Adaptation and Validation of a Questionnaire to Measure Satisfaction With Telephone Care Among Individuals Living With Inflammatory Bowel Disease

Background

Individuals with inflammatory bowel disease (IBD) require routine medical follow-up. The usage of telephone care (TC) appointments increased because of the coronavirus disease 2019 (COVID-19) pandemic. We aimed to adapt a questionnaire to evaluate satisfaction with TC use and validate it among IBD individuals.

Methods

A committee of experts adapted the Telehealth Usability Questionnaire to the TC context and validated its use in individuals with IBD. This committee included three IBD gastroenterology care providers (GCPs), two IBD-patient partners, and two healthcare researchers. The committee evaluated the content validity of the adapted items to measure TC satisfaction. A pilot study assessed the readability and usability of the questionnaire. Individuals with IBD in Saskatchewan completed an online survey with the adapted questionnaire between December 2021 and April 2022. Data were analyzed using descriptive and correlational techniques. Psychometric analyses were conducted to examine the reliability and validity of the questionnaire.

Results

The committee of experts developed the Telephone Care Satisfaction Questionnaire (TCSQ patient), with 16 items and one overall item for TC satisfaction. After the pilot, 87 IBD individuals participated in the online survey. A strong correlation was observed between the 16-item standardized level of TC satisfaction and the overall item, r = 0.85 (95%CI 0.78-0.90, p < 0.001). The TCSQ patient had optimal internal reliability (α = 0.96). Two dimensions were identified in the exploratory factor analysis (i.e., TC usefulness and convenience).

Conclusion

The TCSQ patient is a valid and reliable measure of TC satisfaction among individuals with IBD. This questionnaire demonstrated excellent psychometric properties and we recommend its use.

Exploring the Experiences of Virtual Inflammatory Bowel Disease Care in Saskatchewan

BACKGROUND

Individuals with inflammatory bowel disease (IBD) require life-long interactions with the healthcare system. Virtual care (VC) technologies are becoming increasingly utilized for accessing healthcare services. Research related to the use of VC technology for the management of IBD in Canada is limited. This study aimed to examine the VC experiences from the perspectives of individuals with IBD and gastroenterology care providers (GCPs).

METHODS

A patient-oriented, qualitative descriptive approach was used. Semi-structured interviews were completed with individuals with IBD and GCPs. Data were analyzed using an inductive content analysis approach.

RESULTS

A total of 25 individuals with IBD and five GCPs were interviewed. Three categories were identified: benefits of virtual IBD care delivery, challenges of virtual IBD care delivery, and optimizing IBD care delivery. Individuals with IBD and GCPs were satisfied with the use of VC technology for appointments. Participants believed VC was convenient and allowed enhanced access to care. However, VC was not considered ideal in some instances, such as during disease flares or first appointments. Thus, a blended use of virtual and in-person appointments was suggested for individualized care.

CONCLUSIONS

The virtual method of connecting patients and providers is deemed useful for routine appointments and for persons living in rural areas. VC is becoming more common in the IBD care environment. Nurses are in a key position to facilitate and enhance virtual IBD care delivery for the benefit of both individuals living with IBD and providers.

Guselkumab in Patients With Moderately to Severely Active Ulcerative Colitis: QUASAR Phase 2b Induction Study

BACKGROUND & AIMS

The QUASAR Phase 2b Induction Study evaluated the efficacy and safety of guselkumab, an interleukin-23p19 subunit antagonist, in patients with moderately to severely active ulcerative colitis (UC) with prior inadequate response and/or intolerance to corticosteroids, immunosuppressants, and/or advanced therapy.

METHODS

In this double-blind, placebo-controlled, dose-ranging, induction study, patients were randomized (1:1:1) to receive intravenous guselkumab 200 or 400 mg or placebo at weeks 0/4/8. The primary endpoint was clinical response (compared with baseline, modified Mayo score decrease ≥30% and ≥2 points, rectal bleeding subscore ≥1-point decrease or subscore of 0/1) at week 12. Guselkumab and placebo week-12 clinical nonresponders received subcutaneous or intravenous guselkumab 200 mg, respectively, at weeks 12/16/20 (uncontrolled study period).

RESULTS

The primary analysis population included patients with baseline modified Mayo scores ≥5 and ≤9 (intravenous guselkumab 200 mg, n = 101; 400 mg, n = 107; placebo, n = 105). Week-12 clinical response percentage was greater with guselkumab 200 mg (61.4%) and 400 mg (60.7%) vs placebo (27.6%; both P < .001). Greater proportions of guselkumab-treated vs placebo-treated patients achieved all major secondary endpoints (clinical remission, symptomatic remission, endoscopic improvement, histo-endoscopic mucosal improvement, and endoscopic normalization) at week 12. Among guselkumab week-12 clinical nonresponders, 54.3% and 50.0% of patients in the 200- and 400-mg groups, respectively, achieved clinical response at week 24. Safety was similar among guselkumab and placebo groups.

CONCLUSIONS

Guselkumab intravenous induction was effective vs placebo in patients with moderately to severely active UC. Guselkumab was safe, and efficacy and safety were similar between guselkumab dose groups.

CLINICALTRIALS

gov number: NCT04033445.

Time for a Gut Check: A Qualitative Study of Proposed Interventions to Address Gender Inequality in Gastroenterology

Background

Gender inequalities persist in medicine, particularly in some speciality fields where fewer women are employed. Although previous research has suggested potential interventions to broadly address gender inequality in medicine, no research has focused on interventions in the field of gastroenterology. The purpose of this research was to engage women in the field of gastroenterology in Canada, to identify interventions with potential to be effective in addressing gender inequality.

Methods

A World Café was hosted in 2019 to discuss gender inequality and interventions in gastroenterology. Twelve women employed in the field of gastroenterology (i.e. physicians, nurses, research staff, and trainees) were purposively recruited and participated in the event. The discussion rounds were audio-recorded, transcribed, and thematic analyses was conducted using Braun and Clarke's principles.

Results

Three key themes identifying potential interventions to address gender inequality in gastroenterology were generated: (1) Education; (2) Addressing institutional structures and polices; and 3) Role modelling and mentorship. Participants indicated that interventions should target various stakeholders, including both women and men in gastroenterology, young girls, patients, and administrators.

Conclusion

Many of the interventions identified by participants correspond with existing research on interventions in general medicine, suggesting that institutional changes can be made for maximum effectiveness. Some novel interventions were also identified, including publicizing instances of gender parity and supporting interventions across the educational and professional lifecourse. Moving forward, institutions must assess their readiness for change and evaluate existing policies, programs, and practices for areas of improvement.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Access to and Models of Care

Rising compounding prevalence of inflammatory bowel disease (IBD) (Kaplan GG, Windsor JW. The four epidemiological stages in the global evolution of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol. 2021;18:56-66.) and pandemic-exacerbated health system resource limitations have resulted in significant variability in access to high-quality, evidence-based, person-centered specialty care for Canadians living with IBD. Individuals with IBD have identified long wait times, gaps in biopsychosocial care, treatment and travel expenses, and geographic and provider variation in IBD specialty care and knowledge as some of the key barriers to access. Care delivered within integrated models of care (IMC) has shown promise related to impact on disease-related outcomes and quality of life. However, access to these models is limited within the Canadian healthcare systems and much remains to be learned about the most appropriate IMC team composition and roles. Although eHealth technologies have been leveraged to overcome some access challenges since COVID-19, more research is needed to understand how best to integrate eHealth modalities (i.e., video or telephone visits) into routine IBD care. Many individuals with IBD are satisfied with these eHealth modalities. However, not all disease assessment and monitoring can be achieved through virtual modalities. The need for access to person-centered, objective disease monitoring strategies, inclusive of point of care intestinal ultrasound, is more pressing than ever given pandemic-exacerbated restrictions in access to endoscopy and cross-sectional imaging. Supporting learning healthcare systems for IBD and research relating to the strategic use of innovative and integrative implementation strategies for evidence-based IBD care interventions are greatly needed. Data derived from this research will be essential to appropriately allocating scarce resources aimed at improving person-centred access to cost-effective IBD care.

An Exploratory Study of Health-related Quality of Life and Care Experiences in Older Adults with Inflammatory Bowel Disease

Canada has one of the highest rates of inflammatory bowel disease (IBD), with older adults as the fastest-growing group of individuals affected. This exploratory mixed methods study aimed to understand perceived health-related quality of life and care experiences in older adults with IBD. Participants greater than 60 years of age, who were diagnosed with IBD, and who lived in Saskatchewan, Canada were invited to participate in both an online survey and telephone interview. Seventy-three respondents completed the survey, and 18 participants were interviewed. Most individuals were diagnosed before age 60, believed their IBD was well controlled, believed their current treatment was useful, and were satisfied with their care. Individuals also reported a moderate health-related quality of life. However, collaborative management of IBD care between providers and older adults with IBD was identified as an area with room for improvement. Strategies to enhance disease self-management and engaged chronic illness care are critical.

A84 FACTORS ASSOCIATED WITH HIGH LEVELS OF TELEPHONE CARE SATISFACTION AMONG INDIVIDUALS WITH INFLAMMATORY BOWEL DISEASE

Background

Individuals with inflammatory bowel disease (IBD) require regular medical follow-up with gastroenterology care providers. Individuals in rural areas face barriers in assessing specialized IBD care. Virtual care (VC) may act as a solution. The coronavirus disease 2019 pandemic increased the use of VC, particularly telephone care (TC) appointments in Saskatchewan, Canada. There is limited evidence around the levels and factors associated with satisfaction with TC among individuals with IBD.

Purpose

This study aims to measure satisfaction with TC in individuals with IBD who live in Saskatchewan, Canada, and evaluate the factors associated with TC satisfaction.

Method

A cross-sectional study was conducted among individuals with IBD through an online survey between December 2021 and April 2022 in Saskatchewan. The Telephone Care Satisfaction Questionnaire for individuals with IBD (TCSQ-patient) was a 16-item questionnaire used to measure TC satisfaction on a scale from 1 (very dissatisfied) to 7 (very satisfied). The online survey also included the Quality of Care Through the Patient’s Eyes-IBD (QUOTE-IBD) questionnaire, Short Inflammatory bowel disease questionnaire (SIBDQ), and demographic questions. Factors associated with TC satisfaction were explored using linear regression models. A backward model building strategy was used, and 95% confidence intervals (95%CI) were reported.

Result(s)

In total, 87 individuals with IBD participated in the study. Among the study participants, 54 (64.3%) had Crohn's disease, 53 (61.6%) were female, 60 (69.8%) lived in urban centres, and 37 (43.5%) were between 41-59 years old. The mean satisfaction with TC was 5.70 (SD=0.94). In addition, the means of the QUOTE-IBD and SIBDQ were, respectively, 8.96 (SD=1.70) and 48.14 (SD=13.02). In the bivariate analysis, area of residence (rural vs. urban) and health related quality of life quality (SIBDQ>50 vs SIBDQ<50) were associated with satisfaction with TC, respectively, 0.47 (95%CI 0.02-0.91) and 0.48 (95%CI 0.08-0.88). Adjusting by gender, age group, type of disease, and health care provider managing IBD, we identified that the satisfaction with TC was 0.48 (95%CI 0.02-0.94) higher among individuals with IBD living in rural Saskatchewan in comparison to their urban counterparts.

Conclusion(s)

Individuals living with IBD in Saskatchewan reported high levels of satisfaction with TC. Rural residence is associated with higher levels of TC satisfaction. These results could help in the promotion of TC utilization and improve access to specialized IBD care, especially among those living in rural areas.

Please acknowledge all funding agencies by checking the applicable boxes below

Other

Please indicate your source of funding;

Saskatchewan Health Research Foundation (SHRF)

Disclosure of Interest

None Declared

A83 ADAPTATION AND VALIDATION OF QUESTIONNAIRES TO MEASURE SATISFACTION WITH TELEPHONE CARE AMONG IBD PATIENTS AND GASTROENTEROLOGY CARE PROVIDERS

Background

People living with inflammatory bowel disease (IBD) require regular medical follow-up, which could be challenging for individuals living in rural areas and those who have limited access to specialized care. Telephone care (TC) could improve health care by increasing access to specialized care. The Covid-19 pandemic resulted in increased use of virtual care, which was predominantly TC in Saskatchewan (SK) , Canada. There are no validated questionnaires to measure satisfaction with TC among IBD patients and gastrointestinal care providers (GCPs).

Purpose

This study aimed to adapt and validate a questionnaire to evaluate the satisfaction of IBD individuals and GCPs with TC in SK, Canada.

Method

The Telehealth Usability Questionnaire was adapted to the IBD TC context by a committee of experts, comprised of three IBD GCPs, two IBD-patient partners, and two health care researchers. Two questionnaires were generated -: the Telephone Care Satisfaction Questionnaire (TCSQ) for patients (IBD-TCSQ-patient) and GCPs (IBD-TCSQ-provider). The committee evaluated the content validity of the adapted questionnaires. A pilot assessed the readability and usability of the questionnaire items. Subsequently, individuals living with IBD in SK and GCPs completed an online survey with the TCSQ-patient and IBD-TCSQ-provider questionnaires in the winter of 2022. Data were analysed using descriptive and correlational techniques. Psychometric analyses were conducted to examine the reliability and validity of the TCSQ-patient, but not for the TCSQ-provider due to small sample size.

Result(s)

The IBD-TCSQ-patient and IBD-TCSQ-provider questionnaires were developed, each with 16 individual items and one question on global TC satisfaction. The pilot demonstrated good readability and usability of the questionnaires. Then, 87 IBD individuals completed the IBD-TCSQ-patient and six GCPs the IBD-TCSQ-provider. The standardized level of TC satisfaction for the 16-item IBD-TCSQ-patient was 5.70 (SD=0.94) on a scale from 1.00-7.00. All items of the IBD-TCSQ-patient were significantly correlated (p<0.001). A strong correlation was observed between the 16-item standardized TC satisfaction and its overall item r=0.85 (p<0.001). The IBD-TCSQ-patient had optimal internal reliability (α=0.96). Two factors were identified in the exploratory factor analysis. Factor 1 focused on TC convenience while factor 2 addressed TC usability. Regarding the IBD-TCSQ-provider questionnaire, the standardized level of TC satisfaction was 5.76 (SD=0.68) on a scale from 1.00 to 7.00.

Conclusion(s)

We generated questionnaires to measure satisfaction with TC among individuals living with IBD and GCPs. The study results confirmed good validity and reliability of the IBD-TCSQ-patient questionnaire. The IBD-TCSQ-provider questionnaire was adapted; subsequent studies could assess its validity and reliability among GCPs nationally. These questionnaires could help identify opportunities for improvement and utilization of TC among IBD patients and GCPs.

Please acknowledge all funding agencies by checking the applicable boxes below

Other, None

Please indicate your source of funding;

Saskatchewan Health Research Foundation (SHRF)

Disclosure of Interest

None Declared

Patient-Centered Access to IBD Care: A Qualitative Study

Background

Canada has the highest global age-adjusted incidence and prevalence rates of inflammatory bowel disease (IBD). Due to IBD patient volumes and limited resources, challenges to timely access to specialty care have emerged. To address this gap, the aim of this paper was to understand the experiences and perspectives of persons living with IBD with a focus on accessing health care.

Methods

Using a qualitative descriptive approach, patients diagnosed with IBD (≥18 years of age) were purposively sampled from rural and urban gastroenterology clinics and communities across Canada. Co-facilitated by a researcher and patient research partner, 14 focus groups were recorded, transcribed, and coded for themes. Thematic analysis was used to ascertain the congruence or discordance of IBD specialty care access experiences.

Results

A total of 63 individuals participated in the study. The majority of participants were female (41/63, 65%) and from urban/suburban regions (33/63, 52%), with a mean age of 48.39 (range 16-77 years). The analysis generated three main themes: (1) need for patient to be partner, (2) adapting IBD care access to individual context, and (3) patient-defined care priorities should guide access to IBD care.

Conclusions

The complexity of specialty care access for IBD patients cannot be underestimated. It is vital to possess a robust understanding of healthcare system structures, processes, and the impact of these factors on accessing care. Using a patient-centered exploration of barriers and facilitators, IBD specialty care access in Canada can be better understood and improved on provincial and national levels.

POLYMYALGIA RHEUMATICA AFTER MRNA COVID-19 VACCINATION

Introduction

Polymyalgia rheumatica (PMR) is an inflammatory disorder characterized by muscle pain and stiffness. We present a 67-year-old man who developed PMR after immunization with the mRNA COVID-19 vaccine.

Case Description

A 67-year-old male with a history of viral pericarditis, non-ischemic cardiomyopathy, Raynaud's phenomenon, and prostate cancer presented for evaluation of acute-onset proximal muscle pain and weakness, extreme fatigue, malaise, and weight loss. Symptoms developed 10 days after the first dose of the mRNA COVID-19 vaccine. No associated fever or skin rashes. No history of natural COVID-19 infection. A workup for malignancy was negative. CRP and ESR were elevated. ANA was positive (1:80, speckled pattern). ENAs were negative. CK and aldolase were normal. He had low IgG at 328 mg/dL with normal IgA and IgM. However, repeat IgG levels a week later were normal (1130 mg/dL), raising the possibility of a laboratory error. Lymphocyte subsets in peripheral blood were normal. IgG titers to the SARS-COV2 spike and nucleocapsid proteins were consistent with COVID-19 immunity from prior immunization. He was treated with low-dose oral prednisone with resolution of his symptoms and has been slowly tapering prednisone as tolerated.

Discussion

This case report raises the possibility that PMR may be triggered by an immune response to the mRNA COVID-19 vaccine in susceptible individuals. However, further studies involving a larger population are required to assess whether this association is causative or rather coincidental.

Health care utilization differences between First Nations people and the general population with inflammatory bowel disease: a retrospective cohort study from Saskatchewan, Canada

BACKGROUND

Indigenous people in Canada often face barriers to access specialized care, with limited data in evaluating health care utilization among Indigenous people with inflammatory bowel disease (IBD). We aimed to compare health care utilization between First Nations patients and those in the general population diagnosed with IBD in Saskatchewan.

METHODS

We conducted a patient-oriented, population-based, retrospective cohort study by linking administrative health databases of Saskatchewan between fiscal years 1998/99 and 2017/18. We designed and completed this study in partnership with Indigenous patients and family advocates. We applied a validated algorithm to identify IBD incident cases and then used the self-declared First Nations status variable to divide those cases. We applied a 1:5 ratio for age and sex matching and used Cox proportional models to assess associations. Hazard ratios (HRs) and 95% confidence intervals (CIs) were reported.

RESULTS

We created a matched cohort with 696 IBD incident cases: 116 First Nations patients and 580 patients in the general population. We observed differences between the groups for IBD-specific hospital admissions (HR 1.33, 95% CI 1.01-1.75), IBD-related hospital admissions (HR 1.55, 95% CI 1.20-2.01), medication claims for IBD (HR 0.52, 95% CI 0.41-0.65) and 5-aminosalicylic acid claims (HR 0.56, 95% CI 0.45-0.71) adjusting by rural or urban residence and diagnosis type. There were no significant differences in the hazard rate of outpatient gastroenterology visits (HR 1.13, 95% CI 0.90-1.41), colonoscopies (HR 1.14, 95% CI 0.92-1.41) and surgeries for IBD (HR 1.14, 95% CI 0.80-1.64).

INTERPRETATION

We identified that First Nations patients diagnosed with IBD had a higher rate of hospital admissions owing to IBD than patients in the general population diagnosed with IBD. We also found an inverse association between First Nations status and having prescription medication claims for IBD.

Perceived Barriers to Professional Equality Among Women in Gastroenterology

Although significant progress relating to professional equality among men and women in medicine has been made over the past few decades, evidence derived from the medical literature suggests that inequity persists with respect to income, attainment of leadership positions, and professional advancement. These inequities have been observed to be more pronounced in gastroenterology. Literature relating to gender-specific barriers to professional equity in gastroenterology is limited. This qualitative study explored perceived barriers to professional equality among women in gastroenterology in Canada through focus groups using a World Café Approach. Several perceived barriers to professional equality were identified. Identification of barriers to professional equality is an important first step to creating meaningful interventions that address the root causes of gender-related inequity in gastroenterology.

Composition and Stability of the Vaginal Microbiota of Pregnant Women With Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel disease (IBD) is common in women of childbearing years, and active IBD during pregnancy is associated with increased rates of preterm delivery and low-birth-weight newborns. Changes in the vaginal microbiome have been associated with preterm delivery. We aimed to determine the taxonomic composition of the vaginal microbiota at 3 time points during pregnancy in a population of women with IBD.

METHODS

Participants were recruited from the patient registry of the Preconception and Pregnancy IBD Clinic at Royal University Hospital in Saskatoon, Canada. Self-collected vaginal swabs were obtained from patients at each trimester. Microbiota profiles were created by cpn60 amplicon sequencing.

RESULTS

We characterized the vaginal microbiota of 32 pregnant participants with IBD (33 pregnancies) during each trimester. A total of 32 of 33 pregnancies resulted in a live birth with 43.8% (n = 14 of 32, 2 missing) by caesarean section; 2 of 32 were preterm. Microbiota compositions corresponded to previously described community state types, with most participants having microbiota dominated by Lactobacillus crispatus. In 25 of 29 participants in which samples were available for more than 1 time point, there was no change in the community state type over time. Prevalence of Mollicutes (Mycoplasma and/or Ureaplasma) was significantly higher in pregnant participants with IBD than in a previously profiled cohort of 172 pregnant women without IBD who delivered at term.

CONCLUSIONS

The vaginal microbiome of participants with IBD was stable throughout pregnancy. Prevalence of Mollicutes, which has been associated with preterm delivery, warrants further study in this patient group.

Increasing Prevalence and Stable Incidence Rates of Inflammatory Bowel Disease Among First Nations: Population-Based Evidence From a Western Canadian Province

BACKGROUND

There is limited to no evidence of the prevalence and incidence rates of inflammatory bowel disease (IBD) among Indigenous peoples. In partnership with Indigenous patients and family advocates, we aimed to estimate the prevalence, incidence, and trends over time of IBD among First Nations (FNs) since 1999 in the Western Canadian province of Saskatchewan.

METHODS

We conducted a retrospective population-based study linking provincial administrative health data from the 1999-2000 to 2016-2017 fiscal years. An IBD case definition requiring multiple health care contacts was used. The prevalence and incidence data were modeled using generalized linear models and a negative binomial distribution. Models considered the effect of age groups, sex, diagnosis type (ulcerative colitis [UC], Crohn disease [CD]), and fiscal years to estimate prevalence and incidence rates and trends over time.

RESULTS

The prevalence of IBD among FNs increased from 64/100,000 (95% confidence interval [CI], 62-66) in 1999-2000 to 142/100,000 (95% CI, 140-144) people in 2016-2017, with an annual average increase of 4.2% (95% CI, 3.2%-5.2%). Similarly, the prevalence of UC and CD, respectively, increased by 3.4% (95% CI, 2.3%-4.6%) and 4.1% (95% CI, 3.3%-4.9%) per year. In contrast, the incidence rates of IBD, UC, and CD among FNs depicted stable trends over time; no statistically significant changes were observed in the annual change trend tests. The ratio of UC to CD was 1.71.

CONCLUSIONS

We provided population-based evidence of the increasing prevalence and stable incidence rates of IBD among FNs. Further studies are needed in other regions to continue understanding the patterns of IBD among Indigenous peoples.

HCV Infection Alters Salivary Gland Histology and Saliva Composition

Hepatitis C virus (HCV) infection is the most common blood-borne chronic infection in the United States. Chronic lymphocytic sialadenitis and sicca syndrome have been reported in chronic HCV infection. Up to 55% of these patients may have xerostomia; the mechanisms of the xerostomia and salivary gland (SG) hypofunction remain controversial. The objectives of this project are to establish if xerostomia associates with SG and HCV infection and to characterize the structural changes in SG and saliva composition. Eighteen HCV-infected patients with xerostomia were evaluated for SG dysfunction; 6 of these patients (patients 1–6) were further evaluated for SG histopathological changes and changes in saliva composition. The techniques used include clinical and laboratory assessment, SG ultrasonography, histological evaluation, sialochemical and proteomics analysis, and RNA in situ hybridization. All the HCV patients had low saliva flow, chronic sialadenitis, and SG fibrosis and lacked Sjögren syndrome (SS) characteristic autoantibodies. Further evaluation of a subgroup of 6 HCV patients (patients 1–6) demonstrated diffuse lymphocytic infiltrates that are predominantly CD8+ T cells with a significant increase in the number of inflammatory cells. Alcian Blue/periodic acid–Schiff staining showed significant changes in the ratio and intensity of the acinar secretory units of the HCV patients’ minor SG. The submandibular glands showed significant ultrasonographic abnormalities in the parenchyma relative to the parotid glands. Significant changes were also observed in the concentration of sodium and mucin 5b. Although no significant correlation was observed between the lymphocytic infiltrates and the years of HCV chronic infection, a positive correlation was observed between HCV RNA–positive epithelial cells and the years of HCV infection. Consistent with the low saliva flow and xerostomia, patients showed changes in several markers of SG acinar and ductal function. Changes in the composition of the saliva suggest that HCV infection can cause xerostomia by mechanisms distinct from SS.

Crohn's and Colitis Canada's 2021 Impact of COVID-19 & Inflammatory Bowel Disease in Canada: A Knowledge Translation Strategy

The prevalence of inflammatory bowel diseases (IBD), Crohn’s disease and ulcerative colitis, in Canada, is over 0.75% in 2021. Many individuals with IBD are immunocompromised. Consequently, the World Health Organization’s declaration of a global pandemic uniquely impacted those with IBD. Crohn’s and Colitis Canada (CCC) formed the COVID-19 and IBD Taskforce to provide evidence-based guidance during the pandemic to individuals with IBD and their families. The Taskforce met regularly through the course of the pandemic, synthesizing available information on the impact of COVID-19 on IBD. At first, the information was extrapolated from expert consensus guidelines, but eventually, recommendations were adapted for an international registry of worldwide cases of COVID-19 in people with IBD. The task force launched a knowledge translation initiative consisting of a webinar series and online resources to communicate information directly to the IBD community. Taskforce recommendations were posted to CCC’s website and included guidance such as risk stratification, management of immunosuppressant medications, physical distancing, and mental health. A weekly webinar series communicated critical information directly to the IBD community. During the pandemic, traffic to CCC’s website increased with 484,755 unique views of the COVID-19 webpages and 126,187 views of the 23 webinars, including their video clips. CCC’s COVID-19 and IBD Taskforce provided critical guidance to the IBD community as the pandemic emerged, the nation underwent a lockdown, the economy reopened, and the second wave ensued. By integrating public health guidance through the unique prism of a vulnerable population, CCC’s knowledge translation platform informed and protected the IBD community.

Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Mental Health and Quality of Life

There has been a dramatic rise in mental health difficulties during the coronavirus disease 2019 (COVID-19) pandemic. While young adults have the lowest risk of hospitalization and mortality due to COVID-19, they have been identified as being at highest risk of detrimental mental health outcomes during the pandemic, along with women, those with lower socioeconomic status and those with pre-existing mental health conditions. Somewhat of a crisis in mental health has emerged across the general population through the evolution of the pandemic. A national Canadian survey identified a quadrupling of those experiencing pervasive elevated anxiety symptoms early in the pandemic compared to pre-pandemic levels, and a doubling of those with pervasive elevated depressive symptoms. Independent of the pandemic, persons with inflammatory bowel disease (IBD) can face multiple challenges related to their disease, which can result in a significant psychosocial burden and psychologic distress. Anxiety and depression have been found to be more prevalent in persons with IBD. Many potential factors contribute to the increased psychologic distress and negative impacts on mental health of the COVID-19 pandemic on persons with IBD. These include the fears of contracting COVID-19 or infecting other people. Many believe that IBD or its treatments predispose them to an increased risk of COVID-19 or a worse outcome if acquired. Concerns about access to health care add to mental distress. People with IBD generally report lower quality of life (QOL) compared to community controls. Psychologic interventions, in addition to adequate disease control, have been shown to improve health-related QOL. Uncertainty is another factor associated with reduced health-related QOL. Most studies suggest that persons with IBD have suffered QOL impairment during the pandemic in comparison to the pre-pandemic period. Uncertainties brought on by the pandemic are important contributors for some of the reduction in QOL.

Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Executive Summary

Persons with inflammatory bowel disease (IBD) make up more than 0.75% of the Canadian population in 2021. Early in the COVID-19 pandemic, individuals with IBD, particularly those on immunosuppressive therapies, were concerned that their health status may place them at higher risk of contracting COVID-19 or experiencing more severe disease course if infected with SARS-CoV-2. In response, Crohn’s and Colitis Canada developed the COVID-19 and IBD Taskforce in March 2020 to rapidly synthesize the evolving knowledge of COVID-19 as relevant to Canadians with IBD. The Taskforce communicated expert information directly to the Canadian IBD community through online tools and a webinar series. In order to understand the full impact of COVID-19 on the IBD community, Crohn’s and Colitis Canada commissioned a policy report that was informed through a systematic literature review and synthesized across working groups along the following domains: Epidemiology, Children and Expectant Mothers with IBD, Seniors with IBD, Mental Health, Risk Factors and Medications, Vaccines, and Healthcare Delivery during the Pandemic and the Future Model of IBD Care. This report from Canadian physicians, researchers, and IBD community representatives highlights the physical, mental, and health systems impact of COVID-19 on the entire spectrum of the IBD community, including children, adolescents, adults, seniors, and pregnant people with IBD. This executive summary provides an overview of the crucial information from each of the chapters of the policy report, supplemented with additional information made available through Crohn’s and Colitis Canada’s webinar-based knowledge translation platform.

Perspectives of health care use and access to care for individuals living with inflammatory bowel disease in rural Canada

INTRODUCTION

Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal tract with no known cure. Management of IBD is complex and requires those with IBD to have lifelong interactions with the healthcare system. Individuals with IBD who live in rural areas are at risk of poorer health outcomes due to their limited access to care. This study examined healthcare utilization and access to care for rural adults with IBD. The research questions explored in this study were: What are the care experiences of healthcare providers (HCPs) and persons living with IBD in rural areas? What are the enablers and barriers to optimal IBD care in rural environments? What strategies are necessary to enhance care delivery for these individuals with IBD?

METHODS

This patient-oriented research initiative involved patient and family advisors as active and equal team members in decision-making throughout the project. This article reports on the qualitative findings of a larger mixed-methods study. The setting was one western Canadian province. Fourteen individuals with IBD living in rural areas and three HCPs working in rural areas participated. Interview data were analyzed using thematic analysis.

RESULTS

Three themes were identified: communication, stressors and support systems, and coordination of care. Communication with and between HCPs was challenging due to the distance to access care. Participants described challenges related to rural HCPs' lack of IBD-related knowledge. Virtual communication, such as telehealth and phone clinics, was infrequently used yet highly recommended by participants. Individuals with IBD described various stressors and feelings of isolation while living in rural environments, and both participant groups described the need for additional formal and informal support systems to ease these stressors. Coordination of care was considered essential to optimal health outcomes, but individuals frequently experienced gaps in care. Lack of local services such as outpatient clinics, hospitals, laboratory testing, infusion clinics, and pharmacies meant individuals with IBD frequently had to travel to access care. Some participants reported bypassing existing local services, instead preferring the expedited, specialist care within larger centers.

CONCLUSION

Most participants described challenges associated with living in rural areas and suggested health system improvements. Access to multidisciplinary care teams, including IBD physicians and nurses, psychologists, and dieticians, for individuals in rural areas is encouraged, as is the use of virtual care delivery options such as telehealth, online clinics, telephone clinics or advice lines, web-based video-conferencing, and email communication to increase access to care. Continued efforts to recruit and retain rural HCPs with knowledge of IBD are deemed necessary to provide continuity of care within rural environments. Strengthening formal and informal support systems and enhancing psychosocial supports in rural communities are warranted to ensure optimal wellbeing. Online strategies to provide individual and group education related to IBD are strongly recommended. Facilitating access to care in rural areas can increase disease remission, decrease direct and indirect care costs, and promote quality of life in individuals with IBD.

A183 TELEHEALTH USE IN RURAL SASKATCHEWAN AND INFLAMMATORY BOWEL DISEASE OUTCOMES

Background

Appropriate management of inflammatory bowel disease (IBD) often requires multiple specialist appointments per year. Living in rural locations may pose a barrier to regular specialist care. Saskatchewan (SK) has a large rural population. Prior to COVID-19, telehealth (TH) in SK was not routinely used for either patient assessment or follow up. Furthermore, TH was exclusively between hospitals and specific TH sites without direct contact using patient’s personal phones.

Aims

The objective of this study was to assess the differences in demographics, disease characteristics, outcomes, and health care utilization between patients from rural SK with IBD who used TH and those who did not.

Methods

A retrospective chart review was completed on all rural patients (postal code S0*) with IBD in SK who were followed at the Multidisciplinary IBD Clinic in Saskatoon between January 2018 and February 2020. Patients were classified as using TH if they had ever used it. Information on demographics, disease characteristics, and access to IBD-related health care in the year prior to their last IBD clinic visit or endoscopy was collected. Data was not collected for clinic visits after March 1, 2020 as all outpatient care became remote secondary to the COVID-19 pandemic. Mean, standard deviations, median and interquartile ranges (IQR) were reported. Mann-Witney U and Chi-Square tests were used to determine differences between the groups.

Results

In total, 288 rural SK IBD patients were included, 30 (10.4%) used TH and 258 (89.6%) did not. Patient demographics were not significantly different between the two groups; although, there was a statistically significant difference in the proportion of ulcerative colitis patients (17% TH vs. 38% non-TH, p=0.02). The percentage of patients with clinical remission was 87% for TH patients and 74% for non-TH patients (p=0.13). There were no significant differences in health care utilization patterns and biochemical markers of disease, including c-reactive protein (CRP) and fecal calprotectin (FCP) (p>0.05).

Conclusions

Prior to the pandemic, a small percentage of patients with IBD in rural SK ever used TH. A small proportion of UC patients used TH. No significant differences in disease characteristics, outcomes, or health care utilization were identified. Further study is warranted to identify barriers to use of this technology to tailor care to this patient group and improve access to care, especially now as the COVID-19 pandemic has drastically changed the use of virtual care.

Funding Agencies

None

A182 INFLAMMATORY BOWEL DISEASE AMONG SENIORS IN SASKATCHEWAN

Background

Inflammatory bowel disease (IBD) is a chronic inflammatory condition comprised of two major disorders: ulcerative colitis (UC) and Crohn’s disease (CD).The age of onset for many patients with UC and CD is between 15 and 30 years, with a second peak between 50 and 80 years of age.

Aims

We aim to determine if there are differences in disease characteristics, outcomes, and IBD-related health care utilization between elderly patients with IBD diagnosed at a young age compared to those diagnosed later in life.

Methods

A retrospective chart review of elderly (age ≥ 60 years) patients with IBD was conducted.Patients aged ≥ 60 years who were seen at the Saskatchewan Multidisciplinary IBD Clinic at the Royal University Hospital from 2012 to 2020 were included. Information on demographics, disease characteristics, and access to IBD-related health care was collected. Patients were divided in two groups according to age of diagnosis: &lt;60 and ≥ 60 years. Chi-squares were used to compare the groups. Charts with missing data were omitted in the final analysis. Three patients with indeterminant colitis were excluded from the analyses. Logistic regression models were built to obtain odds ratios (OR) with their corresponding 95% confidence intervals (95%CI) and considering potential confounders.

Results

In total, 264 patients were included in the study; 210(79.5%) diagnosed &lt;60 and 54(20.5%) ≥ 60. The mean age of diagnosis was 47.21(SD=16.18), [&lt;60=41.69(SD=13.25), ≥60=68.00(SD=6.264)].Cross tabulation (Table 2) of age of diagnosis and patient’s characteristics (sex, IBD type, and clinical remission at last visit, current use of biologics and steroids) confirmed lack of inter-variable significance. However, in the same analysis individuals diagnosed ≥ 60 were more likely to be on 5-ASA therapy compared to their counterparts diagnosed before the age of 60. Logistic regression model results demonstrated that: Patients diagnosed ≥ 60 years were 2.06 (1.12–3.80, 95% CI) times more likely to be using 5-ASA therapy.Patients in clinical remission were 3.04 (95% CI, 1.65–5.61) times more likely to be using biologic therapy.

Conclusions

Thus far, the results indicate significant correlation between use of 5-ASA in patients diagnosed age ≥60. In the same cohort, clinical remission was also linked to current use of biologics agents. On further analysis, with data stratification based on type of IBD, the same significance did not hold true, likely associated with low power within the stratified group. Clinical remission with those diagnosed ≥60 years while on biologics treatment, may reflect the specific disease type and inflammatory pathways responsible for second wave of IBD diagnosis in later ages.Patients diagnosed later in life were less likely to have IBD-related hospitalization or surgery, likely a reflection of shorted disease history.

Funding Agencies

NoneNone

A19 HEALTH CARE UTILIZATION DIFFERENCES BETWEEN FIRST NATIONS AND THE GENERAL POPULATION WITH INFLAMMATORY BOWEL DISEASE IN SASKATCHEWAN

Background

Indigenous patients with inflammatory bowel disease (IBD) have expressed concerns about barriers to access IBD care. The limited evidence of IBD among Indigenous people highlights the need for studies evaluating access to IBD care in this population.

Aims

We aimed to compare health care utilization between First Nations (FNs) and individuals from the general population (GP) diagnosed with IBD in Saskatchewan (SK).

Methods

A population-based retrospective cohort study was conducted using administrative health databases of SK from 1998 to 2017 fiscal years. As a patient-oriented research initiative, outcomes of interest were chosen in collaboration with Indigenous patients and family advocates. A validated algorithm requiring multiple health care contacts was applied to identify incident IBD cases. The self-declared FN status variable was used to divide IBD cases between FNs and the general population (GP). To balance the groups, 1:5 age and sex matching was applied. Cox-proportional models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95%CI). Stratified analysis was completed for those diagnosed before and after 2008 (pre- and post-biologic eras).

Results

A matched cohort with 696 IBD incident cases was created (FN=116, GP=580). Comparing health care utilization of FNs and individuals from the GP with IBD, there were no statistically significant differences in outpatient gastroenterology visits (FNs=81.0%, GP=83.6%), colonoscopies (FNs=91.4%, GP=86.9%), and surgeries for IBD (FNs=31.0%, GP=33.5%). We observed differences in prescription claims for any medication for IBD (FNs=79.3%, GP=89.3%) and 5-aminosalicylic acid (5-ASA) claims (FNs=75.9%, GP=81.4%). The HRs adjusted by rural/urban residence and diagnostic type showed differences in prescription claims for any IBD medication (HR=0.52, 95%CI 0.41–0.65) and 5-ASA (HR=0.57, 95%CI 0.45–0.72). In the pre-biologic era, FNs had a lower risk of having a prescription claim for any IBD medication (HR=0.32, 95%CI 0.23–0.45) and 5-ASA (HR=0.33, 95%CI 0.24–0.47), respectively. These differences were not significant in the post-biologic era.

Conclusions

Our study identified an inverse association between FN status and having prescription medication claims for IBD in SK. We considered multiple confounding variables when evaluating this association but could not control by disease severity. Thus, this association might reflect a barrier to access IBD medications or that FNs with IBD might present a milder disease. Further studies should continue evaluating access to IBD care, medication use, and disease severity among FNs living with IBD.

Funding Agencies

Saskatchewan Centre for Patient-Oriented Research (SCPOR), Saskatchewan Health Research Foundation (SHRF), and College of Medicine, University of Saskatchewan.

A60 THE INCIDENCE OF INFLAMMATORY BOWEL DISEASE IS DECREASING IN SASKATCHEWAN: A POPULATION-BASED COHORT STUDY

Background

Canada has one of the highest inflammatory bowel disease (IBD) incidence rates worldwide, although within Canada rates vary. Evidence show increasing incidence rates of IBD in Ontario (i.e. adults aged 30–60), stable in Alberta and decreasing in Manitoba. Additionally, higher incident rates of IBD have been identified among urban regions compared to rural regions. There is limited data on the incidence of IBD in Saskatchewan.

Aims

The study objectives were to 1) estimate IBD incidence rates in Saskatchewan from 1999 to 2016, and 2) test for differences in IBD incidence rates for rural and urban regions of Saskatchewan.

Methods

A population-based study was conducted using linked provincial administrative health databases. Individuals age 18+ old with newly diagnosed Crohn’s disease (CD) or ulcerative colitis (UC) were identified using a validated case definition. Generalized linear models with a negative binomial distribution were used to estimate incidence rates and incidence rate ratios (IRR) adjusted for age group, sex, and rurality with 95% confidence intervals (95%CI).

Results

In total, 4,908 newly diagnosed individuals with IBD were included. The average annual incidence rate of IBD decreased from 75 (95%CI 67–84) per 100,000 people in 1999 to 15 (95%CI 12–18) per 100,000 population in 2016. This decrease was evident in both UC (from 36/100,000 [95%CI 31–42] in 1999 to 6/100,000 [95%CI 4–8] in 2016) and CD (37/100,000 [95%CI 32–42] in 1999 to 8/100,000 [95%CI 6–10] in 2016). A significant decline of 6.9% (95%CI 6.2–7.6) in the average annual incidence of IBD was estimated between 1999 and 2016 (see Figure 1). Urban residents had a greater overall risk of IBD (IRR=1.19, 95%CI 1.11–1.27) than rural residents. This risk difference was statistically significant for CD (IRR=1.25, 95%CI 1.14–1.36), but not UC (IRR=1.08, 95%CI 0.97–1.19).

Conclusions

A decreasing trend in IBD incidence in Saskatchewan was identified after adjusting for age group, sex, and rural/urban region of residence. Around 150 new cases of IBD are still diagnosed annually in Saskatchewan, but this estimate is lower than estimates from other provinces. Urban dwellers have a 25% higher risk of CD onset compared to their rural counterparts. This finding could suggest the presence of specific risk factors in urban settings that require further investigation. Health care providers and decision-makers should plan IBD-specific health care programs taking into account these specific IBD rates in Saskatchewan.

Funding Agencies

College of Medicine, University of Saskatchewan

A61 FOCUSING ON THE FUTURE: REDUCING BARRIERS AND IMPROVING ACCESS TO IBD SPECIALTY CARE ACROSS CANADA

Background

Canada has the highest global age-adjusted incidence and prevalence rates of Inflammatory Bowel Disease (IBD). Resulting from compounding prevalence and limited resources, timely access to specialty care is a challenge faced by patients and healthcare providers. Despite this issue, there has been no published research elucidating the patient perspective using qualitative approaches to compare and contrast the patient experience across Canada.

Aims

To elicit a qualitative data stream to better understand phenomena related to access to healthcare for Canadians living with IBD from a patient-centered perspective.

Methods

Patients diagnosed with IBD (≥18 years of age) were recruited from gastroenterology clinics and communities through IBD specialists and Crohn’s & Colitis Canada. To ensure geographic diversity and representation, patients were recruited from urban and rural regions. In order to acquire multiple access perspectives, patients were invited to bring a family member who was involved in their care to the focus groups. Co-facilitated by a researcher and a patient research partner, the focus groups were held in Nova Scotia, New Brunswick, Quebec, Ontario, Manitoba, Saskatchewan, and British Columbia. All focus groups were audio recorded, transcribed, and coded for themes. Themes were distilled through qualitative thematic analysis using Atlas.ti software to ascertain congruence or discordance of IBD specialty care access experiences.

Results

A total of 63 participants were recruited in fourteen focus groups across seven provinces. The majority of participants were female (41/63, 65%) and from urban/suburban regions (34/63, 54%). The mean age of participants was 48 years (SD=16 years, range=16 to 77 years). Preliminary analyses illustrated three patient-identified access barrier themes: 1) Lack of multidisciplinary care (psycho-social and nutrition support), 2) Diagnostic delay, and 3) Inability to effectively receive and provide communication with healthcare providers. In response, four solutions were proposed: 1) Integration of holistic care into the clinical practice, 2) Readily accessible psycho-social and nutritional support, 3) Increased patient advocacy, and 4) Continuity and liaison through provision of a healthcare navigator resource.

Conclusions

The complexity of specialty care access for IBD patients in Canada cannot be underestimated. It is vital to possess a robust understanding of healthcare system structures, processes, and the significant impact these factors have on patients and the care received. Through the use of patient-centered exploration of barriers and facilitators, access to IBD specialty care in Canada can be better understood and improved on both a provincial and national scale.

Funding Agencies

CIHRNova Scotia Health Authority Research Fund

A4 A FRAMEWORK TO STUDY INFLAMMATORY BOWEL DISEASE AMONG INDIGENOUS PEOPLES AND PRELIMINARY RESULTS FROM SASKATCHEWAN, CANADA

Background

Inflammatory Bowel Disease (IBD) is a chronic condition with significant life-threatening disease-related complications and reductions in quality of life if left untreated. Despite available research about IBD in the general population, there is limited-to-no evidence about IBD among Indigenous peoples in Canada and around the world.

Aims

We aimed to define a collaborative framework, estimate the prevalence and incidence rates of IBD among First Nations in Saskatchewan, Canada, and explore perceptions of IBD among Indigenous peoples in the province.

Methods

This study began when Indigenous patients shared their health experiences with IBD with research team members. An interdisciplinary research team was formed including Indigenous patient and family advocates (IPFAs, Indigenous patients living with IBD and parents of an Indigenous person with IBD), an IBD gastroenterologist, knowledge users, and Indigenous and non-Indigenous researchers. Our research team committed to raise awareness of IBD among Indigenous peoples within Indigenous communities and among health care providers and to advocate for better healthcare and well-being by providing evidence of IBD among Indigenous peoples living with IBD in Saskatchewan. We defined a mixed methodology. The first phase of the study used Saskatchewan administrative health data to estimate the prevalence and incidence rates with 95% confidence intervals (95%CI) of IBD among First Nations. The second phase of the study will use a photovoice methodology to gather “the voices” of Indigenous peoples with IBD, encouraging self-interpretation of pictures, engaging their communities, and empowering them with the study findings.

Results

The IPFAs play a critical role in the project by sharing their experiences and defining the directions of the project, as well as defining our research framework (Figure 1). Preliminary results show that the prevalence of IBD among First Nations in Saskatchewan increased from 66 (95%CI 65–68) per 100,000 population in 1999 to 148 (95%CI 145–151) per 100,000 people in 2015. In contrast, the incidence rates appear to be stable over time, 11/100,000 (95%CI 4–24) in 1999 and 11/100,000 (95%CI 5–20) in 2015. We started recruiting participants for the photovoice study in September 2019.

Conclusions

This ground-breaking patient-driven study is the first stage to improve health among Indigenous peoples living with IBD in Saskatchewan. This project will generate community-engaged knowledge and expertise to inform the development of an Indigenous IBD framework that could promote better and knowledge-based healthcare for Indigenous peoples with IBD in Canada and worldwide.

Funding Agencies

CIHRSaskatchewan Health Research Foundation (SHRF) and Saskatchewan Centre for Patient-Oriented Research (SCPOR)

An Advanced Pharmacy Practice Experience for Community Pharmacies Based on a Clinical Intervention Targeting Patients With Inflammatory Bowel Disease

Experiential education is a critical component of any pharmacy undergraduate curriculum. Establishing new, high-quality practice sites can be challenging. We designed a new advanced pharmacy practice experiential rotation suitable for implementation in most community pharmacy settings. The aim of this article is to describe the design of this rotation entitled the Targeted Pharmacy Intervention in Inflammatory Bowel Disease (TPI-IBD) and to determine its impact on student knowledge and confidence using a before-after survey design. The TPI-IBD utilizes a student-delivered intervention as a platform for experiential learning in community pharmacy practice. The TPI was focused on patients with IBD, and implementation was guided by a co-preceptor from the university in collaboration with onsite-preceptors at each pharmacy. The TPI-IBD rotation was delivered from 6 community pharmacies during 5 weeks in 2018. Students conducted standardized monitoring on patients with IBD and met weekly with the university preceptor for case presentations and therapeutic discussions. Electronic charts were maintained by students who were responsible for ensuring detailed documentation on each patient. Knowledge, confidence, and overall satisfaction were assessed by a survey given to students before and after the rotation. Students were highly satisfied with the learning experience and improvements in knowledge and confidence were clearly demonstrated. The TPI strategy was an effective way to expand rotation options in community pharmacy sites with minimal burden on local preceptors.

Appropriateness of Biologics in the Management of Crohn's Disease Using RAND/UCLA Appropriateness Methodology

BACKGROUND

3 classes of biologics are now available for the treatment of Crohn's disease. The availability of multiple treatment options has led to questions regarding the appropriateness of each agent for a given patient. We aimed to evaluate physician preferences for the use of specific biologic agents in a variety of Crohn's disease management scenarios using the RAND/UCLA Appropriateness Methodology.

METHODS

A panel consisting of members of the CINERGI group (Canadian IBD Network for Research and Growth in Quality Improvement) was assembled. A literature review was performed on factors identified as influential upon choice of biologic therapy. Clinical scenarios were developed, and panelists rated the appropriateness of biologic therapy classes in each scenario individually and again during a face-to-face meeting after moderated discussion.

RESULTS

Two hundred eighty-eight modifications of 3 clinical scenarios were rated. Factors that influenced biologic choice included perianal disease, antidrug antibody status, extraintestinal manifestations, consideration of potential pregnancy, and history of serious infection or malignancy. Anti-TNF therapy was considered appropriate in the postoperative patient. Ustekinumab and vedolizumab were considered appropriate in patients without perianal disease over the age of 65 with a history of malignancy or serious infection. The use of anti-TNF therapy was considered inappropriate in some scenarios whereby drug level was adequate and no antidrug antibody (ADA) was detectable.

CONCLUSIONS

We evaluated the appropriateness of the 3 available classes of biologics in a number of scenarios for the treatment of Crohn's disease. History of serious infection and malignancy, particularly in individuals over 65 years, and consideration of future pregnancy were patient-specific variables that impacted treatment decisions. These findings can serve as a guide for providers considering biologic therapy in patients with Crohn's disease.

10.1093/ibd/izy333_video1izy333.video15850922807001.

Non-pharmacological therapies for inflammatory bowel disease: Recommendations for self-care and physician guidance

We performed a scoping review on sought-after complementary therapies for patients with inflammatory bowel disease (IBD), specifically diet, physical activity and exercise (PA/E), and psychotherapy. We aim to update patients with IBD on therapies for self-care and provide physicians with guidance on how to direct their patients for the management of IBD. A search of MEDLINE, EMBASE, and PUBMED was completed in Sept 2016. Studies on diet, PA/E, or psychotherapy in patients with IBD were included. Medical Subject Heading terms and Boolean operators were used. The search was limited to full-text English articles describing an adult population. This review included 67 studies: Diet (n = 19); PA/E (n = 19); and psychotherapy (n = 29). We have made the following recommendations: (1) Diet: Consumption of diets rich in vegetables, fruit and soluble fiber may be beneficial in IBD. A trial of a low FODMAP diet can be considered in those patients with functional gastrointestinal symptoms. Restrictive diets are lacking in evidence and should be avoided; (2) PA/E: Regular low-moderate intensity activity, including cardiovascular and resistance exercise, has been shown to improve quality of life (QOL) and may improve inflammation; and (3) psychotherapy: Therapies such as cognitive-behavioural interventions, mindfulness, hypnosis, and stress management have been shown to improve QOL, but evidence is limited on their impact on anxiety, depression, and disease activity. Overall, these complementary therapies are promising and should be used to treat patients with IBD from a more holistic perspective.

Elevation of serum pyruvate kinase M2 (PKM2) in IBD and its relationship to IBD indices

OBJECTIVES

Endoscopy remains the gold standard to diagnose and evaluate inflammatory bowel disease (IBD) activity. Current biomarkers or their combinations cannot adequately predict IBD risk, diagnosis, progression or relapse, and response to therapy. Pyruvate kinase M2 (PKM2) is emerging as a significant mediator of the inflammatory process. We aimed to assess levels of serum PKM2 in healthy and newly diagnosed IBD patients and its relationship with IBD indices and microbiota changes.

DESIGN AND METHODS

IBD serum samples from newly diagnosed patients were collected and analyzed using a PKM2-ELISA and correlated with disease activity scores, IBD disease type, and intestinal microbiota. Furthermore, we tested the genetic and protein expression of PKM2 in an in vitro intestinal cell model of inflammation.

RESULTS

Serum PKM2 levels were 6-fold higher in IBD patients compared to healthy controls, with no sensitivity to disease phenotype (Crohn's Disease or Ulcerative Colitis) or localization of inflammation. Serum PKM2 had considerably less interindividual variability than established IBD fecal biomarkers. A positive Pearson correlation (r=0.6121) existed between serum PKM2 and Bacteroidetes fecal levels in Crohn's disease (CD), while a negative (r=-0.6128) correlation was observed with Actinobacteria fecal levels. Furthermore, LPS (500ng/mL) significantly increased PKM2 expression in vitro, which was significantly suppressed by an anti-inflammatory flaxseed bioactive agent.

CONCLUSION

Our data suggests PKM2 as a putative biomarker for IBD and the dysbiosis of microflora in CD. Investigations involving larger number of clinical patients are necessary to validate its use as a serum biomarker of IBD.

Protocol for a 24-Week Randomized Controlled Study of Once-Daily Oral Dose of Flax Lignan to Healthy Older Adults

Background

Increased oxidative stress and inflammation are associated with aging, and contribute to an increased risk of chronic disease in older adults. Flaxseed lignans demonstrate antioxidant and anti-inflammatory activity, but their ability to reduce oxidative stress and inflammation markers in older adult populations has received limited investigation.

Objective

This is a chronic intervention trial of community-dwelling healthy older adults to examine the effects of a flaxseed lignan (secoisolariciresinol diglucoside; SDG) enriched supplement (BeneFlax) compared to a placebo. The primary aim was to demonstrate the safety of BeneFlax and confirm its anti-inflammatory efficacy on markers of oxidative stress and inflammation, and subsequent functional outcomes, including those associated with its anti-inflammatory efficacy. A secondary aim was to determine flaxseed lignan metabolite concentrations in blood.

Methods

A double-blind randomized clinical trial was conducted. Subjects were healthy community-dwelling adults aged 60-80 years. Testing was performed at baseline, 8, 16, and 24 weeks. The 24-week intervention consisted of 600 milligrams (mg) of SDG daily or an equivalent amount (volume) of placebo. All participants received 1000 international units of vitamin D to ensure adequate vitamin D status. Measurements consisted of blood pressure, hematology, and tolerability for safety assessments; blood oxidative stress and inflammatory biomarkers for efficacy; and cognition, muscle strength, and pain as functional outcomes. Secondary endpoints of plasma levels of lignan metabolites were analyzed by mass spectrometry. Other tests, such as bone turnover markers and fecal levels of flax cyclolinopeptides, will be performed at a later date.

Results

Thirty-two participants were recruited (19 intervention and 13 control) and all completed the trial. Numerous Health Canada-imposed exclusion criteria limited recruitment success. Analyses are ongoing, but the baseline data available for a number of parameters indicate no differences between treatment groups. Safety measures (vital signs) did not change from baseline and were not significantly different between treatment and placebo groups at 24 weeks.

Conclusions

Preliminary results indicate that no safety concerns are associated with administering 600 mg SDG for 24 weeks to adults between the ages of 60 and 80 years.

Trial Registration

Clinicaltrials.gov NCT01846117; https://clinicaltrials.gov/ct2/show/NCT01846117 (Archived by WebCite at http://www.webcitation.org/6nlDZNjmA)