Canadian Association Of Gastroenterology Research Articles

A205 PRACTICE PATTERNS FOR EOSINOPHILIC ESOPHAGITIS IN ADULTS VARY WIDELY AMONG CANADIAN GASTROENTEROLOGISTS: INTERIM ANALYSIS OF A NATIONWIDE SURVEY

Abstract Background Eosinophilic esophagitis (EoE) is a chronic allergic, type 2 immune-mediated, condition of the esophagus with increasing prevalence in Canada. Practice patterns among Canadian gastroenterologists are not well described. Aims To identify practice variation among Canadian gastroenterologists who care for adults with EoE. Methods A cross-sectional, web-based survey was distributed to Canadian gastroenterologists through the Canadian Association of Gastroenterology as well as administrations at Canadian universities. Results Of 53 respondents, 68% currently work in an academic setting. 77% manage at least 6 patients with EoE per year, with 19% managing over 50 patients per year. 51% of respondents obtain biopsies in every new patient presenting with an acute food bolus, while 26% take biopsies in less than 50% of cases or never at all. 36% take less than 5 biopsies on initial endoscopy with 23% only taking biopsies from one location in the esophagus. 58% are either unaware of the EoE Endoscopic Reference Score (EREFS) or never use it in clinical practice. Most respondents (72%) prefer proton pump inhibitors as initial therapy while 17% prefer starting multiple treatment modalities. 9% use topical steroids initially. Only 6% keep their patients on topical steroids indefinitely, if started. Preferred dietary approach vary with 36% choosing 6-food elimination diet (FED), 23% 2-FED, 19% 4-FED, 13% milk-only elimination diet, 6% allergy test-directed diet, and 4% elemental diet. Only 17% feel very comfortable starting biologic therapies. When evaluating treatment effectiveness, 23% use improving patient symptoms alone, while 74% include repeat histological assessments. 42% do not regularly screen for adaptive behaviours, such as excessive chewing, or texture modification and avoidance. In those who perform repeat endoscopic evaluation, 13% do so in less than 3 months after starting therapy, 32% in 3-5.9 months, 28% in 6-11.9 months, and 8% after a year. 11% will only repeat endoscopic evaluation if a patient reports symptom recurrence. 64% do not regularly refer to an allergist. For guidance, 59% follow the American Gastroenterology Association 2020 guidelines, 34% American Society of Gastrointestinal Endoscopy 2022 guidelines, 4% British Society of Gastroenterology 2022 guidelines, while 21% do not use any guidelines. 83% feel Canadian guidelines would be useful in their practice. Conclusions EoE practice patterns among Canadian adult gastroenterologists vary widely, with management differing from the current consensus guidelines. Strategies aimed at decreasing these variations, such as the development of Canadian guidelines, are needed to standardize practice. Funding Agencies None

Capsule Endoscopy for the Diagnosis of Suspected Small Bowel Bleeding

   This review discusses the role of capsule endoscopy in diagnosing suspected small bowel bleeding and compares guidelines of the European Society of Gastrointestinal Endoscopy (ESGE), the American College of Gastroenterology (ACG), the American Society for Gastrointestinal Endoscopy (ASGE), the Canadian Association of Gastroenterology (CAG), and the consensus document of 4 Japanese medical societies. European and North American experts recommend capsule endoscopy as a first-line diagnostic modality for suspected small bowel bleeding without life-threatening signs in adult patients when ileocolonoscopy and esophagogastroduodenoscopy failed to be informative. Japanese experts, on the contrary, prefer cross-sectional imaging “from the chest to the pelvis” and consider capsule endoscopy as an alternative.

Canadian Gastroenterology Career Pathway Experiences: Exploring the Gender Divide.

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

A97 DEVELOPMENT OF PREDICTION MODELS FOR THE TRIAGING OF REFERRALS OF INDIVIDUALS WITH SUSPECTED INFLAMMATORY BOWEL DISEASE TO IMPROVE PROMPT ACCESS TO CARE

BackgroundThe negative impact of a delayed inflammatory bowel disease (IBD) diagnosis has been well established. We created a clinical pathway referred to as the “High-Risk IBD clinic” within a centralized referral program in a tertiary referral centre, in order to improve access to subspecialist care for individuals suspected but not yet diagnosed with IBD. Despite the creation of this specialized clinic, wait times continue to be above the recommended benchmarks established by the Canadian Association of Gastroenterology (CAG).AimsThe purpose of our study was to create predictive models to identify factors associated with an IBD diagnosis in order to improve triage of referrals of individuals with features highly suggestive of IBD. We hypothesized that features suggestive of IBD could be used to create discriminating prediction models between IBD and IBS.MethodsWe conducted a retrospective cohort study of referrals to the High-Risk IBD clinic from February 2014 to December 2018. Referral information, investigations, endoscopic findings and final diagnosis were obtained from 316 consented individuals. Information required included symptoms (e.g. diarrhea, abdominal pain, rectal bleeding), risk factors (e.g. family history, rheumatological disease) and investigations (e.g. hemoglobin, CRP, abdominal imaging). Univariate logistic regression was performed to explore the association between factors included in the referral form, and a diagnosis of Crohn’s disease (CD) and ulcerative colitis (UC). For creation of predictive models, any variable with a p-value of <0.1 in univariate logistic regression was selected for entry into the multivariate model for CD and UC.ResultsFor UC, the predictive model included weight loss, the presence of rectal bleeding and abdominal pain. Using these criteria, the sensitivity and specificity of the model were 62.5% and 74.1%, respectively. The negative predictive value (NPV) was high at 94.2%. For CD, the predictive model included male gender, elevated CRP, presence of anemia and presence of weight loss. The sensitivity and specificity of this model were 61.7% and 71.2%, respectively. As for UC, the NPV was also high (89.2%). For IBS, the most common diagnosis encountered in patients referred to the HR-IBD clinic, the model included absence of weight loss, presence of abdominal pain and female gender. The sensitivity and specificity were 71.6% and 64.0%, respectively. The positive predictive value was 60.6% and NPV was 74.5%.ConclusionsWe established predictive tools associated with a final diagnosis of IBD and IBS as a means to expedite the care of individuals with undiagnosed IBD.Funding AgenciesCCC

A100 A PROVINCIAL APPROACH TO ASSESSING ENDOSCOPY PATIENT EXPERIENCE ENHANCES SITE PARTICIPATION AND CANADA-GLOBAL RATING SCALE COMPLIANCE

BackgroundThe Canada-Global Rating Scale (C-GRS) is a web-based, patient centered endoscopy quality improvement tool. It assesses the quality of services a unit provides in two dimensions: clinical quality and patient experience. Endoscopy units submit results to the Canadian Association of Gastroenterology twice a year. In Alberta, units receive an A, B, C or D grade for each of the 12 C-GRS Items and a C-GRS score.The C-GRS promotes that patient feedback is sought annually. Patient feedback is important because it informs practice improvement opportunities. However, survey creation, distribution, analysis and reporting can be time consuming and costly for an endoscopy unit and is a potential barrier to participation.AimsThe purpose of this quality improvement project is to demonstrate how a provincial infrastructure, which includes coordination, management and reporting of an endoscopy patient satisfaction survey, can enhance provincial endoscopy unit survey participation and facilitate C-GRS compliance.MethodsThe Digestive Health Strategic Clinical Network (DHSCN), the Alberta Colorectal Cancer Screening Program and Primary Data Support (PDS) collaborated on the Provincial Endoscopy Patient Experience Survey (PEPES) in 2019. An existing paper survey was adapted to meet the needs of the 50 endoscopy units in AB with the addition of an electronic version. Education about the PEPES process was provided via a webinar and site visits. Each unit was responsible for distribution of the surveys to their patients. PDS coordinated the paper survey process and the DHSCN managed the electronic survey submissions. Paper survey results were merged with electronic PEPES data. A summary report was provided to units and shared with each AHS Zone Endoscopy Executive Leadership Team.ResultsProvincially coordinated implementation of the PEPES fosters compliance with C-GRS criteria. Participating endoscopy units were able to achieve at minimum 9 C-GRS descriptors and improve their C-GRS score in the following 7 of the 12 C-GRS Items: consent, comfort, equality, booking, privacy, aftercare and feedback.Initial enrollment in the PEPES increased with the onset of provincial coordination (Figure 1). However, subsequent participation was negatively impacted by COVID-19 as many endoscopy units in AB were required to decrease their capacity and redeploy staff.ConclusionsA provincially coordinated approach to the management of an endoscopy patient experience survey is an effective way to enhance site participation and improve C-GRS scores. Units can focus on actioning survey results, rather than the burden of survey administration. Future work includes comparison of results across sites allowing for potential provincial equity issues to be addressed. Funding AgenciesNone

A173 EVALUATING VACCINATION IN INFLAMMATORY BOWEL DISEASE – A QUALITY ASSESSMENT STUDY IN THE WINNIPEG HEALTH REGION

BackgroundThe Canadian Association of Gastroenterology published a two-part clinical practice guideline, highlighting that IBD patients may be more susceptible to vaccine preventable diseases. Various studies have demonstrated shortcomings in vaccination rates amongst IBD patients. It is imperative to ensure that an individual’s vaccination status be known prior to starting immunosuppressive therapy; and deficiencies be addressed to optimize patient outcomes.AimsIdentify physician perceived barriers to vaccinations in the IBD cohort.Determine discrepancies in vaccination rates in IBD patients, pre and post-introduction of the clinical tool.MethodsGastroenterologists in the Winnipeg Health Region (WRHA) will be provided with a survey to assess barriers to vaccination. This survey will be used to inform the clinical tool that will be developed to support physicians. The study is divided into a retrospective component (“pre-clinical tool”) and a prospective component (“post-clinical tool”). In the pre-clinical tool assessment, patient charts of new biological starts at St. Boniface Hospital (SBGH); between January – December 2020, will be reviewed to determine vaccination discussions. For the post-clinical tool assessment, SBGH Gastroenterologists will be provided a document containing guideline recommended vaccination schedule for IBD patients. Subsequently, vaccination rates in IBD patients starting biological therapy will be evaluated over the following 3 months.ResultsResponse rates were 90% for the 10 WRHA Gastroenterologists surveyed. Only 55% felt comfortable providing vaccine related care to their IBD patients. Despite being comfortable, 40% correctly identified recommended annual vaccination and 60% accurately identified vaccines that were contraindicated in IBD patients on immunosuppressive therapy. 55% would assess vaccination status with their IBD patients “sometimes,” and 33% state they have “never” provided age-appropriate vaccinations prior to initiation of immunosuppression. Physician related factors (Physician Knowledge) was the most commonly cited obstacle faced in providing immunization care. 80% believed that Primary Care Physicians should keep track and be responsible for administering vaccines to IBD patients. 88% specified that having a clinical tool describing vaccine recommendations would be useful in their practice. Retrospective chart review is in progress and prospective data collection is scheduled to be completed in February 2022.ConclusionsSurvey analysis demonstrates that vaccine practices in WRHA are inadequately addressed; the leading obstacle for physician related factors was knowledge. Though chart review is underway, we anticipate that current vaccination assessments in IBD patients undergoing biological starts are low. We anticipate that rates of vaccinations will improve with the provision of a clinical tool.Funding AgenciesNone

Canadian Association of Gastroenterology (CAG) Position Statement on the Use of Hyoscine-n-butylbromide (Buscopan) During Gastrointestinal Endoscopy.

Hyoscine butylbromide, also known as hyoscyamine or scopolamine, and sold under the trade name Buscopan, is an antimuscarinic agent commonly used to induce smooth muscle relaxation and reduce spasmodic activity of the gastrointestinal (GI) tract during endoscopic procedures. However, the balance between desirable and undesirable (adverse) effects is not clear when used during GI endoscopy. The Clinical Affairs Committee of the Canadian Association of Gastroenterology (CAG) conducted systematic reviews and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations for the use of Buscopan during GI endoscopy. To summarize, we recommend against the use of Buscopan before or during colonoscopy (strong recommendation, high certainty of evidence). We suggest against the use of Buscopan before or during gastroscopy (conditional recommendation, very low certainty of evidence). We suggest the use of Buscopan before or during ERCP (conditional recommendation, very low certainty of evidence). More research is needed to determine whether patients undergoing advanced procedures such as endoscopic mucosal resection or endoscopic submucosal dissection benefit from its use. Buscopan should be used with caution in patients with cardiac comorbidities. According to its product monograph, Buscopan is contraindicated in patients with tachycardia, angina, and cardiac failure. Thus, Buscopan should be used very cautiously in patients with these conditions, and only when the potential benefits of its use outweigh the potential risks in a particular case. Such patients require careful cardiac monitoring in an environment where resuscitation equipment and appropriately trained staff to use it are readily available. According to its product monograph, Buscopan is also contraindicated in patients with prostatic hypertrophy with urinary retention, and therefore, should be used very cautiously in such patients as well, and only when the potential benefits of its use outweigh the potential risks in a particular case. Obtaining a preprocedural history of glaucoma is unlikely to be of value when considering Buscopan use. However, in cases where Buscopan has been used, patients should be counselled postprocedurally and told to present to an emergency facility should they experience eye pain, redness, decreased vision, nausea and vomiting or headache.

The Under-representation of Canadian Women in Gastroenterology from Residency to Leadership.

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

Single-Center Review of Appropriateness and Utilization of Upper Endoscopy in Dyspepsia in the United States.

BackgroundWe compared real-world practice of dyspepsia management to the new American College of Gastroenterology (ACG)/Canadian Association of Gastroenterology (CAG) guidelines 2017.MethodsWe conducted a retrospective, observational study using administrative data to include patients undergoing esophagogastroduodenoscopy (EGD) for dyspepsia.ResultsOut of 122 EGDs, only 30 (24.5%) were deemed appropriate per guidelines. Only 13 (14.1%) patients had undergone both Helicobacter pylori (H. pylori) test and treat and adequate proton pump inhibitor (PPI) before undergoing endoscopy. Nineteen (15.5%) patients had alarm symptoms (weight loss, melena and early satiety). Positivity rate of H. pylori was 36.3%, but only half completed treatment. Twenty-six patients (21.3%) had abnormalities on endoscopy, most commonly gastritis. There were no cases of gastric/esophageal cancer.ConclusionsThe rate of inappropriate upper gastrointestinal endoscopy is higher than the existing literature, likely because of the stricter use of EGD in patients < 60 years. Only one in eight patients underwent the recommended workup before undergoing endoscopy.

A63 REFINING THE CANADIAN ASSOCIATION OF GASTROENTEROLOGY GUIDELINE ON SCREENING IN PERSONS WITH A FAMILY HISTORY OF NONHEREDITARY COLORECTAL CANCER OR ADENOMA: A MODIFIED DELPHI PROCESS

Abstract Background In 2018, the Canadian Association of Gastroenterology (CAG) published an extensive systematic review and guideline on screening in persons with a family history (FHx) of nonhereditary colorectal cancer (CRC) and adenoma. While CAG’s recommendations were evidence-based, some recommendations lacked precision (e.g. ranges for some start ages &amp; intervals) and screening cessation age was not addressed, leading to implementation challenges for practitioners and CRC screening programs. Aims To review and update the evidence since the 2018 guideline and to formulate implementable recommendations in the Ontario context that are aligned with the CAG guideline. Methods ColonCancerCheck (Ontario’s organized CRC screening program) conducted a modified version of the literature search used by CAG (Jan 2017 - Sept 2019). A 19-member expert panel with Canadian and international representatives from endoscopy, primary care, epidemiology, organized CRC screening programs, Ontario’s cancer system and the general public refined the recommendations of the CAG guideline for the purposes of implementation in an organized CRC screening program using a modified Delphi process. This iterative process involved a series of webinars and anonymous survey rounds where the panel reviewed evidence materials and provided online feedback to develop, refine &amp; achieve consensus on screening recommendations in persons with a FHx of CRC/adenoma. Consensus was achieved if ≥75% of members agreed or strongly agreed with the statement. Results Six new systematic reviews and 2 new guidelines were identified. New evidence included data on the absolute risk (10 year &amp; lifetime risk) of CRC by type of FHx, as well as the performance of fecal immunochemical testing (FIT) and barriers to CRC screening in persons with a FHx of CRC. The expert panel participated in 3 webinars and 4 online surveys to arrive at consensus. Panel recommendations and level of consensus will be reported for the 6 statements (Table). Conclusions Building from the CAG guideline, we derived evidence-based and implementable recommendations for screening persons with a FHx of CRC or adenoma. Funding Agencies Ontario Health (Cancer Care Ontario)

A96 GENDER DIFFERENCES IN GASTROENTEROLOGY AND HEPATOLOGY AUTHORSHIP AND EDITORIAL BOARDS

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

COVID-19 Vaccination in Patients With Inflammatory Bowel Disease: Communiqué From the Canadian Association of Gastroenterology.

COVID-19 Vaccination in Patients With Inflammatory Bowel Disease: Communiqué From the Canadian Association of Gastroenterology.

The Burden of Psychiatric Disorders Associated With Orofacial Cleft Pathology Among Children in Ontario, Canada

Background: Individuals with orofacial cleft (OFC) may be at higher risk of developing psychiatric disorders(PD). We determined the risk of psychiatric diagnoses in children with OFC in Canada. Methods: This population-based retrospective cohort study used health administrative data from the province of Ontario, Canada. Children with OFC who were born from April 1, 1994 to March 31, 2017 in Ontario were each matched to five non-OFC children based on sex, date of birth and mother’s age. We determined rate of events and time-to-event for first diagnosis of PD in children aged ≥3 years(y), and for intellectual developmental delay (IDD) from birth. Risk factors for PD and IDD were assessed using 1-way ANOVA for means, Kruskal-Wallis for medians, χ 2 test for categorical variables. Outcomes: There were 3,051 children with OFC (matched to 15,255 controls), of whom 2,515 OFC patients had complete follow-up to the third birthday (matched to 12,575 controls). The mean age to first PD diagnosis was 8.6±4.2y for OFC patients; the cleft palate group had a higher risk (HR 1.33, 95% CI 1.18-1.49). The OFC patients had a higher risk of IDD diagnosis (HR 8.08, 95% CI 7.28-8.97, p<001), especially those with other congenital malformations (HR 4.57, 95% CI 3.95-5.28 p<0.001). Geography (place of living) was a significant risk factor for PD and IDD. Interpretation: Children born with OFC in Ontario had a higher risk of psychiatric diagnosis and IDD compared to controls. Further research is required to better understand the cause of geographical variation and identify potential areas for intervention. Funding: Claudia Malic was supported by the ICES Faculty Scholars Program. Eric Benchimol was supported by a New Investigator Award from the Canadian Institutes of Health Research, Canadian Association of Gastroenterology, and Crohn’s and Colitis Canada. He was also supported by the Career Enhancement Program of the Canadian Child Health Clinician Scientist Program. Conflict of Interest: Simone Vigod reports royalties from UpToDate Inc for authorship of chapters related to depression and pregnancy. The remaining authors have no conflicts of interest to disclose. Ethical Approval: The Research Ethics Board of the Children’s Hospital of Eastern Ontario approved this study and informed consent was not required as per Ontario privacy law.

COVID-19: Framework for the Resumption of Endoscopic Activities From the Canadian Association of Gastroenterology.

COVID-19: Framework for the Resumption of Endoscopic Activities From the Canadian Association of Gastroenterology.

Gastroenterology Practitioner and Trainee Numbers in Canada 2018: Annual Report From the Canadian Association of Gastroenterology.

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

Resident bacteria in the small intestine can shape host drug metabolism through innate lymphoid cell‐derived IL‐22

The ability of the intestinal microbiota to influence drug metabolism has been recognized, however the mechanisms through which this occurs remain relatively unexplored. Recent work in germ‐free mice has demonstrated that conventionalization with specific pathogen free (SPF) microbiota influences the expression of cytochrome P450 (CYP) enzymes in the liver and small intestine (SI), two important sites for drug metabolism. Given that CYP enzymes, including CYP3A11 in mice, account for roughly 75% of total drug metabolism, we sought to investigate the role of specific gut‐residing microbes in shaping the expression and activity of these enzymes. Utilizing PCR arrays, we found that colonization of SPF mice with the immunomodulatory bacteria segmented filamentous bacteria (SFB) altered the expression of various CYP enzymes in the SI (but not liver), with Cyp3a11 being one of the most downregulated genes. Further analysis showed that SFB‐induced IL‐22 production by type 3 innate lymphoid cells (ILC3) correlated with reduced SI Cyp3a11 expression. Additionally, SFB colonization had no effect on the expression of Cyp3a11 in the SI of IL‐22−/− mice or RAG1−/− mice in which ILCs were depleted with anti‐Thy1 antibody. Both SFB colonization and administration of IL‐23, to activate IL‐22 from ILC3, increased the ability of the CYP3A11‐metabolized drug glibenclamide to decrease basal blood glucose levels when administered orally. In mouse SI enteroid cultures, IL‐22 dose‐dependently reduced the expression of Cyp3a11 and decreased the ability of SI enteroids to metabolize CYP3A11 specific substrates, effects that were blocked by the STAT3 inhibitor Stattic. Finally, when applied to human ileal organoids, IL‐22 induced robust changes in the transcriptome, with substantial effects on drug metabolism pathways centred around CYP3A. Our data suggest that specific gut‐resident microbes can influence the expression and activity of the drug metabolizing enzyme CYP3A11. This involves the production of IL‐22 by small intestinal ILC3, which down regulates CYP3A11 in the SI epithelium. These findings provide an understanding of how the intestinal microbiota modulates host drug metabolism, and how microbiota‐immune cell crosstalk may influence the efficacy and toxicity of various drugs.Support or Funding InformationAlberta Innovates, Canadian Association of Gastroenterology, Canadian Institute of Health Research

2019 Harry Shwachman Award

The Shwachman Award is presented annually by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) to an individual who has made major, lifelong scientific or educational contributions to the field of pediatric gastroenterology, hepatology, or nutrition in North America. The 2019 Shwachman Award recipient is Anne Marie Griffiths, MD, FRCPC, Professor, in the Department of Paediatrics at the University of Toronto and former Chief and Fellowship Training Program Director in the Division of Gastroenterology, Hepatology and Nutristion at the Hospital for Sick Children (SickKids) in Toronto. Dr Griffiths is also co-lead for the SickKids IBD Centre, and holds the Northbridge Chair in Pediatric IBD. Anne is a shining star as a scientist, clinician, educator, and mentor in the field of pediatric inflammatory bowel diseases (IBD), and a guiding star to her many trainees and mentees. Anne was born in Montreal, Québec and moved to Toronto, Ontario as a child. She remembers Montreal fondly, citing Dr Wilder Penfield, a neuroscientist and surgeon (and namesake for Penfield Avenue, which runs through McGill University's downtown campus) as one of her favorite scientists. She gained her sense of scholarship, leadership, and commitment from her parents, themselves spiritual leaders in their community. Anne completed undergraduate and medical studies at the University of Toronto, and her residency in pediatrics and pediatric gastroenterology training at SickKids. A lifelong learner, she returned to University of Toronto while junior faculty to complete graduate training in Clinical Epidemiology to ensure that her ongoing clinical research remained of the highest standards. At SickKids, Anne built her legacy—impactful scientific research, the empathetic care of children, and mentorship of a generation of pediatric gastroenterologists who have themselves become international leaders in the field. Anne states that she was influenced later in her medical career to pursue scientific research by her colleagues and mentors at SickKids. In particular, Peter Durie and Phil Sherman (both former Shwachman recipients) played a profound role in her growth as a scientist through inspiration and career facilitation. This inspiration has resulted in more than 300 peer-reviewed publications to date. Observations in the SickKids IBD clinic of the familiality of Crohn disease and ulcerative colitis in young patients prompted her with Innovation funding from the SickKids Foundation to begin collecting DNA from multiplex families, when the study of genetic susceptibility in complex disorders was just beginning. Becoming a leader in the genetics of pediatric IBD, Anne went on to collaborate and co-author multiple publications with the North American and International IBD Genetics consortia. More recently, her knowledge about the genetics of IBD and foresight in banking DNA from affected children and their parents has contributed to the discovery of multiple monogenic forms of Very Early Onset IBD. In addition, Anne developed multiple measurement tools, which have become essential to clinical trials in pediatric IBD, including the Pediatric Crohn's Disease Activity Index (with Jeffrey Hyams), the Pediatric Ulcerative Colitis Activity Index (with Dan Turner), and the IMPACT questionnaire for quality of life (with Anthony Otley). More recently, her leadership skills and scientific acumen were recognized by being nominated as the Principal Investigator of the Canadian Children IBD Network: A Joint Partnership of CIHR and the CH.I.L.D. Foundation. Her quietly effective leadership and strong sense for the needs of the IBD community continue to be recognized both nationally and internationally. Anne's impact is felt most strongly by her mentees. She has directly trained or mentored a large cadre of gastroenterologists and scientists who currently hold leadership positions in more than 20 countries around the world. In addition, her leadership in making SickKids an IBD clinical and research center of excellence and her work as Fellowship Director and Division Head allowed Anne to attract trainees to SickKids who are now international leaders in IBD, liver disease, nutrition, pancreatic illnesses, and other specialties. Anne has always had the uncanny ability to “skate where the puck is going, not where it has been” (a quote from Wayne Gretzky's father, Walter Gretzky) when it comes to IBD research. However, she only occasionally skated there by herself, instead choosing to point her trainees in the direction of the most important IBD research questions and allowing them to build their own careers with their guidance. Anne has raised her 4 lovely and successful children, Gerald, Joanna, Malcolm, and Christopher, together with her lifelong partner Jonathan. The children have careers in law, business, and medicine. In addition to her ongoing professional career, Anne cherishes time with her 3 young grandchildren, as well as experiencing other cultures through international travels with Jonathan and her family. The honor of the Shwachman Award comes after Anne received numerous international awards for her contribution to gastroenterology in recent years. These include: induction into the International Organization for the Study of IBD (IOIBD) (2015), The Dr. August von Hauner Medal from the University of Munich (2017), the Physician Research Award for Career Excellence from SickKids (2018), the R.D. McKenna Memorial Lecturer Award from the Canadian Association of Gastroenterology (2019), and the American Association of Gastroenterology Institute Research Mentor Award (2019). The latter was particularly memorable because it was awarded through nomination by many of her current and former trainees. The NASPGHAN Shwachman Award encapsulates a lifetime of contributions Dr Griffiths has made to the fields of clinical care and research in pediatric IBD, and her work to expand pediatric gastroenterology overall through training and mentorship of the next generation of leaders in our field. Congratulations Anne!

Response to the Joint Canadian Association of Gastroenterology and Crohn's Colitis Canada Position Statement on Biosimilars for the Treatment of Inflammatory Bowel Disease.

Response to the Joint Canadian Association of Gastroenterology and Crohn's Colitis Canada Position Statement on Biosimilars for the Treatment of Inflammatory Bowel Disease.

A245 IMPROVING KNOWLEDGE TRANSFER OF PREVENTATIVE CARE IN INFLAMMATORY BOWEL DISEASE USING ELECTRONIC LEARNING

Abstract Background Inflammatory bowel disease (IBD) is a complex chronic disease and it is imperative that gastroenterologists are familiar with the unique needs of the IBD patient. An important part of management involves education surrounding the general health maintenance needs of this patient population, especially those on immunomodulator and biologic therapy or those being considered for such treatment. A recent study showed that Canadian GI trainees are uncomfortable managing preventative care in IBD including vaccinations and bone protection. Using educational videos for trainees to improve core knowledge of these concepts remains unclear. Aims Assess educational efficacy of a core training module on trainee confidence and knowledge on preventative care in IBD. Methods This study assessed a preventative care in IBD video used as an educational tool in the University of Toronto GI trainee program as part of the annual GI in-training objective structured clinical examination (OSCE). Prior to the OSCE, a randomly selected cohort of trainees were provided the preventative care video. The remaining trainees prepared for the OSCE as standard. At the OSCE, one station asked all trainees to address preventative care in IBD with a standardized patient. Following the OSCE, a standardized evaluation of trainee confidence and degree of knowledge on vaccination, cancer screening, bone health, and mental health in IBD patients was performed. These evaluations and OSCE score were then compared between both cohorts. Data was analyzed using a t-test and p&amp;lt;0.05 was considered significant. Results A total of 10 subjects took part in the study. 5 subjects were exposed to the video prior to the OSCE and 5 were not exposed. Overall total score for trainees who had seen the video prior to the OSCE had a mean score of 85.3% (38.4/45) compared to those who had not seen the video prior had a mean score of 65.3% (29.4/45) with a p = 0.03. Global score in those exposed to the video was 70% (3.5/5) compared to 48% (2.4/5) in the unexposed group with a p= 0.006. Upon assessment of individuals topics, there was a trend in improved knowledge of vaccination and mental health screening in those exposed vs. unexposed to the educational video (52.6% vs. 32.6%, and 80% vs. 20%, respectively). No significant difference was identified between groups with respect to cancer screening and bone health. Conclusions Our study shows evidence that use of educational videos was efficacious with respect to GI trainee confidence and knowledge surrounding key concepts in preventative care of IBD patients. This exposure allows for improved patient education and management and lead to better-quality patient care. Overall, this study identifies a knowledge gap in trainee education and highlights the need for development of training tools to improve overall management of this complex and dynamic disease. Funding Agencies CAGVideo was a CAG accredited educational material, and supported by an educational grant from the Canadian Association of Gastroenterology and Abbvie Canada

A139 CANADIAN GASTROENTEROLOGY CAREER PATHWAY EXPERIENCES: A GENDER DIVIDE UNDER EXAMINATION

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