD patients on thiopurines (azathioprine or 6-mercaptopurine) from January 2019-March 2020, at a tertiary care center in North India. The presence of the ITPA (C.94C > A) polymorphism was evaluated in all patients, along with its association with thiopurine-related leukopenia.

RESULTS

Of the 33 patients (from a total of 119 patients) that developed leukopenia, 8 had the TPMT (n = 1) or NUDT15 (n = 7) polymorphism. Of the remaining 111 patients, their mean age was 36.36 ± 13.54 years and 57 (51.3%) were males. Twenty-five (21.01%) had unexplained leukopenia. The ITPA polymorphism was detected in 4 (16%) patients in the unexplained leukopenia group and 24 (27.9%) patients in the non-leukopenia group (p = 0.228). The odds ratio for predicting leukopenia with the ITPA polymorphism was 0.4921 (95% CI 0.1520-1.5830, p = 0.234).

CONCLUSION

The ITPA (C.94C > A) polymorphism was frequently detected in the study population but was not predictive for leukopenia in patients with IBD on thiopurine therapy.

Deep-learning models for differentiation of xanthogranulomatous cholecystitis and gallbladder cancer on ultrasound

BACKGROUND

The radiological differentiation of xanthogranulomatous cholecystitis (XGC) and gallbladder cancer (GBC) is challenging yet critical. We aimed at utilizing the deep learning (DL)-based approach for differentiating XGC and GBC on ultrasound (US).

METHODS

This single-center study comprised consecutive patients with XGC and GBC from a prospectively acquired database who underwent pre-operative US evaluation of the gallbladder lesions. The performance of state-of-the-art (SOTA) DL models (GBCNet-convolutional neural network [CNN] and RadFormer, transformer) for XGC vs. GBC classification in US images was tested and compared with popular DL models and a radiologist.

RESULTS

Twenty-five patients with XGC (mean age, 57 ± 12.3, 17 females) and 55 patients with GBC (mean age, 54.6 ± 11.9, 38 females) were included. The performance of GBCNet and RadFormer was comparable (sensitivity 89.1% vs. 87.3%, p = 0.738; specificity 72% vs. 84%, p = 0.563; and AUC 0.744 vs. 0.751, p = 0.514). The AUCs of DenseNet-121, vision transformer (ViT) and data-efficient image transformer (DeiT) were significantly smaller than of GBCNet (p = 0.015, 0.046, 0.013, respectively) and RadFormer (p = 0.012, 0.027, 0.007, respectively). The radiologist labeled US images of 24 (30%) patients non-diagnostic. In the remaining patients, the sensitivity, specificity and AUC for GBC detection were 92.7%, 35.7% and 0.642, respectively. The specificity of the radiologist was significantly lower than of GBCNet and RadFormer (p = 0.001).

CONCLUSION

SOTA DL models have a better performance than radiologists in differentiating XGC and GBC on the US.

Endoscopic ultrasound-guided drainage of early pancreatic necrotic collection: Single-center retrospective study

BACKGROUND

Endoscopic ultrasound (EUS)-guided drainage is the standard of care for drainage of pancreatic necrosis. Though initially it was mainly used for drainage of only walled-off necrosis, recently, a few studies have also shown its safety in the management of acute necrotic collections. We did a retrospective study to evaluate the safety and efficacy of EUS-guided drainage in the early phase of pancreatitis as compared to interventions in the late phase.

METHODS

We retrieved baseline disease-related, procedure-related and outcome-related details of patients who underwent EUS-guided drainage of pancreatic necrosis. Patients were divided into early (≤ 28 days from onset of pancreatitis) or delayed (> 28 days) drainage groups. Both groups were compared for disease-related characteristics and outcomes.

RESULTS

Total 101 patients were included in the study. The mean age of included patients was 35.54 ± 13.58 years and 75 were male. Thirty-five patients (34.7%) underwent early drainage. In the early group, a majority of patients underwent intervention due to infected collection (88.6% vs. 18.2%; p < 0.001). More patients in the early group had < 30% wall formation (28.6% vs. 0%; p < 0.001) and > 30% solid debris within the collection (42.9% vs. 15.2%; p = 0.005). Patients in the early group were also more likely to require endoscopic necrosectomy (57.1% vs. 27.3%; p = 0.003) and additional percutaneous drainage (31.4% vs. 12.1%; p = 0.018). Overall, three patients in the early group and one patient in the delayed group had procedure-related complications. Four patients in the early group and one patient in the delayed group succumbed to illness (p = 0.029).

CONCLUSION

Though delayed interventions remain standard of care in the management of acute pancreatitis, some patients may require early intervention due to infected collection with deteriorating clinical status. Early EUS-guided interventions in such carefully selected patients have in similar clinical outcomes and complication rates compared to delayed intervention. However, such patients are more likely to require additional endoscopic or percutaneous interventions.

Envelope coronally advanced flap with site-specific bilaminar acellular dermal matrix or connective tissue graft for management of multiple marginal tissue recessions: A retrospective analysis of cases

BACKGROUND

A proper case selection and decision making is essential for management of multiple marginal tissue recessions (MTR) using a conventional or bilaminar approach. Coronally advanced flap (CAF) is one of the commonly used methods for management of MTR. CAF has been advocated in combination with soft tissue grafts as bilaminar technique, which had showed significant success in terms of root coverage.

METHODS AND RESULTS

Aim of this case series was to retrospectively evaluate Zucchelli's modification of envelope CAF (eCAF) and site-specific bilaminar methods using Acellular Dermal Matrix (ADM) and Connective Tissue Graft (CTG) for management of MTR. A total of 15 subjects (five subjects/25 sites per technique, total number of sites = 75) who were managed by three different techniques with 12 months postoperative records were retrospectively evaluated. All patients showed significant clinical improvement in root coverage outcomes when compared to baseline. Mean root coverage achieved at 3 months (90%), 6 months (95%) and 12 months (95%) postoperatively did not reveal significant difference between three methods. Complete root coverage was observed in 86.6% of eCAF cases and in 86.6% and 95% of ADM/CTG with eCAF, respectively. There was an increase in width of keratinised tissue, both individually and collectively across all of the groups.

CONCLUSION

Clinical outcomes suggested that bilaminar techniques should be used only in specific cases. Predictable results can be obtained without the use of a soft tissue graft or substitute if a careful treatment plan for technique selection is developed on an individual case-by-case basis.

KEY POINTS

Why is this case new information? Comparison of site-specific bilaminar modalities with modified coronally advanced flap alone What are the keys to successful management of such cases? Flap advancement and mobilisation Flap passivity What are the primary limitations to success in such cases? Case selection Flap tension Soft tissue phenotype Thickness of graft Operator skills.

Gastrointestinal involvement in gallbladder cancer: Computed tomography findings and proposal of a classification system

BACKGROUND

There is relatively scarce data on the computed tomography (CT) detection of gastrointestinal (GI) involvement in gallbladder cancer (GBC). We aim to assess the GI involvement in GBC on CT and propose a CT-based classification.

METHODS

This retrospective study comprized consecutive patients with GBC who underwent contrast-enhanced computed tomography (CECT) for staging between January 2019 and April 2022. Two radiologists evaluated the CT images independently for the morphological type of GBC and the presence of GI involvement. GI involvement was classified into probable involvement, definite involvement and GI fistulization. The incidence of GI involvement and the association of GI involvement with the morphological type of GBC was evaluated. In addition, the inter-observer agreement for GI involvement was assessed.

RESULTS

Over the study period, 260 patients with GBC were evaluated. Forty-three (16.5%) patients had GI involvement. Probable GI involvement, definite GI involvement and GI fistulization were seen in 18 (41.9%), 19 (44.2%) and six (13.9%) patients, respectively. Duodenum was the most common site of involvement (55.8%), followed by hepatic flexure (23.3%), antropyloric region (9.3%) and transverse colon (2.3%). There was no association between GI involvement and morphological type of GBC. There was substantial to near-perfect agreement between the two radiologists for the overall GI involvement (k = 0.790), definite GI involvement (k = 0.815) and GI fistulization (k = 0.943). There was moderate agreement (k = 0.567) for probable GI involvement.

CONCLUSION

GBC frequently involves the GI tract and CT can be used to categorize the GI involvement. However, the proposed CT classification needs validation.

Endoscopic and chemopreventive management of familial adenomatous polyposis syndrome

Familial adenomatous polyposis (FAP) is an autosomal dominant syndrome predisposing affected individuals to gastrointestinal (GI) cancers through a high burden of polyposis. Colorectal cancer rates reach 100% by the age of 45, making early colectomy a mainstay of treatment. While most patients undergo colectomy at an early age, ongoing screening and surveillance of the upper gastrointestinal tract and rectal pouch must continue throughout adulthood. Endoscopic therapy of gastric, duodenal, ampullary and rectal pouch polyps is critical to reduce morbidity and cancer related mortality. Management of these lesions is not uniform, and is dependent on their location, size, histology, and risk of malignant potential. Medical therapies targeting pathways that reduce the malignant progression of pre-cancerous lesions have been studied for many years. While studies on the use of aspirin and non-steroidal anti-inflammatories (NSAIDs) in chemoprevention have shown encouraging results in Lynch syndrome and primary colorectal cancer, the potential benefits of these medications have not been duplicated in FAP cohorts. While data remains limited on chemoprevention in FAP, a number of randomized trials are currently underway examining targeted therapies with the potential to slow the progression of the disease. This review aims to provide an in-depth review of the literature on current endoscopic options and chemopreventive therapies targeting FAP. While the endoscopic management has robust data for its use, chemoprevention in FAP is still in its infancy. The complementary use of chemopreventive agents and endoscopic therapy for FAP patients is quickly becoming a growing and exciting area of research.

Role of Biliary Stent in Recurrence of Biliary Stones and Complications After Stone Clearance in Patients Awaiting Cholecystectomy: A Randomized Trial

INTRODUCTION

The role of prophylactic biliary stenting after clearance of choledocholithiasis in patients awaiting cholecystectomy for concomitant cholelithiasis is controversial. We planned a randomized controlled trial to study the effect of prophylactic biliary stenting after achieving biliary clearance in reducing recurrence of choledocholithiasis and biliary complications in patients awaiting cholecystectomy.

METHODS

Patients with concomitant cholelithiasis and choledocholithiasis were included, and those who had evidence of clearance of choledocholithaisis (documented on occlusion cholangiogram during endoscopic retrograde cholangiography [ERC]) were randomized to prophylactic biliary stenting or no stenting. Choledocholithaisis recurrence rate (primary outcome), biliary complications and need for repeat/emergency ERC (secondary outcomes) were compared till 3 months after clearance.

RESULTS

Between September 2021 and July 2022, 70 patients were randomized into group A, stenting (n = 35), and group B, no stenting (n = 35). Sixty-six patients were included in the final analysis. Baseline characteristics were comparable between the 2 groups. Ten (15.2%) patients had recurrence of choledocholithiasis, and it was comparable between the 2 groups (7/34 [20.6%] and 3/34 [9.4%], P = 0.306). Five patients (2 cholecystitis and 3 post-ERC pancreatitis) from the stent group while none from the no stent group developed complications, and this difference was statistically significant ( P = 0.024). None of the patients in both the groups needed emergency ERC during the follow-up.

DISCUSSION

This randomized trial shows a higher complication rate with prophylactic stenting, while there is no benefit in preventing choledocholithiasis recurrence in patients waiting for cholecystectomy after biliary clearance (CTRI registration number: CTRI/2021/09/036538).

Factors contributing to flares of ulcerative colitis in North India- a case-control study

BACKGROUND

Ulcerative colitis is a relapsing and remitting disease that may be associated with flares. The causes of flares in the Indian setting are not well recognized.

METHODS

The present prospective case-control study was conducted at a single center in North India. Cases were defined as patients admitted for flare of ulcerative colitis, while controls were patients in remission enrolled from the outpatient department. The basis of the diagnosis of flare was a simple clinical colitis activity index (SCCAI) of ≥ 5 and endoscopic activity, while remission was based on SCCAI < 4 and a normal fecal calprotectin. A questionnaire evaluating recent infections, stress, drug intake (antibiotics, pain medication), adherence to therapy, and use of complementary and alternative therapy (CAM) was administered.

RESULTS

We included 84 patients (51 with flare and 33 in remission) with a median age of 38 years, of whom 47 (55.9%) were males. The two groups were similar for baseline parameters, including age (38, 23-50 and 38, 25.5-48.5 years), male gender (52.9% and 60.6%), extent of disease, extraintestinal manifestations (21.6% and 12.1%), use of 5-aminosalicylates (76.5% and 90.9%). The thiopurine use was lower in those having a flare (15.7% and 36.4%). Amongst the predictors of flare, the recent infections (39.2% and 30.3%), recent travel (31.4 and 27.3%), eating outside food (47.1% and 39.4%), consumption of milk products (88.2% and 75.8%), use of pain medication (43.1% and 33.3%) and recent stress (62.7% and 60.6%) were similar between cases and controls. The rates of antibiotic use (29.4% and 6.1%), lack of adherence (50.9% and 15.2%), and intake of CAM (70.6% and 33.3%) were higher in those with flare. Patients attributed a lack of adherence to the cost of therapy, presumed cure (due to lack of symptoms), and fear of adverse effects.

CONCLUSION

Lack of adherence to inflammatory bowel disease therapies and recent CAM and antibiotic intake was higher in patients with flares of UC. The study makes ground for educational intervention(s) promoting knowledge and adherence to IBD therapies.

Role of Interleukin-6 in Prediction of Early Complications After Minimally Invasive Oesophagectomy-a Pilot Study

Infectious complications following oesophagectomy are associated with significant morbidity. Early prediction of these complications may mitigate significant morbidity and mortality. Patients undergoing minimally invasive oesophagectomy for carcinoma oesophagus between January 2019 and June 2020 were included in the study. All patients underwent standard preoperative investigations and preparation. Post-operative complications including infectious complications were recorded. Association of post-operative serum interleukin-6 (IL-6) levels with post-operative complications were analysed. A total of twenty-two participants were included in the study (median age; 51 years, 13 (%) male). The tumour site was middle 1/3rd of oesophagus in 13 (59.1%), lower 1/3rd of oesophagus in 9 (40.9%). The tumour histology was squamous cell carcinoma in all patients. Eight (36.4 %) patients developed major complications and five of them developed anastomotic leak. IL-6 levels were significantly higher on POD 3 in patients who developed major complications (p = 0.009) and anastomotic leak (p = 0.031). At receiver operating characteristic curve (ROC curve) analysis, an IL-6 cut-off level of 36.4 pg/ml on POD 3 yielded a sensitivity of 87% and a specificity of 79% for the prediction of major complication and cut-off level of 44.3 pg/ml on POD 3 yielded a sensitivity of 80% and a specificity of 82% for the prediction of anastomotic leak. A high post-operative IL-6 level helps in the prediction of major complications and cervical oesophagogastric anastomotic leak.

Synthesis and in silico studies of some new pyrrolidine derivatives and their biological evaluation for analgesic and anti-inflammatory activity

BACKGROUND

An array of commercially viable intermediate molecules necessary for the synthesis of a variety of bioactive molecules are chemically synthesized by pyrrolidine and its derivatives, which play a significant role in drug design and development process.

AIM

The aim of the present research work was to explore the synthesis of some new pyrrolidine derivatives and to perform their in silico studies and finally evaluation of analgesic and anti-inflammatory activity.

OBJECTIVE

The purpose of this study was to synthesis new pyrrolidine derivatives, examine how they affected the COX-1 and COX-2 enzymes computationally, and to screen their in vivo analgesic and anti-inflammatory activity on laboratory animals.

METHOD

The new pyrrolidine derivatives were synthesized by condensing N-(3-acetylphenyl)-2-(pyrrolidin-1-yl)acetamide with substituted aniline in ethanol in the presence of catalytic amounts of glacial acetic acid. The structures of novel pyrrolidine derivatives were characterised using IR, NMR, and mass spectroscopy. Several molecular properties of the newly synthesized derivatives were calculated in order to evaluate the nature of the drug-like candidate. A specific reference cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) enzyme was used to dock the newly synthesized pyrrolidine derivatives.

RESULTS

From the observed data, it was noted that amongst all newly synthesized compounds, A-1 and A-4 exhibited the highest anti-inflammatory and analgesic effects, respectively.

CONCLUSION

On the basis of findings of present research, it was concluded that A-1 and A-4 might be utilized as a promising new lead compound for Non-Steroidal Anti-Inflammatory Drug (NSAIDs) development.

Revisiting the Green Synthesis of Nanoparticles: Uncovering Influences of Plant Extracts as Reducing Agents for Enhanced Synthesis Efficiency and Its Biomedical Applications

Background

Conventional nanoparticle synthesis methods involve harsh conditions, high costs, and environmental pollution. In this context, researchers are actively searching for sustainable, eco-friendly alternatives to conventional chemical synthesis methods. This has led to the development of green synthesis procedures among which the exploration of the plant-mediated synthesis of nanoparticles experienced a great development. Especially, because plant extracts can work as reducing and stabilizing agents. This opens up new possibilities for cost-effective, environmentally-friendly nanoparticle synthesis with enhanced size uniformity and stability. Moreover, bio-inspired nanoparticles derived from plants exhibit intriguing pharmacological properties, making them highly promising for use in medical applications due to their biocompatibility and nano-dimension.

Objective

This study investigates the role of specific phytochemicals, such as phenolic compounds, terpenoids, and proteins, in plant-mediated nanoparticle synthesis together with their influence on particle size, stability, and properties. Additionally, we highlight the potential applications of these bio-derived nanoparticles, particularly with regard to drug delivery, disease management, agriculture, bioremediation, and application in other industries.

Methodology

Extensive research on scientific databases identified green synthesis methods, specifically plant-mediated synthesis, with a focus on understanding the contributions of phytochemicals like phenolic compounds, terpenoids, and proteins. The database search covered the field's development over the past 15 years.

Results

Insights gained from this exploration highlight plant-mediated green synthesis for cost-effective nanoparticle production with significant pharmacological properties. Utilizing renewable biological resources and controlling nanoparticle characteristics through biomolecule interactions offer promising avenues for future research and applications.

Conclusion

This review delves into the scientific intricacies of plant-mediated synthesis of nanoparticles, highlighting the advantages of this approach over the traditional chemical synthesis methods. The study showcases the immense potential of green synthesis for medical and other applications, aiming to inspire further research in this exciting area and promote a more sustainable future.

SARS-CoV-2: Current Tools to Fight COVID-19 ST-Elevation Myocardial Infarction

The capacity of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to wreak havoc on the inflammatory and coagulation pathways via the cytokine storm has led to over 6.3 million fatalities globally. Based on recent data, the mechanism predominately involves the formation of microvascular thrombosis when pertaining to cardiovascular disease. However, a subset of coronavirus disease-2019 (COVID-19)-positive patients present emergently with acute ST-elevation myocardial infarction (STEMI) are found to have severe epicardial thrombosis which is refractory to traditional coronary revascularization. We have noted mortality in these patients presenting to our facility to be as high as 90% and all angiographically confirmed to have thrombus which was refractory to traditional therapy. We present a case series of COVID-19-positive patients presenting with STEMI found to have epicardial thrombus who were treated with different traditional STEMI therapies but with fatal outcomes. Other possible techniques including mechanical thrombectomy, optimizing traditional and nontraditional anticoagulation therapy with the use of early hemodynamic support may prove more efficacious to destroy thrombus and potentially improve mortality.

Oxidized Low-density Lipoproteins and Lipopolysaccharides Augment Carotid Artery Plaque Vulnerability in Hypercholesterolemic Microswine

Atherosclerosis is a chronic inflammatory disease and hypercholesterolemia is a risk factor. This study aims to compare the potency of lipopolysaccharide (LPS) and oxidized low-density lipoproteins (oxLDL) to induce plaque formation and increase plaque vulnerability in the carotid artery of hypercholesterolemic Yucatan microswine. Atherosclerotic lesions at the common carotid artery junction and ascending pharyngeal artery were induced in hypercholesterolemic Yucatan microswine at 5-6 months of age with balloon angioplasty. LPS or oxLDL were administered intraluminally at the site of injury after occluding the arterial flow temporarily. Pre-intervention ultrasound (US), angiography, and optical coherence tomography (OCT) were done at baseline and just before euthanasia to assess post-op parameters. The images from the US, OCT, and angiography in the LPS and the oxLDL-treated group showed increased plaque formation with features suggestive of unstable plaque, including necrotic core, thin fibrous caps, and a signal poor region more with oxLDL compared to LPS. Histomorphology of the carotid artery tissue near the injury corroborated the presence of severe lesions in both LPS and oxLDL-treated pigs but more in the oxLDL group. Vascular smooth muscle and endothelial cells treated with LPS and oxLDL showed increased folds changes in mRNA transcripts of the biomarkers of inflammation and plaque vulnerability compared to untreated cells. Collectively, the results suggest that angioplasty-mediated intimal injury of the carotid arteries in atherosclerotic swine with local administration of LPS or ox-LDL induces vulnerable plaques compared to angioplasty alone and oxLDL is relatively more potent than LPS in inducing vulnerable plaque.

Differentiating gastrointestinal tuberculosis and Crohn's disease- a comprehensive review

Gastrointestinal Tuberculosis (GITB) and Crohn's disease (CD) are both chronic granulomatous diseases with a predilection to involve primarily the terminal ileum. GITB is often considered a disease of the developing world, while CD and inflammatory bowel disease are considered a disease of the developed world. But in recent times, the epidemiology of both diseases has changed. Differentiating GITB from CD is of immense clinical importance as the management of both diseases differs. While GITB needs anti-tubercular therapy (ATT), CD needs immunosuppressive therapy. Misdiagnosis or a delay in diagnosis can lead to catastrophic consequences. Most of the clinical features, endoscopic findings, and imaging features are not pathognomonic for either of these two conditions. The definitive diagnosis of GITB can be clinched only in a fraction of cases with microbiological positivity (acid-fast bacilli, mycobacterial culture, or PCR-based tests). In most cases, the diagnosis is often based on consistent clinical, endoscopic, imaging, and histological findings. Similarly, no single finding can conclusively diagnose CD. Multiparametric-based predictive models incorporating clinical, endoscopy findings, histology, radiology, and serology have been used to differentiate GITB from CD with varied results. However, it is limited by the lack of validation studies for most such models. Many patients, especially in TB endemic regions, are initiated on a trial of ATT to see for an objective response to therapy. Early mucosal response assessed at two months is an objective marker of response to ATT. Prolonged ATT in CD is recognized to have a fibrotic effect. Therefore, early discrimination may be vital in preventing the delay in the diagnosis of CD and avoiding a complicated course.

Negative pressure wound therapy versus standard care for incisional laparotomy subcutaneous wounds in gastrointestinal perforations: A randomized controlled study

BACKGROUND

Surgical site infections after gastrointestinal perforation with peritonitis have significant morbidity, increased hospital stays, and cost of treatment. The appropriate management of these wounds is still debatable.

METHODS

Patients undergoing surgery for gastrointestinal perforation with peritonitis via midline incision were screened for inclusion. After the closure of the midline fascia, patients were randomized into an open negative pressure wound therapy group (application of negative pressure wound therapy and attempted delayed closure at day 4) or a standard care group (no negative pressure wound therapy and attempted delayed closure at day 4). Postoperative outcomes, including surgical site infection till 30 days, were compared between the groups. This was assessed by an independent assessor not involved in the study for delayed closure. Although a priori sample size was calculated, an interim analysis was performed due to slow recruitment during the COVID pandemic. After interim analysis, a continuation of the trial was deemed unethical and terminated.

RESULTS

Ninety-six patients were assessed, and 69 were randomized (34 in the negative pressure wound therapy group and 31 in the standard care group). The age, body mass index, comorbidities, blood loss, operative time, and stoma formation were comparable. The surgical site infection was significantly lower in the negative pressure wound therapy group compared to the standard care group (6 [18%] vs 19 [61%], P < .01). The number needed to prevent 1 surgical site infection was 2.3. In a subgroup analysis, the use of negative pressure wound therapy also significantly decreased the rate of surgical site infection in stoma patients (4 [30.7%] vs 9 [69.3%], P = .03).

CONCLUSION

Open negative pressure wound therapy significantly decreases the incisional surgical site infection rate in patients with a dirty wound secondary to gastrointestinal perforation with peritonitis.

Pancreatic Dysfunction and Reduction in Quality of Life Is Common After Pancreaticoduodenectomy

BACKGROUND

Improvements in survival after pancreaticoduodenectomy has increased the number of patients potentially at risk of pancreatic insufficiency.

AIMS

We studied long-term (> 1 year) pancreatic functions (endocrine and exocrine) after pancreaticoduodenectomy and aimed to recognize the impact of various clinicopathological factors and postoperative complications on pancreatic functions.

METHODS

All patients who underwent pancreaticoduodenectomy at least 1 year prior were recruited from July 2020 to December 2021. Endocrine function was assessed using HbA1c, fasting blood sugar and postprandial blood sugar levels. Pancreatic exocrine function was assessed clinically with history of steatorrhea and objectively with quantitative estimation of fecal elastase-1 levels in stool samples. Volume of remnant pancreas, parenchymal thickness and duct diameter were assessed by computed tomography. Quality of life assessment was done using SF-36 questionnaire.

RESULTS

Of the 106 patients assessed, 64 patients met the inclusion criteria. Endocrine insufficiency was noted in 51.6%, and 34.3% had new onset diabetes mellitus. The incidence of pancreatic exocrine insufficiency was 87.5% and severe insufficiency was found in 62.5% of patients. Twenty-nine (45.3%) patients had both exocrine and endocrine insufficiency. Patients with CRPOPF had higher risk of severe exocrine insufficiency (5 vs. 2, OR 1.57(0.28-8.81) p = 0.6). The SF-36 scores were lower than general population especially in role limitation due to physical health, role limitation due to emotional problems, energy/fatigue, general health perception and health change domains.

CONCLUSION

Post-pancreaticoduodenectomy patients have a high frequency of pancreatic insufficiency and should be screened for same. The post-operative pancreatic fistula increases the risk of pancreatic exocrine insufficiency.

Current concepts in the management of radial head fractures: a national survey and review of the literature

INTRODUCTION

This study aims to report on current practice in the management of radial head fractures (RHFs) in the United Kingdom and to review the literature to identify areas for future investigation.

METHODS

A 12-question online survey was sent to 500 surgeon members of the British Elbow and Shoulder Society in 2021. Questions focused on clinical assessment, indications for surgical treatment and willingness to participate in future studies. Descriptive statistical analysis summarised the responses.

RESULTS

The response rate was 20.4% (n = 102). For minimally displaced RHFs, non-operative management with immediate mobilisation was reported by 90.2% (n = 92) as opposed to 9.8% (n = 10) for initial immobilisation in plaster or brace. The most cited indication for radial head arthroplasty as opposed to fixation was increased patient age or low functional demand in 69.9% of responses (n = 71). In total, 41.2% (n = 42) indicated the need for a future randomised controlled trial (RCT) concerning the management of RHF. Only five RCTs were returned by the literature review.

DISCUSSION

There is considerable variability in the management of RHF among an experienced cohort of surgeons. With the interest declared by the participating surgeons, there is a call for a well-designed sufficiently powered RCT.

Neutrophil-lymphocyte Ratio Predicts Clinical Response to Percutaneous Transhepatic Biliary Drainage in Acute Cholangitis

Background

Predicting response to biliary drainage is critical to stratify patients with acute cholangitis. Total leucocyte count (TLC) is one of the criteria for predicting the severity of cholangitis and is routinely performed. We aim to investigate the performance of neutrophil-lymphocyte ratio (NLR) in predicting clinical response to percutaneous transhepatic biliary drainage (PTBD) in acute cholangitis.

Patients and methods

This retrospective study comprised consecutive patients with acute cholangitis who underwent PTBD and had serial (baseline, day 1, and day 3) TLC and NLR measurements. Technical success, complications of PTBD, and clinical response to PTBD (based on multiple outcomes) were recorded. Univariate and multivariate analysis was performed to identify factors significantly associated with clinical response to PTBD. The sensitivity, specificity, and area under the curve of serial TLC and NLR for predicting clinical response to PTBD were calculated.

Results

Forty-five patients (mean age 51.5 years, range 22-84) met the inclusion criteria. PTBD was technically successful in all the patients. Eleven (24.4%) minor complications were recorded. Clinical response to PTBD was recorded in 22 (48.9%) patients. At univariate analysis, the clinical response to PTBD was significantly associated with baseline TLC (P = 0.035), baseline NLR (P = 0.028), and NLR at day 1 (P=0.011). There was no association with age, the presence of comorbidities, prior endoscopic retrograde cholangiopancreatography, admission to PTBD interval, diagnosis (benign vs. malignant), severity of cholangitis, organ failure at baseline, and blood culture positivity. At multivariate analysis, NLR-1 independently predicted the clinical response. Area under the curve of NLR at day 1 for predicting clinical response was 0.901. NLR-1 cut-off value of 3.95 was associated with sensitivity and specificity of 87% and 78%, respectively.

Conclusion

TLC and NLR are simple tests that can predict clinical response to PTBD in acute cholangitis. NLR-1 cut-off value of 3.95 can be used in clinical practice to predict response.

Perfusion Computed Tomography May Help in Discriminating Gastrointestinal Tuberculosis and Crohn’s Disease

Gastrointestinal tuberculosis (GITB) and Crohn’s disease (CD) are close mimics. This prospective study aimed to evaluate the diagnostic performance of perfusion computed tomography (CT) in differentiating GITB from CD. Consecutive patients with ileocaecal thickening underwent perfusion CT of the ileocaecal region between January 2019 and July 2020. Two radiologists (blinded to the final diagnosis) independently assessed blood flow (BF), blood volume (BV), mean transit time (MTT), and permeability at perfusion CT. These parameters were compared among the patients with GITB as well as active and inactive CD. Receiver operating characteristic curves were utilized for determining the diagnostic performance of perfusion CT. Interclass correlation coefficient and Bland–Altman analysis were performed to compare the observations of the two radiologists. During the study period, 34 patients underwent perfusion CT. Eight patients had diagnoses other than intestinal tuberculosis or CD. Thus, 26 patients (mean age 36 ± 14 years, 18 males) with GITB (n = 11), active CD (n = 6), and inactive CD (n = 9) were evaluated. BF, MTT, and permeability showed significant differences among the groups, while BV did not differ significantly among the groups. BF and permeability had 100% sensitivity and 100% specificity, while MTT had 61.5–100% sensitivity and 70–100% specificity for differentiating GITB from active CD and active from inactive CD. The interclass correlation coefficient for perfusion CT parameters was 0.88–1. Perfusion CT is a novel imaging technique that can improve the diagnostic performance of differentiating tuberculosis from CD.

Quantification of joint space width with different grades of manual traction in patients with adhesive capsulitis-A fluoroscopic study

Adhesive capsulitis causes adaptive shortening of the non-contractile structures around the shoulder joint which may affect the distraction distance or joint space width (JSW) between the glenoid and humeral head. Joint traction is a commonly used manual therapy technique to reduce pain and gain range of motion in patients with adhesive capsulitis. However, changes in JSW with manual traction are not objectively assessed. This study aimed to find differences in shoulder JSW with different grades of traction and made comparisons between the affected and the unaffected side using 2D fluoroscopy. Forty-one subjects (24 males, 17 females; age 53.9±7.9 years) diagnosed with adhesive capsulitis with low to moderate joint irritability were included. Their mean duration of symptoms was 5.25±1.7 months. True anteroposterior view images of the shoulder were taken with the patient in a supine position with their arms held at 75° of abduction. Images of the affected and unaffected side were taken while no traction, grade 2 and grade 3 manual traction were applied. The JSW was determined as the linear distance between the articular surfaces. Repeated measures ANOVA with post hoc testing was used for analysing differences across the sides (affected and unaffected side) and conditions (No, grade 2 and grade 3 traction). There was no significant interaction between conditions and sides (P=0.99). Averaged across sides, the JSW with grade 2 or 3 traction was 0.18 and 0.23 mm more than the no traction condition (P=0.013 and P=0.001, respectively). There were no differences in the JSW with grade 2 or 3 traction. Averaged across the conditions, the JSW on the unaffected side was 0.21 mm more than the affected side (P=0.03). The study demonstrates that adhesive capsulitis causes a reduction in JSW at 75° abducted position and grade 2 or 3 manual traction can significantly increase this JSW.

Clinical Trial Registry India: CTRI/2018/12/016657.

A183 VARIATION IN HEALTH SERVICES UTILIZATION AND RISK OF SURGERY ACROSS CHILDREN WITH INFLAMMATORY BOWEL DISEASE: A MULTIPROVINCE COHORT STUDY

Background

Marked variation in access to care and health services utilization is a marker of variation in quality of care. With the rising incidence of pediatric inflammatory bowel disease (IBD), we must understand variation in access to and outcomes of care to improve quality.

Purpose

Describe variation in care for pediatric IBD treated in 4 Canadian provinces.

Method

Incident cases of IBD diagnosed in children <16y were identified from health administrative data in Alberta (AB), Manitoba, Nova Scotia, and Ontario (ON) using validated algorithms. Children were assigned to one of 8 centres of care using a hierarchical assessment of health services use within 6 months of diagnosis. Children treated by adult gastroenterologists or community-based pediatric gastroenterologists were excluded due to small sample size. Outcomes included IBD-related hospitalizations, emergency department (ED) visits (AB/ON only), and IBD-related abdominal surgery. Hospitalizations and ED visits were counted cumulatively from 6-60 months after diagnosis. The risk of first surgery was defined during the same 6-60 month period. Mixed-effects meta-analysis was used to pool results across centres. Heterogeneity among centres was quantified using I² (variation in pooled event rates between centres) and τ (standard deviation of the true event rates). R² quantified the residual heterogeneity in outcomes not attributable to among-province variation.

Result(s)

We identified 3777 incident cases of pediatric IBD, 2936 (78%) of which were treated at 8 pediatric centres. The number of hospitalizations was 0.67 (95% CI 0.56-0.79) per person with high between-centre heterogeneity (I² 84%, τ 0.1556). Provincial differences accounted for 93% of heterogeneity across centres (residual heterogeneity: I² 29%, τ 0.0412). Hospitalizations were less frequent in AB than other provinces (0.43 vs. 0.72-0.78). Children averaged 1.94 IBD-related ED visits, with significant heterogeneity (I² 99%, τ 1.33) with 99.7% of heterogeneity attributable to among-province differences (residual heterogeneity: I² 32%; τ 0.074). Mean ED visits were 1.1 visits in ON (I² 39%) and 3.7 in AB (I² 0%). Intestinal resection was required by 12% (95% CI 0.08-0.15) of Crohn’s patients with high among-centre heterogeneity (I² 81%, τ 0.042), and low (19%) heterogeneity due to provincial differences (residual heterogeneity: I² 76%; τ 0.039). Colectomy was required by 12% (95% CI 10-14) of children with ulcerative colitis (UC) with no between-centre heterogeneity (I² 0%, τ 0).

Conclusion(s)

There is a high degree of between-province (but not between-centre, within province) variability in health services utilization among children with IBD. There was significant between-centre variability in surgery rates for Crohn’s, but not colectomy for UC. Differences in patient characteristics or provincial health systems may be more important predictors of variation in care. Surgery for Crohn’s disease may be a target for inter-centre quality improvement efforts.

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CCC

Disclosure of Interest

None Declared

A35 FORECASTING THE INCIDENCE AND PREVALENCE OF INFLAMMATORY BOWEL DISEASE: A CANADIAN NATION-WIDE ANALYSIS

Background

Canada is currently in the third epidemiological stage in the evolution of IBD: compounding prevalence. A high incidence of IBD, in conjunction with low mortality, leads to a steadily rising prevalence over time. By understanding historical epidemiological trends, we can forecast incidence and prevalence into the future to inform healthcare systems in Canada of the rising burden of IBD to society.

Purpose

To analyze past epidemiological trends in order to forecast the overall incidence and prevalence of IBD, Crohn’s disease (CD), and ulcerative colitis (UC) and stratified by age (<18, 18-64, 65+).

Method

Canadian population-based administrative data was acquired from: AB, BC, SK, MB, QC, and ON. Data were age and sex standardized to the matching year and provincial data aggregated into a representative sample of the Canadian population for prevalence (2002-2014) and incidence (2007-2014: 5-year washout period). Incidence and prevalence (per 100,000 persons) were calculated, with 95% confidence intervals (CI), using Canadian population estimates from Statistics Canada for IBD, CD, UC (IBD-unclassifiable+UC). Autoregressive Integrated Moving Average models were created, and rates forecasted from 2014 to 2035 with 95% prediction intervals (PI). Poisson (or negative binomial) for incidence and log binomial regression for prevalence estimated the Average Annual Percentage Change (AAPC), with 95% CIs, of the forecasted data.

Result(s)

The 2014 incidence of IBD in Canada was 28.4 per 100,000 (95%CI: 27.8, 29.0) and forecasted to significantly increase (AAPC: 0.58%; 95%CI: 0.04, 1.04) from 30.0 per 100,000 in 2023 to 32.1 (95%PI: 27.9, 36.3) in 2035. Pediatric onset IBD was 13.9 per 100,000 (95%CI: 13.0, 14.9) in 2014 and is forecasted to significantly increase to 18.0 per 100,000 (95%PI: 15.7, 20.2) in 2035 with an AAPC of 1.23% (95%CI: 0.76, 1.63). Adult and elderly onset incidence rates were forecasted to remain stable. Prevalence of IBD increased between 2002 (389 per 100,000) and 2014 (636 per 100,000) and is forecasted to continue to climb by an AAPC of 2.44% (95%CI: 2.34, 2.53). In 2023, the prevalence of IBD is 825 per 100,000. By 2035 prevalence is forecasted to climb to 1075 per 100,000 (95%PI: 1047, 1103) with 470,000 Canadians living with IBD. Prevalence across all age strata were forecasted to significantly increase. The highest AAPC was seen in the elderly (2.76%; 95%CI: 2.73, 2.79) with a prevalence of 841 per 100,000 (95%CI: 834, 849) in 2014 and forecasted to climb to 1534 per 100,000 (95%PI: 1519, 1550) in 2035.

Image

Conclusion(s)

Incidence of IBD continues to rise in Canada, driven by pediatric-onset IBD. In 2023, over 320,000 Canadians (0.83%) will be living with IBD. By 2035 prevalence will exceed 1% of the population with approximately 470,000 individuals in Canada with IBD. Future research should establish the environmental determinates of IBD that may influence temporal trends in the incidence of IBD, while healthcare systems adapt to the compounding prevalence of IBD.

Please acknowledge all funding agencies by checking the applicable boxes below

CIHR, Other

Please indicate your source of funding;

The Leona M. and Harry B. Helmsley Charitable Trust

Disclosure of Interest

S. Coward: None Declared, E. Benchimol Consultant of: Hoffman La-Roche Limited and Peabody & Arnold LLP for matters unrelated to medications used to treat inflammatory bowel disease and McKesson Canada and the Dairy Farmers of Ontario for matters unrelated to medications used to treat inflammatory bowel disease., C. Bernstein Grant / Research support from: Unrestricted educational grants from Abbvie Canada, Janssen Canada, Pfizer Canada, Bristol Myers Squibb Canada, and Takeda Canada. Has received research grants from Abbvie Canada, Amgen Canada, Pfizer Canada, and Sandoz Canada and contract grants from Janssen, Abbvie and Pfizer, Consultant of: Abbvie Canada, Amgen Canada, Bristol Myers Squibb Canada, JAMP Pharmaceuticals, Janssen Canada, Pfizer Canada, Sandoz Canada, and Takeda., Speakers bureau of: Abbvie Canada, Janssen Canada, Pfizer Canada and Takeda Canada, J. A. Avina-Zubieta: None Declared, A. Bitton: None Declared, L. Hracs: None Declared, J. Jones Consultant of: Janssen, Abbvie, Pfizer, Takeda, Speakers bureau of: Janssen, Abbvie, Pfizer, Takeda, E. Kuenzig: None Declared, L. Lu: None Declared, S. Murthy: None Declared, Z. Nugent: None Declared, A. Otley Grant / Research support from: Unrestricted educational grants from AbbVie Canada and Janssen Canada, Consultant of: Advisory boards of AbbVie Canada, Janssen Canada and Nestle, R. Panaccione Consultant of: Abbott, AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Celltrion, Cosmos Pharmaceuticals, Eisai, Elan, Eli Lilly, Ferring, Galapagos, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pendopharm, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz, Satisfai Health, Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Theravance Biopharma, Trellus, Viatris, UCB. Advisory Boards for: AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Speakers bureau of: AbbVie, Amgen, Arena Pharmaceuticals, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Gilead Sciences, Janssen, Merck, Organon, Pfizer, Roche, Sandoz, Shire, Takeda Pharmaceuticals, J.-N. Pena-Sanchez: None Declared, H. Singh Consultant of: Pendopharm, Amgen Canada, Bristol Myers Squibb Canada, Roche Canada, Sandoz Canada, Takeda Canada, and Guardant Health, Inc., L. Targownik Grant / Research support from: Investigator initiated funding from Janssen Canada, Consultant of: [Advisory board] AbbVie Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, Roche Canada, and Sandoz Canada, J. Windsor: None Declared, G. Kaplan Grant / Research support from: Ferring, Janssen, AbbVie, GlaxoSmith Kline, Merck, and Shire, Consultant of: Gilead, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, and Takeda

A189 EMERGENCY DEPARTMENT UTILIZATION AND RISK OF INTESTINAL RESECTION IS LOWER AMONG CHILDREN DIAGNOSED WITH INFLAMMATORY BOWEL DISEASE BEFORE 10 YEARS OF AGE: A MULTIPROVINCE POPULATION-BASED COHORT STUDY

Background

In Canada, the incidence of inflammatory bowel disease (IBD) is increasing faster among those <10 years (y) of age than in any other age group. Understanding the health services burden of IBD in this population is important for health system planning.

Purpose

To compare healthcare utilization and risk of surgery among children diagnosed with IBD across age groups defined by the Paris Classification (A1a: <10y; A1b: 10 to <16y) across 5 Canadian provinces.

Method

Children diagnosed with IBD <16 years of age were identified from health administrative data using validated algorithms in Alberta, Manitoba, Nova Scotia, Ontario, and Québec. Negative binomial regression models were used to compare (1) the pre-diagnosis frequency of health services utilization (outpatient, emergency department (ED), and hospitalization) using diagnostic codes suggestive of future IBD and (2) the annual post-diagnosis frequency of IBD-specific and IBD-related (signs, symptoms, and extra-intestinal manifestations of IBD) visits among children diagnosed <10y (A1a) and 10 to <16y (A1b). Cox proportional hazard models compared the risk of surgery (identified with validated procedure codes) across age groups. All regression models were adjusted for sex, rural/urban residence, and mean neighbourhood income quintile. Province-specific event counts (all ages combined) and models (comparing age groups; reference: A1b [10 to <16y]) were pooled using random-effects meta-analysis.

Result(s)

Among 5124 children with IBD (1165 [23%] were <10y at diagnosis), the mean number of pre-diagnosis healthcare encounters was 1.0 (95% CI 0.38 to 1.68, I²=99.6%). The mean annual post-diagnosis number of IBD-specific outpatient visits was 3.2 (95% CI 1.9-4.4, I²=99.6%); hospitalizations, 0.19 (95% CI 0.17-0.21, I²=74%); ED visits, 0.17 (95% CI 0.19-0.39, I²=99%). The mean annual post-diagnosis number of IBD-related outpatient visits was 3.9 (95% CI 2.3-5.5, I²=99.7%); hospitalizations, 0.21 (95% CI 0.19-0.23, I²=79%); ED visits, 0.29 (95% CI 0.19-0.39, I²=97%). Intestinal resection or colectomy within 5y of diagnosis occurred in 13% (95%CI 8-22, I²=93%) with Crohn’s disease (CD) and 16% (95% CI 14-18, I²=40%) with ulcerative colitis. IBD-specific ED visits (RR 0.70, 95% CI 0.50-0.97, I²=80) and the risk of intestinal resection in CD (HR 0.49, 95% CI 0.26-0.92, I²=40%) were significantly lower among children diagnosed <10y. There were no age-related differences in pre-diagnosis health services utilization or other post-diagnosis outcomes, including frequency of outpatient visits to a gastroenterologist.

Conclusion(s)

Health services utilization was generally similar for children diagnosed with IBD at <10y and between 10 and <16y, except for lower rates of IBD-specific ED visits and intestinal resection in children with CD. Further exploration of between-province differences, represented by the high statistical heterogeneity (I²) in the meta-analyses, is needed to understand sources of variation in care.

Please acknowledge all funding agencies by checking the applicable boxes below

CCC

Disclosure of Interest

E. Kuenzig: None Declared, H. Singh Consultant of: Amgen Canada, Bristol-Myers Squibb Canada, Sandoz Canada, Roche Canada, Takeda Canada and Guardant Health, A. Bitton: None Declared, G. Kaplan Grant / Research support from: Ferring, Consultant of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, M. Carroll: None Declared, A. Otley Grant / Research support from: Research support: AbbVie Global. Research site: AbbVie, Pfizer, Eli-Lily, Janssen, Consultant of: AbbVie Canada, T. Stukel: None Declared, S. Spruin: None Declared, A. Griffiths Grant / Research support from: Abbvie, Consultant of: Abbvie, Amgen, BristolMyersSquibb, Janssen, Lilly, Takeda, Speakers bureau of: Abbvie, Janssen, Takeda, D. Mack: None Declared, K. Jacobson Grant / Research support from: Abbvie Canada and Janssen Canada, Consultant of: Abbvie Canada, Janssen Canada, Merck Canada and Mylan Pharmaceuticals, Speakers bureau of: Abbvie Canada and Janssen Canada, G. Nguyen: None Declared, L. Targownik Grant / Research support from: Janssen Canada, Consultant of: AbbVie Canada, Sandoz Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, and Roche Canada, W. El-Matary Consultant of: Abbvie and MERCK, Speakers bureau of: Abbvie and MERCK, E. Benchimol Consultant of: McKesson Canada, Dairy Farmers of Ontario (unrelated to medications used to treat inflammatory bowel disease)

A226 EFFECT OF PHYSICAL ACTIVITY AMONG INDIVIDUALS WITH QUIESCENT OR MILDLY ACTIVE INFLAMMATORY BOWEL DISEASE: A SYSTEMATIC REVIEW

Background

Individuals with quiescent inflammatory bowel diseases (IBD) can continue to have several symptoms. Physical activity (PA) can improve immunological response and psychological health.

Purpose

We performed a systematic review of trials investigating the safety and efficacy of PA as an adjunct therapy to manage persistent symptoms in quiescent or mildly active IBD.

Method

We searched for randomised controlled trials (RCTs) and nonrandomised non-controlled trials (non-RCTs) in eight databases, trial registries and conference proceedings, published in English between 2011 and 2021. We focused on trials in adults (>18 years) using any form of PA as an adjunct therapy to medical therapy. Outcomes of interest were health-related quality of life, fatigue, joint pain, abdominal pain, stress, anxiety, and depression.

Result(s)

From 10,862 retrieved citations, we identified seven RCTs and one non-RCT that met our inclusion criteria. All trials deemed PA safe for individuals with quiescent or mildly active IBD. Clinical heterogeneity was noted among the trials for all outcomes. Six RCTs utilized parallel-group design while one utilized a cross-over design. Seven trials provided partially or fully supervised PA interventions, and one provided no supervision. All trials used different types of PA, which varied between running, resistance training, yoga, and aerobic exercises. The trials used different parameters to measure PA intensity including Peak Power Output, Resistance Intensity Scale for Exercise, percentage of maximum heart rate, ability to talk while running. Heterogeneity was noted in the duration and frequency of PA.

Conclusion(s)

Even though PA is safe for individuals with quiescent or mildly active IBD, heterogeneity in available trials make it difficult to ascertain precise estimates of treatment effect. This also presents a challenge when determining the specific modes of PA that are beneficial for individuals with quiescent or mildly active IBD. This highlights the need for standardization of the definitions of parameters involved in PA in IBD research.

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CAG

Disclosure of Interest

None Declared

A210 THE BURDEN OF IBD HOSPITALIZATION IN CANADA: AN ASSESSMENT OF THE CURRENT AND FUTURE BURDEN IN A NATION-WIDE ANALYSIS

Background

Hospitalizations pose a significant burden on both the individual and the healthcare system. Those with inflammatory bowel disease (IBD) are at increased risk of hospitalization as compared to the general population due to flaring of disease activity and complications related to IBD. The advent of biologics over the past twenty years may have influenced the rates of hospitalization for IBD.

Purpose

To assess current and forecast the overall hospitalization rates of those with IBD stratified by types of hospitalizations (all cause hospitalizations, IBD-related, and IBD-specific).

Method

Population-based administrative data on hospitalization of IBD (2002-2014) were obtained from: AB, BC, MB, and SK. Data were age and sex standardized to the matching year and aggregated into a representative sample of the Canadian population. Hospitalization rates were assessed as follows: 1. All cause hospitalizations: all admissions regardless of indication; 2. IBD-specific: an admission directly resulting from IBD (e.g., IBD-flare); 3. IBD-related: an admission for IBD, or a symptom or comorbidity associated with IBD (e.g. rheumatoid arthritis). Using prevalence estimates from the provinces, hospitalization rates (per 100 persons with IBD) were calculated, with 95% confidence intervals (CI). Autoregressive Integrated Moving Average models were created to estimate number of hospitalizations and corresponding prevalence to forecast hospitalization rates to 2030 with 95% prediction intervals (PI). Poisson (or negative binomial) regression estimated the Average Annual Percentage Change (AAPC), with 95% CIs, of the forecasted data.

Result(s)

In 2002 there were 35.3 per 100 (95%CI: 34.7, 35.9) all cause hospitalizations for IBD patients and this decreased to 24.9 per 100 (24.5, 25.2) in 2014. Similar trends were seen for IBD-specific hospitalizations [16.8 per 100 (95%CI: 16.4, 17.2) in 2002 to 8.7 per 100 (95%CI: 8.5, 9.0) in 2014] and IBD-related (22.6 per 100 (95%CI: 22.1, 23.1) in 2002 to 13.4 per 100 (95%CI: 13.2, 13.7) in 2014). When forecasted out to 2030 all hospitalization types were significantly decreasing—the AAPC for all cause hospitalizations was -2.12% (95%CI: -2.31, -1.93), -3.77% (95%CI: -4.63, -3.08) for IBD-specific, and -3.09% (95%CI: -3.65, -2.62) for IBD-related. By 2030, the rates of hospitalization are forecasted to be 17.0 per 100 (95%PI: 16.2, 17.9), 4.6 per 100 (95%PI: 3.7, 5.4), and 7.9 per 100 (95%PI: 6.9, 8.9) for all cause, IBD-specific, and IBD-related, respectively.

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Conclusion(s)

In Canada, rates of hospitalizations for those with IBD have decreased from 2002 to 2014. The use of anti-TNF therapy in conjunction with the evolution of clinical monitoring, management and guidelines, likely has contributed to dropping hospitalization rates. Forecast models estimate a continued drop in hospitalization rates out to 2030. Importantly, healthcare resource planning should account for the shift from hospital-based to clinic-centric models of IBD care.

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CIHR

Disclosure of Interest

S. Coward: None Declared, E. Benchimol Consultant of: Hoffman La-Roche Limited and Peabody & Arnold LLP for matters unrelated to medications used to treat inflammatory bowel disease and McKesson Canada and the Dairy Farmers of Ontario for matters unrelated to medications used to treat inflammatory bowel disease., C. Bernstein Grant / Research support from: Unrestricted educational grants from Abbvie Canada, Janssen Canada, Pfizer Canada, Bristol Myers Squibb Canada, and Takeda Canada. Has received research grants from Abbvie Canada, Amgen Canada, Pfizer Canada, and Sandoz Canada and contract grants from Janssen, Abbvie and Pfizer, Consultant of: Abbvie Canada, Amgen Canada, Bristol Myers Squibb Canada, JAMP Pharmaceuticals, Janssen Canada, Pfizer Canada, Sandoz Canada, and Takeda., Speakers bureau of: Abbvie Canada, Janssen Canada, Pfizer Canada and Takeda Canada, J. A. Avina-Zubieta: None Declared, A. Bitton: None Declared, L. Hracs: None Declared, J. Jones Consultant of: Janssen, Abbvie, Pfizer, Takeda, Speakers bureau of: Janssen, Abbvie, Pfizer, Takeda, E. Kuenzig: None Declared, L. Lu: None Declared, S. Murthy: None Declared, Z. Nugent: None Declared, A. Otley Grant / Research support from: Unrestricted educational grants from AbbVie Canada and Janssen Canada, Consultant of: Advisory boards of AbbVie Canada, Janssen Canada and Nestle, R. Panaccione Consultant of: Abbott, AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Celltrion, Cosmos Pharmaceuticals, Eisai, Elan, Eli Lilly, Ferring, Galapagos, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pendopharm, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz, Satisfai Health, Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Theravance Biopharma, Trellus, Viatris, UCB. Advisory Boards for: AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Speakers bureau of: AbbVie, Amgen, Arena Pharmaceuticals, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Gilead Sciences, Janssen, Merck, Organon, Pfizer, Roche, Sandoz, Shire, Takeda Pharmaceuticals, J.-N. Pena-Sanchez: None Declared, H. Singh Consultant of: Pendopharm, Amgen Canada, Bristol Myers Squibb Canada, Roche Canada, Sandoz Canada, Takeda Canada, and Guardant Health, Inc.,, L. Targownik Grant / Research support from: Investigator initiated funding from Janssen Canada, Consultant of: [Advisory board] AbbVie Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, Roche Canada, and Sandoz Canada, J. Windsor: None Declared, G. Kaplan Grant / Research support from: Ferring, Janssen, AbbVie, GlaxoSmith Kline, Merck, and Shire, Consultant of: Gilead, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, and Takeda

A154 CANCERS ASSOCIATED WITH INFLAMMATORY BOWEL DISEASE IN CANADA: A POPULATION-BASED ANALYSIS OF CASES AND MATCHED CONTROLS

Background

Individuals with inflammatory bowel disease (IBD) are known to have a higher risk of digestive tract cancers and cancers associated with immunosuppression. As the IBD population is ageing, age-related cancers may be more commonly diagnosed.

Purpose

To assess whether IBD patients were at a higher odds of incident cancers than their matched controls stratified by age above and below 65 years.

Method

A population-based surveillance study was conducted in Alberta, Canada (April 1, 2002 to March 30, 2018). A validated algorithm identified cases of IBD. Each case was age and sex matched to up to 10 non-IBD cases from the general population and linked to the Alberta provincial cancer registry to extract pathology-confirmed incident cancer. Controls were removed if they were not residents of Alberta at the time the matched case was diagnosed with IBD. Only incident cancers diagnosed after the diagnosis of IBD (or matched indexed date for controls) were considered. Age was calculated based on year of inclusion in the cohort or, if applicable, the year of cancer diagnosis. Cancer diagnoses were classified: bladder, biliary and liver, breast, cervix, colorectal, endometrium, gastrointestinal, gynecological, head and neck, hematological, kidney, lung, melanoma, neurological, non-melanoma, pancreas, prostate, renal and bladder, small intestine, thyroid, and miscellaneous. Odds ratios (OR), with 95% confidence intervals (CI), compared IBD cases to matched controls using conditional logistic regression. Stratified analysis at age 65 (<65 and ≥65) was done for all cancers.

Result(s)

Overall, 3695 incident cancers were diagnosed among 35,763 individuals with IBD as compared to 22,687 cancers among 289,212 controls (OR:1.12; 95%CI: 1.08, 1.16). Those less than 65 years old were at higher odds of developing cancer (1.20; 95%CI: 1.15, 1.26) than those ≥65 (0.97; 95%CI: 0.90, 1.04). Those with IBD had a higher odds biliary and liver (7.41; 95%CI: 5.58, 9.84) and gastrointestinal (2.26; 95%CI: 2.06, 2.48), which including: colorectal (1.78; 95%CI: 1.57, 2.02), pancreas (7.79; 95%CI: 5.53, 10.97), and small intestine (6.59; 95%CI: 4.65, 9.35). Melanoma and non-melanoma, head and neck, and thyroid cancers did not have an increased odds but hematological, lung, neurological, and kidney cancers did show an increased odds among those with IBD. Cancers outside of the gastrointestinal tract were at a lower odds for IBD patients, including: bladder (0.68; 95%CI: 0.54, 0.87), breast (0.72; 95%CI: 0.64, 0.81), gynecological (incl. cervix (0.68; 95%CI: 0.61, 0.78) and endometrium (0.48; 95%CI: 0.34, 0.66), and prostate (0.64; 95%CI: 0.57, 0.73).

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Conclusion(s)

Under the age of 65, individuals with IBD have a higher odds of being diagnosed with cancer than the general population, with cancers of the digestive tract driving this association across the age spectrum. Healthcare providers should be aware of higher occurrence of hematological, neurological, lung and renal cancers in those with IBD.

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CIHR

Disclosure of Interest

S. Coward: None Declared, S. Murthy: None Declared, H. Singh Consultant of: Pendopharm, Amgen Canada, Bristol Myers Squibb Canada, Roche Canada, Sandoz Canada, Takeda Canada, and Guardant Health, Inc., E. Benchimol Consultant of: Hoffman La-Roche Limited and Peabody & Arnold LLP for matters unrelated to medications used to treat inflammatory bowel disease and McKesson Canada and the Dairy Farmers of Ontario for matters unrelated to medications used to treat inflammatory bowel disease., E. Kuenzig: None Declared, G. Kaplan Grant / Research support from: Ferring, Janssen, AbbVie, GlaxoSmith Kline, Merck, and Shire, Consultant of: Gilead, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, and Takeda

A220 ONTARIO POPULATION TRENDS IN INTESTINAL AND EXTRA-INTESTINAL CANCERS OVER 25 YEARS AMONG PERSONS WITH INFLAMMATORY BOWEL DISEASES AND MATCHED CONTROLS

NOT PUBLISHED AT AUTHOR’S REQUEST

A169 THE DIRECT COSTS OF INFLAMMATORY BOWEL DISEASE IN CANADA: A POPULATION-BASED ANALYSIS OF HISTORICAL AND CURRENT COSTS

Background

Inflammatory bowel disease (IBD) is a costly disease to manage due to hospitalizations, regular ambulatory monitoring, and expensive pharmaceutical therapies. While hospitalization rates have fallen, the increased use of biologics have escalated the cost of care to the healthcare system.

Purpose

To assess historical direct healthcare costs of the IBD population in Canada.

Method

Population-based administrative costing data were obtained from: Alberta, British Columbia, and Manitoba. Costs were calculated based on administrative data (2009 to 2016) which captured: hospitalizations, physician costs, ambulatory care such as: emergency visits, day surgery, and colonoscopy (AB only), and medication costs of IBD-specific medications, such as: mesalamine, biologics, steroids, and immunomodulators. Costs were converted to 2020 dollars using the consumer price index. Average annual cost per person (ACPP) was calculated for each province. Using province specific IBD prevalence estimates these ACPP were meta-analyzed to obtain the annual weighted costs, with 95% confidence intervals (CI), and these costs underwent meta-regression to ascertain the average annual change in cost per year. An Autoregressive Integrated Moving Average model was created to estimate the ACPP in 2023 with 95% prediction intervals (PI). Canada-wide total direct care costs of IBD patients, in billions (B), were calculated using the ACPP, Canada-specific IBD prevalence estimates (historical and forecasted), and total Canadian population calculations from Statistics Canada (historical and forecasted).

Result(s)

In 2009 the ACPP was $7000 (95%CI: 5389, 8610), representing $1.18B (95%CI: 0.91B, 1.45B) in direct healthcare costs in Canada for all IBD patients. The ACPP in 2016 was increased to $10,336 (95%CI: 6803, 13869), which equates to $2.37B (95%CI: 1.56B, 3.18B) per year in direct healthcare costs. From 2009 to 2016, the ACPP increased an average of $450 (95%CI: 132, 767) per year. If these historical trends continue to 2023 the ACPP is forecasted to be $13,333 (95%PI: 12827, 13839) per person per year. The largest contributor to these costs is medications—accounting for an estimated 50% of the total costs of IBD patients.

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Conclusion(s)

The direct healthcare cost of IBD has risen steadily from 2009 to 2016 when the healthcare system spent over $10,000 per person with IBD and $2.37B nationwide. The primary driver of costs is medical management. Forecast models estimate that the annual cost may be over $13,000 per person in 2023. However, these estimates do not account for advent and increased uptake of novel biologics and small molecules, nor the downward cost pressure of biosimilars. These costs are those paid directly by the healthcare system and do not account for those born by the individual—it is estimated that the true cost of IBD (direct and indirect) is much higher.

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CIHR

Disclosure of Interest

S. Coward: None Declared, E. Benchimol Consultant of: Hoffman La-Roche Limited and Peabody & Arnold LLP for matters unrelated to medications used to treat inflammatory bowel disease and McKesson Canada and the Dairy Farmers of Ontario for matters unrelated to medications used to treat inflammatory bowel disease., C. Bernstein Grant / Research support from: Unrestricted educational grants from Abbvie Canada, Janssen Canada, Pfizer Canada, Bristol Myers Squibb Canada, and Takeda Canada. Has received research grants from Abbvie Canada, Amgen Canada, Pfizer Canada, and Sandoz Canada and contract grants from Janssen, Abbvie and Pfizer, Consultant of: Abbvie Canada, Amgen Canada, Bristol Myers Squibb Canada, JAMP Pharmaceuticals, Janssen Canada, Pfizer Canada, Sandoz Canada, and Takeda., Speakers bureau of: Abbvie Canada, Janssen Canada, Pfizer Canada and Takeda Canada, J. A. Avina-Zubieta: None Declared, A. Bitton: None Declared, L. Hracs: None Declared, J. Jones Consultant of: Janssen, Abbvie, Pfizer, Takeda, Speakers bureau of: Janssen, Abbvie, Pfizer, Takeda, E. Kuenzig: None Declared, L. Lu: None Declared, S. Murthy: None Declared, Z. Nugent: None Declared, A. Otley Grant / Research support from: Unrestricted educational grants from AbbVie Canada and Janssen Canada, Consultant of: Advisory boards of AbbVie Canada, Janssen Canada and Nestle, R. Panaccione Consultant of: Abbott, AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Celltrion, Cosmos Pharmaceuticals, Eisai, Elan, Eli Lilly, Ferring, Galapagos, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pendopharm, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz, Satisfai Health, Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Theravance Biopharma, Trellus, Viatris, UCB. Advisory Boards for: AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Speakers bureau of: AbbVie, Amgen, Arena Pharmaceuticals, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Gilead Sciences, Janssen, Merck, Organon, Pfizer, Roche, Sandoz, Shire, Takeda Pharmaceuticals, J.-N. Pena-Sanchez: None Declared, H. Singh Consultant of: Pendopharm, Amgen Canada, Bristol Myers Squibb Canada, Roche Canada, Sandoz Canada, Takeda Canada, and Guardant Health, Inc.,, L. Targownik Grant / Research support from: Investigator initiated funding from Janssen Canada, Consultant of: [Advisory board] AbbVie Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, Roche Canada, and Sandoz Canada, J. Windsor: None Declared, G. Kaplan Grant / Research support from: Ferring, Janssen, AbbVie, GlaxoSmith Kline, Merck, and Shire, Consultant of: Gilead, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, and Takeda

Randomized crossover trial of 'Roll-over' technique of abdominal paracentesis versus standard technique in suspected malignant ascites

BACKGROUND

The sensitivity of single abdominal paracentesis for diagnosis of peritoneal carcinomatosis (PC) varies from 40-70%. We hypothesized that rolling-over the patient before paracentesis might improve the cytological yield.

RESEARCH DESIGN AND METHODS

This was a single center pilot study with a randomized cross-over design. We compared the cytological yield of fluid obtained by roll-over technique (ROG) with standard paracentesis (SPG) in suspected PC. In the ROG group, patients were rolled side-to-side thrice, and the paracentesis was done within 1 minute. Each patient served as their own control, and the outcome assessor (cytopathologist) was blinded. The primary objective was to compare the tumor cell positivity between SPG and ROG groups.

RESULTS

Of 71 patients, 62 were analyzed. Of 53 patients with malignancy-related ascites, 39 had PC. Most of the tumor cells were adenocarcinoma (30, 94%) with one patient each having suspicious cytology and one having lymphoma. The sensitivity for diagnosis of PC was (31/39) 79.49% in SPG group and (32/39) 82.05% in ROG group (p = 1.00). The cellularity was similar between both the groups (good cellularity in 58% of SPG and 60% of ROG, p = 1.00).

CONCLUSIONS

Rollover paracentesis did not improve the cytological yield of abdominal paracentesis.

TRIAL REGISTRATION

CTRI/2020/06/025887 and NCT04232384.

COVID-19 induced mesenteric ischemia in a patient with ulcerative colitis and paroxysmal nocturnal haemoglobinuria despite thromboprophylaxis

Inflammatory bowel disease and paroxysmal nocturnal hemoglobinuria (PNH) are both well-known prothrombotic states. However, ongoing thromboprophylaxis is usually effective in such conditions. We report an imbalance that was triggered by COVID-19 infection. There is evidence that COVID-19 infection leads to thrombosis of vessels. The thrombosis of mesenteric vessels can be multifocal and without respiratory symptoms and leads to devastating consequences like resection of large segments of the bowel and lifelong requirement of parenteral nutritional support. We report about a case of ulcerative colitis (in remission) and PNH where COVID-19 resulted in mesenteric ischemia.

Evaluation of the Quality of Undergraduate Full Veneer Crown Preparations at a UK Dental Teaching Hospital

OBJECTIVES

To determine the quality of full veneer crown preparations produced by supervised undergraduate students at a UK dental teaching hospital.

METHODS

One hundred and eighty-five scanned digital dies between October 2019 and March 2021 were obtained. Using cross-sections in four planes, the total angle of convergence, abutment height, margin design and margin depth were evaluated. Statistical comparisons were made by plane, location, material-type, tooth-type, and inter- and intra-arch positions.

RESULTS

Across all preparations the mean total angle of convergence was 24.8° ± 11.7°. and mean abutment height was 3.6 mm ± 1.0 mm. Mandibular and molar teeth were significantly more tapered (P ⟨0.001) and exhibited significantly shorter abutment heights (P ⟨0.001). Chamfer margins were the most frequently observed and mean margin depths ranged from 0.49-1.06 mm. The compliance to recommended taught parameters were 28.1%, 42.7%, 34.1% and 6.5% for total angle of convergence, abutment height, margin design and margin depth, respectively.

CONCLUSIONS

The findings from this study suggest that compliance to taught parameters is poor, especially for molar teeth, and demonstrates the use of digital software in guiding future research and teaching.

Multiparametric MR imaging with diffusion-weighted, intravoxel incoherent motion, diffusion tensor, and dynamic contrast-enhanced perfusion sequences to assess gallbladder wall thickening: a prospective study based on surgical histopathology

OBJECTIVE

To investigate the diagnostic performance of a multiparametric magnetic resonance imaging (MRI) protocol comprising quantitative MRI (diffusion-weighted imaging (DWI), intravoxel incoherent motion (IVIM), diffusion tensor imaging (DTI), and dynamic contrast-enhanced (DCE) perfusion MRI) and conventional MRI in the characterization of gallbladder wall thickening (GWT).

METHODS

This prospective study comprised consecutive adults with GWT who underwent multiparametric MRI between July 2020 and April 2022. Two radiologists evaluated the MRI independently. The final diagnosis was based on surgical histopathology. The association of MRI parameters with malignant GWT was evaluated. The area under the curve (AUC) for the quantitative MRI parameters and diagnostic performance of conventional, and multiparametric MRI were compared. The interobserver agreement between two radiologists was calculated.

RESULTS

Thirty-five patients (mean age, 56 years, 23 females) with GWT (25 benign and ten malignant) were evaluated. The quantitative MRI parameters significantly associated with malignant GWT were apparent diffusion coefficient on DWI (p = 0.007) and mean diffusivity (MD) on DTI (p = 0.013), perfusion fraction (f) on IVIM (p = 0.033), time to peak enhancement (TTP, p = 0.008), and wash in rate (p = 0.049) on DCE-MRI. TTP had the highest AUC of 0.790, followed by MD (0.782) and f (0.742) (p = 0.213) for predicting malignant GWT. Multiparametric MRI had significantly higher sensitivity (90% vs. 80%, p = 0.045) than conventional MRI for diagnosing malignant GWT. The two radiologists' reading had substantial to near-perfect agreement (kappa = 0.639-1) and moderate to strong correlation (interclass correlation coefficient = 0.5-0.88).

CONCLUSION

Multiparametric protocol incorporating advanced sequences improved the diagnostic performance of MRI for differentiating benign and malignant GWT.

KEY POINTS

• Multiparametric MRI had 90% sensitivity and 88% specificity for diagnosing malignant GWT, compared to 80% sensitivity and 88% specificity for conventional CE-MRI. • Among the quantitative MRI parameters, TTP (perfusion-MRI) had the highest AUC of 0.790, followed by MD (0.782) and IVIM-f (0.742). • For most quantitative MRI parameters, there was moderate to strong agreement (ICC = 0.5-0.88).

Frequency, outcomes, and need for intervention in stricturing gastrointestinal tuberculosis: a systematic review and meta-analysis

BACKGROUND

Gastrointestinal strictures impact clinical presentation in abdominal tuberculosis and are associated with significant morbidity.

AIM

To conduct a systematic review of the prevalence of stricturing disease in abdominal and gastrointestinal tuberculosis and response to antitubercular therapy (ATT).

METHODS

We searched Pubmed and Embase on 13th January 2022, for papers reporting on the frequency and outcomes of stricturing gastrointestinal tuberculosis. The data were extracted, and pooled prevalence of stricturing disease was estimated in abdominal tuberculosis and gastrointestinal (intestinal) tuberculosis. The pooled clinical response and stricture resolution (endoscopic or radiologic) rates were also estimated. Publication bias was assessed using the Funnel plot and Egger test. The risk of bias assessment was done using a modified Newcastle Ottawa Scale.

RESULTS

Thirty-three studies reporting about 1969 patients were included. The pooled prevalence of intestinal strictures in abdominal tuberculosis and gastrointestinal TB was 0.12 (95%CI 0.07-0.20, I² = 89%) and 0.27 (95% CI 0.21-0.33, I² = 85%), respectively. The pooled clinical response of stricturing gastrointestinal tuberculosis to antitubercular therapy was 0.77 (95%CI 0.65-0.86, I² = 74%). The pooled stricture response rate (endoscopic or radiological) was 0.66 (95%CI 0.40-0.85, I² = 91%). The pooled rate of need for surgical intervention was 0.21 (95%CI 0.13-0.32, I² = 70%), while endoscopic dilatation was 0.14 (95%CI 0.09-0.21, I² = 0%).

CONCLUSION

Stricturing gastrointestinal tuberculosis occurs in around a quarter of patients with gastrointestinal tuberculosis, and around two-thirds of patients have a clinical response with antitubercular therapy. A subset of patients may need endoscopic or surgical intervention. The estimates for the pooled prevalence of stricturing disease and response to ATT had significant heterogeneity.

Genotoxic and mutagenic potential of 7-methylxanthine: an investigational drug molecule for the treatment of myopia

7-Methylxanthine (7-MX, CAS No. 552-62-5, purity 99.46%) is the first orally administered drug candidate, which showed anti-myopic activity in different pre-clinical studies. In the present study, we investigated the in-vivo genotoxic and mutagenic toxicity of 7-MX in Wistar rats using comet/single-cell gel electrophoresis, chromosomal aberration and micronucleus assays after oral administration. For the single-dose study (72 h), two doses of 7-MX 300 and 2000 mg/kg body weight were selected. For a repeated dose 28 d study, three doses (250, 500, and 1000 mg/kg) of 7-MX were selected. The doses were administered via oral gavage in the suspension form. Blood and major vital organs such as bone marrow, lung and liver were used to perform comet/single cell gel electrophoresis, chromosomal aberration, and micronucleus assays. The in-vitro Ames test was performed on TA98 and TA100 strains. In the chromosomal aberration study, a non-significant increase in deformities such as stickiness, ring chromosome, and endoreduplication was observed in bone marrow cells of 7-MX treated groups. These chromosomal alterations were observed upon treatment with doses of 2000 mg/kg single dose for 72 h and 1000 mg/kg repeated dose for 28 d. At a dose of 500 mg/kg, DNA damage in terms of tail length, tail moment, % tail DNA and the olive tail moment was also found to be non-significant in 7-MX treated groups. The Ames test showed the non-mutagenic nature of 7-MX in both strains of TA98 and TA100 of Salmonella typhimurium with or without metabolic activation. Thus, the present work is interesting in view of the non- genotoxicity and non-mutagenicity of repeated doses of 7-MX.

Disparity in female and Asian representation amongst cardiology journal editorial boards members: a call for empowerment

BACKGROUND

While progress is evident in gender and ethnic representation in the workplace, this disparity remains prevalent in academic positions.

OBJECTIVES

We examined gender and Asian ethnic representation in editorial boards of cardiology journals.

METHODS

A cross-sectional analysis was conducted using publicly available data on Cardiology and Cardiovascular medicine journals in the first quartile of the 2020 Scimago Journal & Country Rank indicator. The proportions of female and Asian editorial board members, associate editors and editors-in-chief were assessed. Subgroup analyses were conducted based on the journal's geographical origin, subspecialty and demographic of the editor-in-chief.

RESULTS

Seventy-six cardiology journals, involving 8915 editorial board members, were included. Only 19.6% of editorial board members were female, 20.8% Asians and 4.0% Asian females. There were less female representation amongst editors-in-chief (9.9%) compared to associate editors (22.3%). European (18.1%) and North American-based journals (21.1%) had higher female representation compared to Asian-based journals (8.7%). There was lower Asian representation in European (18.1%) and North American-based journals (19.9%) compared to Asian-based journals (72.3%). Females were underrepresented in interventional (14.5%) journals, while Asians were underrepresented in general cardiology (18.3%) and heart failure (18.3%) journals. Journals led by female editors-in-chief had significantly higher female representation compared to male-led ones, while journals with Asian editors-in-chief had greater Asian representation compared to non-Asian led ones.

CONCLUSION

This study highlights the female and Asian ethnic underrepresentation in academic roles in cardiology journal editorial boards. Further analysis is needed for other ethnicities, while the community pushes towards gender-balanced and ethnic diversity across editorial boards.

Ultrasound Shear Wave Elastography of Normal Pancreas in Adult Subjects

Background and Purpose Transabdominal ultrasound (US)-based shear wave elastography (SWE) provides an attractive method of estimating pancreatic stiffness. There is limited data on the SWE values of the healthy pancreas in Indian subjects. The current study aimed to evaluate SWE of the normal pancreas.

Methods We performed a study from January 2019 to March 2019. We included adult patients who presented for the US of the upper abdomen for vague abdominal symptoms, unrelated to the pancreas. The SWE values were obtained from the pancreatic head and body. The association of pancreatic SWE with age, gender, fatty liver, chronic liver disease, and cholelithiasis was recorded.

Results During the study period, 205 subjects underwent SWE of the pancreas. The mean age of subjects was 41.3 (standard deviation [SD] 15.3) years. There were 93 males and 112 females. The mean SWE value in the head of the pancreas was 8.98 (SD 2.46 kPa), and that in the body region was 8.67 (SD 2.67 kPa). There was a positive correlation of SWE with age. The SWE of the pancreatic body was significantly higher in patients who had a fatty liver on US (p < 0.05). There was no significant association of SWE of the pancreas with gender, presence of chronic liver disease, or gallstones.

Conclusion The normal values of pancreatic SWE are correlated with age and fatty change in the liver.