ADALIMUMAB VERSUS INFLIXIMAB IN LUMINAL PEDIATRIC CROHN'S DISEASE: COMPARABLE OUTCOMES IN A PROSPECTIVE MULTICENTER COHORT STUDY.

BACKGROUND: This study compared real-world effectiveness between adalimumab (ADA) and infliximab (IFX) in children with Crohn's disease (CD). METHODS: Children enrolled into the prospective Canadian Children Inflammatory Bowel Disease Network (CIDsCaNN) National Inception Cohort between 2014 and 2020 who commenced ADA or IFX as first anti-tumor necrosis factor (antiTNF) agent for luminal CD were included. Multivariate logistic regression modelled the propensity of commencing ADA; propensity score matching was used to match IFX-treated children to ADA-treated children. The primary outcome at one year was steroid-free clinical remission (SFCR). Secondary outcomes at one year were I) combined SFCR and c-reactive protein (CRP) remission; II) treatment intensification; and III) antiTNF durability. Odds ratios (aOR) and hazard ratio (aHR) adjusted for concomitant immunomodulator use with 95% confidence interval (CI) are reported. RESULTS: In the propensity score matched cohort of 147 ADA-treated and 147 IFX-treated children, 92 (63%) ADA- and 87 (59%) IFX-treated children achieved SFCR at one year (aOR: 1.4, 95% CI 0.9-2.4); 75 of 140 (54%) ADA- and 85 of 144 (59%) IFX-treated children achieved combined SFCR and CRP remission (aOR: 1.0, 95% CI 0.6-1.6). ADA-treated children less frequently underwent treatment intensification (21 [14%]) compared to IFX-treated children (69 [47%]) (P<0.0001). Discontinuation of antiTNF occurred in 18 (12%) ADA-treated and 15 (10%) IFX-treated children (aHR: 1.2, 95% CI 0.6-2.2). CONCLUSION: Children with Crohn's disease achieved favourable outcomes at one year with either ADA or IFX as first antiTNF agents. Those receiving IFX did not have significantly superior outcomes compared to clinically similar children receiving ADA.

Assessment of Knowledge of Gluten-Free Diet Amongst Food Handlers in Hospitals.

Purpose: When admitted to the hospital, individuals with celiac disease rely on food handlers for provision of safe, uncontaminated gluten-free meals. We aimed to assess the knowledge of gluten-free diet (GFD) amongst individuals involved in meal preparation for patients.Methods: A questionnaire with 10 demographic and 35 test items to assess knowledge of GFD, including workplace scenarios encountered in meal preparation, was administered to food handlers including cooks, utility workers, dietary technicians, and supervisors in 2 tertiary care, university-affiliated hospitals. A score of ≥28 of 35 (≥80%) was considered a "pass".Results: A total of 72 individuals completed the study, mean age 40.3 ± 1.6 years, 75% female. Only 42 (56.8%) scored ≥80% and achieved a pass. The average score was 75.9% ± 13.4%, range 25.7%-100%. The supervisors had significantly higher scores (87.9% ± 11.4%) than utility workers (73.0% ± 11.4%; P = 0.01) and cooks (71.7% ± 14.5%; P = 0.01). Cooks had the lowest scores with 80% scoring <80%. Females scored higher than males (77.8% vs. 68.8%; P = 0.02).Conclusions: There are significant differences in GFD knowledge amongst various groups involved in food preparation in hospitals. The gaps identified in knowledge can potentially compromise the safety of patients with celiac disease. Targeted interventions to educate hospital food handlers about GFD are warranted. Registered Dietitians can play an important role in providing this education.

Teaching Families of Children with Celiac Disease about Gluten-Free Diet Using Distributed Education: a Pilot Study.

Introduction: Treatment of celiac disease is a strict life-long gluten-free diet (GFD). The GFD is complex, and counseling by a dietitian is essential. The number of new referrals for GFD education has increased. We studied the feasibility of GFD teaching using distributed education.Methods: The IWK Health Center in Halifax is the only tertiary-care pediatric hospital in the 3 Maritime provinces with GFD experienced dietitians. Families travel long distances to attend teaching sessions. Families outside the Halifax area were offered to participate in the 2.5-hour education sessions held once a month via live videoconference link at their regional hospitals. All participants were surveyed with a 10-item questionnaire assessing the content and delivery and usefulness of information.Results: Over a 6-month period, 39 families attended the sessions, 21 locally and 18 at distributed sites across the Maritimes. The survey was completed by 26 participants (67%). All participants at both sites strongly agreed or agreed that their setting was good for learning and the information provided was easy to understand. There were no significant differences between the 2 groups on any individual questions in the 2 domains assessed (all P > 0.06).Conclusions: Distributed education on GFD is feasible and as effective as in person education. It affords convenience and savings to families by reducing travel costs.

Assessment of Malnutrition Risk in Canadian Pediatric Hospitals: A Multicenter Prospective Cohort Study.

OBJECTIVE: To assess the prevalence, causes, and consequences of malnutrition, as well as the evolution of nutritional status, in Canadian pediatric health care institutions. STUDY DESIGN: In this multicenter prospective cohort study, a total of 371 patients were recruited from pediatric hospitals in 5 Canadian provinces. Subjects were aged 1 month to 18 years; admitted to a medical, surgical, or oncology ward; and had a planned hospital stay of >48 hours. Data on demographics, medical condition, anthropometric measures, and dietary intake were collected. The Screening Tool Risk on Nutritional Status and Growth (STRONGkids) and Subjective Global Nutritional Assessment (SGNA) were applied at admission. Malnutrition was defined as a weight-for-age, height-for-age, body mass index-for-age, or weight-for-length/height z score <-2 SD. RESULTS: Among 307 subjects (median age, 5.3 years; median length of stay, 5 days), 19.5% were malnourished on admission. Both STRONGkids and SGNA classifications were associated with baseline nutritional status. Mean weight-for-age z score was lower at discharge compared with admission (-0.14 vs -0.09; P < .01), and nearly one-half of all patients lost weight during their hospital stay. Only one-half of the children who were malnourished or screened as high risk of malnutrition were visited by a dietitian during their stay. The percentage of patients who lost weight during hospitalization was significantly greater in the group not visited by a dietitian (76.5 vs 23.5%; P < .01). CONCLUSION: Nutritional status deterioration and malnutrition are common in hospitalized Canadian children. Screening tools, anthropometric measurements, and dietitian consultation should be used to establish adequate nutritional support.

Coeliac disease in Pakistan: A bibliographic review of current research status.

Coeliac disease is a common disorder worldwide but its impact in Pakistan is unknown. We reviewed the literature to investigate what is published on coeliac disease and gluten-free diet in Pakistan. Search engines including Medline, Embase, Google were used to retrieve information. Only articles published in a medical journal were included. A total of 34 articles were retrieved, 28 of which were clinical. Of these, 14 pertained to adults and 14 described paediatric patients. Most consisted of descriptions of small series of patients or individual case reports. Five articles addressed treatment issues including gluten-free diet. Most (65%) were from Pakistani journals. All publications were from Sindh or Punjab. For a common disorder, there is a paucity of high quality scientific literature on coeliac disease from Pakistan. Systematic, prospective research studies are needed to investigate the impact of coeliac disease in Pakistan including prevalence, clinical presentations and challenges of gluten-free diet.

Management of bone health in patients with celiac disease: Practical guide for clinicians.

OBJECTIVE: To describe clinical issues related to bone health in patients with celiac disease (CD) and to provide guidance on monitoring bone health in these patients. SOURCES OF INFORMATION: A PubMed search was conducted to review literature relevant to CD and bone health, including guidelines published by professional gastroenterological organizations. MAIN MESSAGE: Bone health can be negatively affected in both adults and children with CD owing to the inflammatory process and malabsorption of calcium and vitamin D. Most adults with symptomatic CD at diagnosis have low bone mass. Bone mineral density should be tested at diagnosis and at follow-up, especially in adult patients. Vitamin D levels should be measured at diagnosis and annually until they are normal. In addition to a strict gluten-free diet, supplementation with calcium and vitamin D should be provided and weight-bearing exercises encouraged. CONCLUSION: Bone health can be adversely affected in patients with CD. These patients require adequate calcium and vitamin D supplementation, as well as monitoring of vitamin D levels and bone mineral density with regular follow-up to help prevent osteoporosis and fractures.

Gastrointestinal Findings in the Largest Series of Patients With Hereditary Biallelic Mismatch Repair Deficiency Syndrome: Report from the International Consortium.

OBJECTIVES: Hereditary biallelic mismatch repair deficiency (BMMRD) is caused by biallelic mutations in the mismatch repair (MMR) genes and manifests features of neurofibromatosis type 1, gastrointestinal (GI) polyposis, and GI, brain, and hematological cancers. This is the first study to characterize the GI phenotype in BMMRD using both retrospective and prospective surveillance data. METHODS: The International BMMRD Consortium was created to collect information on BMMRD families referred from around the world. All patients had germline biallelic MMR mutations or lack of MMR protein staining in normal and tumor tissue. GI screening data were obtained through medical records with annual updates. RESULTS: Thirty-five individuals from seven countries were identified with BMMRD. GI data were available on 24 of 33 individuals (73%) of screening age, totaling 53 person-years. The youngest age of colonic adenomas was 7, and small bowel adenoma was 11. Eight patients had 19 colorectal adenocarcinomas (CRC; median age 16.7 years, range 8-25), and 11 of 18 (61%) CRC were distal to the splenic flexure. Eleven patients had 15 colorectal surgeries (median 14 years, range 9-25). Four patients had five small bowel adenocarcinomas (SBC; median 18 years, range 11-33). Two CRC and two SBC were detected during surveillance within 6-11 months and 9-16 months, respectively, of last consecutive endoscopy. No patient undergoing surveillance died of a GI malignancy. Familial clustering of GI cancer was observed. CONCLUSIONS: The prevalence and penetrance of GI neoplasia in children with BMMRD is high, with rapid development of carcinoma. Colorectal and small bowel surveillance should commence at ages 3-5 and 8 years, respectively.

Serologic testing in celiac disease: Practical guide for clinicians.

OBJECTIVE: To address the questions and challenges commonly faced by primary care physicians when ordering serologic tests for celiac disease (CD) and provide practical clinical tips to help in the interpretation of test results. SOURCES OF INFORMATION: MEDLINE was searched from 2000 to 2015 for English-language guidelines on the diagnosis and management of CD published by professional gastroenterological organizations. MAIN MESSAGE: To screen patients for CD, measurement of the immunoglobulin A (IgA) tissue transglutaminase antibody is the preferred test. Total serum IgA level should be measured to exclude selective IgA deficiency and to avoid false-negative test results. Patients with positive serologic test results should be referred to a gastroenterologist for endoscopic small intestinal biopsies to confirm the diagnosis. Testing for human leukocyte antigens DQ2 and DQ8 can help exclude the diagnosis. A gluten-free diet should not be started before confirming the diagnosis of CD. CONCLUSION: Serologic testing is very useful for screening patients with suspected CD. Early diagnosis is essential to prevent complications of CD.

Assessment of Nutritional Adequacy of Packaged Gluten-free Food Products.

PURPOSE: There is concern about the nutritional quality of processed gluten-free (GF) products. The aim was to investigate the nutrient composition and cost of processed GF products compared with similar regular products. METHODS: Product size, price, caloric value, and macro- and micronutrient composition were compared between foods labeled "Gluten-free" and comparable regular products in 5 grocery stores in 3 Canadian cities. Data were calculated per 100 g of product. RESULTS: A total of 131 products were studied (71 GF, 60 regular). Overall, calories were comparable between GF and regular foods. However, fat content of GF breads was higher (mean 7.7 vs. 3.6 g, P = 0.003), whereas protein was lower (mean 5.0 vs. 8.0 g, P = 0.001). Mean carbohydrate content of GF pasta was higher (78 vs. 74 g, P = 0.001), whereas protein (7.5 vs. 13.3 g, P < 0.001), fibre (3.3 vs. 5.8 g, P = 0.048), iron (9% vs. 25%DV, P < 0.001), and folate content (5% vs. 95%DV, P < 0.001) were lower. Mean price of GF products was $1.99 versus $1.23 for regular products (P < 0.001). CONCLUSIONS: Some commonly consumed packaged GF foods are higher in fat and carbohydrates and lower in protein, iron, and folate compared with regular products. GF products are more expensive. Dietitians should counsel patients on the GF diet regarding its nutritional and financial impact.

Factors affecting adherence to a gluten-free diet in children with celiac disease.

BACKGROUND: The treatment of celiac disease is a strict, life-long gluten-free (GF) diet. This diet is complex and can be challenging. Factors affecting adherence to the GF diet are important to identify for improving adherence. OBJECTIVE: To identify factors that inhibit or improve adherence to a GF diet in children with celiac disease. METHODS: Patients (<18 years of age) with biopsy-confirmed celiac disease followed by the gastroenterology service at a tertiary care paediatric institution were surveyed using a mailed questionnaire. Factors influencing adherence to a GF diet were scored from 1 to 10 based on how often they were problematic (1 = never, 10 = always). Parents of patients <13 years of age were instructed to complete the survey with their child. Adolescents ≥13 years of age were asked to complete the survey themselves. RESULTS: Of 253 subjects, 126 completed the survey; the median age was 12 years (range two to 18 years). Forty percent were adolescents. Overall, participants reported good adherence at home and school, but lower adherence at social events. Adolescents reported lower adherence compared with parents. Availability of GF foods and cost were the most significant barriers. Other factors identified to help with a GF diet included education for schools/restaurants and improved government support. CONCLUSIONS: Availability, cost and product labelling are major barriers to adherence to a GF diet. Better awareness, improved labelling and income support are needed to help patients.

HISTORIQUE: Le traitement de la maladie cœliaque consiste à suivre un régime sans gluten (RSG) rigoureux jusqu'à la fin de ses jours. Ce régime est complexe et peut-être difficile à respecter. Il est important de déterminer les facteurs influant sur l'adhérence au RSG pour améliorer cette adhérence. OBJECTIF: Déterminer les facteurs qui inhibent ou améliorent l'adhérence au RSG chez les enfants atteints de la maladie cœliaque. MÉTHODOLOGIE: À l'aide d'un questionnaire envoyé par la poste, les chercheurs ont sondé les patients (de moins de 18 ans) atteints d'une maladie cœliaque confirmée par biopsie et suivis au service de gastroentérologie d'un établissement pédiatrique de soins tertiaires. Les facteurs influant sur l'adhérence à un RSG ont été classés de un à dix selon la fréquence à laquelle ils causaient problème (1 = jamais, 10 = toujours). Les parents des patients de moins de 13 ans étaient invités à remplir le questionnaire avec l'enfant. Ceux de 13 ans et plus étaient invités à le remplir seuls. RÉSULTATS: Sur 253 sujets, 126 ont rempli le sondage. Ils avaient 12 ans d'âge médian (plage de deux à 18 ans). Quarante pour cent étaient des adolescents. Dans l'ensemble, les participants signalaient une bonne adhérence à la maison et à l'école, mais une adhérence plus faible lors d'événements sociaux. Les adolescents déclaraient une adhérence plus faible que les parents. L'offre d'aliments sans gluten et le coût étaient les principaux obstacles. D'autres facteurs ont été signalés pour faciliter un RSG, y compris l'éducation dans les écoles et les restaurants et un meilleur soutien gouvernemental. CONCLUSIONS: L'offre, le coût et l'étiquetage des produits sont d'importants obstacles à l'adhérence à un RSG. Une meilleure sensibilisation, un meilleur étiquetage et le soutien du revenu s'imposent pour aider les patients.

Vitamin B12 deficiency with intrinsic factor antibodies in an infant with poor growth and developmental delay.

Vitamin B12 deficiency is very rare in infants and may lead to serious hematological and neurodevelopmental abnormalities. The present article describes a case involving a seven-month-old boy with severe vitamin B12 deficiency, likely caused by juvenile pernicious anemia, an entity rarely described. The child presented with feeding intolerance, poor growth and developmental delay. He was noted to have macrocytic anemia, a markedly low serum vitamin B12 level, and elevated homocysteine and methylmalonic acid levels. Antibodies to intrinsic factor were positive. The mother was healthy, with normal vitamin B12 status. Therapy with vitamin B12 supplements led to excellent recovery of symptoms. Vitamin B12 deficiency should be considered in children presenting with failure to thrive, especially when compounded with neurological symptoms. Early diagnosis and adequate treatment is essential to avoid serious complications.

La carence en vitamine B12, très rare chez les nourrissons, peut causer de graves anomalies hématologiques et neurodéveloppementales. Le présent article expose le cas d'un garçon de sept mois ayant une grave carence en vitamine B12, probablement causée par une anémie pernicieuse juvénile, une entité rarement décrite. L'enfant présentait une intolérance alimentaire et un retard de croissance et de développement. Il avait une anémie macrocytaire, un très faible taux de vitamine B12 dans le sérum et des taux élevés d'homocystéine et d'acide méthylmalonique. Les anticorps du facteur intrinsèque étaient positifs. La mère était en bonne santé et son statut de vitamine B12 était normal.Un traitement aux suppléments de vitamine B12 a donné lieu à une excellente résorption des symptômes. Il faut envisager une carence en vitamine B12 chez les enfants ayant un retard staturopondéral, surtout en présence de symptômes neurologiques. Il est essentiel de poser rapidement un diagnostic et d'amorcer un traitement pertinent pour éviter de graves complications.

Outcomes Following Acute Severe Colitis at Initial Presentation: A Multi-centre, Prospective, Paediatric Cohort Study.

AIM: To assess contemporary outcomes in children with acute severe ulcerative colitis [ASUC] at initial presentation. METHODS: Between April 2014 and January 2019, children aged <17 years, with new onset ASUC (Paediatric Ulcerative Colitis Activity Index [PUCAI ≥65) were prospectively followed in a Canadian inception cohort study. 16S rRNA amplicon sequencing captured microbial composition of baseline faecal samples. Primary endpoint was corticosteroid-free clinical remission with intact colon at 1 year [PUCAI <10, no steroids ≥4 weeks]. RESULTS: Of 379 children with new onset UC/IBD-unclassified, 105 [28%] presented with ASUC (42% male; median [interquartile range; [IQR]) age 14 [11-16] years; extensive colitis in all). Compared with mild UC, gut microbiome of ASUC patients had lower α-diversity, decreased beneficial anaerobes, and increased aerobes; 54 [51%] children were steroid-refractory and given infliximab [87% intensified regimen]. Corticosteroid-free remission at 1 year was achieved by 62 [61%] ASUC cohort (by 34 [63%] steroid-refractory patients, all on biologics; by 28 [55%] steroid responders,13 [25%] on 5- aminosalicylic acid [5-ASA], 5 [10%] on thiopurines, 10 [20%] on biologics). By 1 year, 78 [74%] escalated to infliximab including 24 [47%] steroid-responders failed by 5-ASA and/or thiopurines. In multivariable analysis, clinical predictors for commencing infliximab included hypoalbuminaemia, greater PUCAI, higher age, and male sex. Over 18 months, repeat corticosteroid course[s] and repeat hospitalisation were less likely among steroid-refractory versus -responsive but -dependent patients (adjusted odds ratio [aOR] 0.71 [95% CI 0.57-0.89] and 0.54 [95% CI 0.45-0.66], respectively). CONCLUSION: The majority of children presenting with ASUC escalate therapy to biologics. Predictors of need for advanced therapy may guide selection of optimal maintenance therapy.

Pre-Diagnosis Diet Predicts Response to Exclusive Enteral Nutrition and Correlates with Microbiome in Pediatric Crohn Disease.

Exclusive enteral nutrition (EEN) is effective in inducing remission in pediatric Crohn disease (CD). EEN alters the intestinal microbiome, but precise mechanisms are unknown. We hypothesized that pre-diagnosis diet establishes a baseline gut microbiome, which then mediates response to EEN. We analyzed prospectively recorded food frequency questionnaires (FFQs) for pre-diagnosis dietary patterns. Fecal microbiota were sequenced (16SrRNA) at baseline and through an 18-month follow-up period. Dietary patterns, Mediterranean diet adherence, and stool microbiota were associated with EEN treatment outcomes, disease flare, need for anti-tumor necrosis factor (TNF)-α therapy, and long-term clinical outcomes. Ninety-eight patients were included. Baseline disease severity and microbiota were associated with diet. Four dietary patterns were identified by FFQs; a "mature diet" high in fruits, vegetables, and fish was linked to increased baseline microbial diversity, which was associated with fewer disease flares (p < 0.05) and a trend towards a delayed need for anti-TNF therapy (p = 0.086). Baseline stool microbial taxa were increased (Blautia and Faecalibacterium) or decreased (Ruminococcus gnavus group) with the mature diet compared to other diets. Surprisingly, a "pre-packaged" dietary pattern (rich in processed foods) was associated with delayed flares in males (p < 0.05). Long-term pre-diagnosis diet was associated with outcomes of EEN therapy in pediatric CD; diet-microbiota and microbiota-outcome associations may mediate this relationship.

Prise en charge de la santé des os chez les patients atteints de la maladie cœliaque: Guide pratique à l'usage des cliniciens.

OBJECTIF: Décrire les enjeux cliniques liés à la santé des os chez les patients atteints de la maladie cœliaque (MC) et orienter la surveillance de la santé des os chez ces patients. SOURCES D'INFORMATION: Une recherche a été effectuée sur PubMed dans le but d'examiner les publications appropriées à la MC et la santé des os, y compris les lignes directrices publiées par des organisations professionnelles de gastro-entérologie. MESSAGE PRINCIPAL: Le processus inflammatoire et la malabsorption du calcium et de la vitamine D compromettent la santé des os chez les adultes et les enfants atteints de la MC. La masse osseuse est réduite chez la plupart des adultes dont la MC est symptomatique au diagnostic. Il faut mesurer la densité minérale osseuse au diagnostic et au suivi, surtout chez les adultes. Il faut mesurer le taux de vitamine D au diagnostic et tous les ans, jusqu'à ce qu'il soit normal. Outre un régime strict sans gluten, il faut assurer la supplémentation en calcium et en vitamine D, et encourager les exercices contre résistance. CONCLUSION: La santé des os peut être compromise chez les patients atteints de la MC. Ces patients ont besoin d'une supplémentation adéquate en calcium et en vitamine D, de même que de la surveillance du taux de vitamine D et de la densité minérale osseuse lors des suivis réguliers afin de prévenir l'ostéoporose et les fractures.

Inflammatory Bowel Disease Among Canadian Children: Comparison Between Children of Non-European Descent and Children of European Descent.

BACKGROUND: Inflammatory bowel disease (IBD) phenotypes may differ between countries and ancestral groups. The study aim was to examine ancestry and subtype variations of children newly diagnosed with IBD. METHODS: Children newly diagnosed with IBD enrolled into the Canadian Children Inflammatory Bowel Disease Network inception cohort study were categorized into 8 ancestral groups. Prospectively collected data at diagnosis and follow-up were compared between ancestral groups. RESULTS: Among 1447 children (63.2% Crohn's disease, 30.7% ulcerative colitis), 67.8% were European, 9.4% were South Asian, 3.8% were West Central Asian and Middle Eastern, 2.3% were African, 2.2% were East/South East Asian, 2.0% were Caribbean/Latin/Central/South American, 9.9% were mixed, and 2.6% were other. Children of African descent with ulcerative colitis had an older age of diagnosis compared with children of European descent (median 15.6 years vs 13.3 years; P = .02). Children of European descent had a higher proportion of positive family history with IBD (19.3% vs 12.1%; P = .001) compared with children of non-European descent. Children of European descent also had a lower proportion of immigrants and children of immigrants compared with children of non-European descent (9.8% vs 35.9%; P < .0001; and 3.6% vs 27.2%; P < .0001, respectively) . CONCLUSIONS: Important differences exist between different ancestral groups in pediatric patients with IBD with regard to age of diagnosis, family history, and immigrant status. Our study adds to the knowledge of the impact of ancestry on IBD pathogenesis.

This study explores the ancestral and phenotypic variation of Canadian children newly diagnosed with inflammatory bowel disease. It identifies differences between children of European and non-European descent in phenotypes of inflammatory bowel disease, disease location and behavior, family history, and immigrant status.

Oral manifestations of celiac disease: a clinical guide for dentists.

Celiac disease (gluten sensitive enteropathy) is a common disorder affecting both children and adults. As many people with celiac disease do not present with the classic malabsorptive syndrome, delays in diagnosis are common. Dental enamel defects and recurrent aphthous ulcers, which may occur in patients with celiac disease, may be the only manifestation of this disorder. When dentists encounter these features, they should enquire about other clinical symptoms, associated disorders and family history of celiac disease. In suspected cases, the patient or family physician should be advised to obtain serologic screening for celiac disease and, if positive, confirmation of the diagnosis by intestinal biopsy. Dentists can play an important role in identifying people who may have unrecognized celiac disease. Appropriate referral and a timely diagnosis can help prevent serious complications of this disorder.

Oral manifestations of celiac disease: a clinical guide for dentists.

Celiac disease (gluten sensitive enteropathy) is a common disorder affecting both children and adults. As many people with celiac disease do not present with the classic malabsorptive syndrome, delays in diagnosis are common. Dental enamel defects and recurrent aphthous ulcers, which may occur in patients with celiac disease, may be the only manifestation of this disorder. When dentists encounter these features, they should enquire about other clinical symptoms, associated disorders and family history of celiac disease. In suspected cases, the patient or family physician should be advised to obtain serologic screening for celiac disease and, if positive, confirmation of the diagnosis by intestinal biopsy. Dentists can play on important role in identifying people who may have unrecognized celiac disease. Appropriate referral and a timely diagnosis can help prevent serious complications of this disorder.

Investigating the importance of clinical topics for developing a curriculum on gastroenterology for pediatric residents.

BACKGROUND: Focused objectives provide effective learning. Pediatric residents in Canada follow objectives set by the Royal College of Physicians and Surgeons of Canada (RCPSC) with the goal of becoming competent general pediatricians. During the gastroenterology rotation, it remains unclear as to what clinical problems listed in the aforementioned objectives are crucial to understand as part of general pediatric practice. The purpose of this study was to identify the gastroenterological conditions of most importance to incorporate into a focused curriculum for pediatric residents. METHODS: All pediatricians across four Canadian Atlantic provinces were surveyed by a mailed questionnaire. Questions included demographics and ranking of the 14 clinical problems currently listed in the RCPSC objectives along with six more generated after input was gained from pediatric gastroenterologists. RESULTS: Of the 234 pediatricians surveyed, 132 (56%) responded, 48% of whom were general pediatricians. Celiac disease, gastroesophageal reflux, and obesity (currently not on the RCPSC list) were identified as important/very important conditions to understand by 94.4%, 96.1%, and 96.0% of respondents, respectively. There were no significant differences in rankings between general pediatricians and subspecialists. A large majority recommended that a rotation in gastroenterology be mandatory during pediatric residency. CONCLUSIONS: Pediatricians from four Canadian Atlantic provinces recommended a list of gastrointestinal conditions to be included in pediatric residency training. It would be important to consider these recommendations to keep the training curriculum in sync with real world needs.

CONTEXTE: L'établissement d'objectifs ciblés favorise un apprentissage efficient. Au Canada, les résidents en pédiatrie poursuivent les objectifs fixés par le Collège royal des médecins et des chirurgiens du Canada (CRMCC) pour devenir de bons pédiatres généralistes. Durant le stage en gastro-entérologie, les problèmes cliniques à prioriser dans cette liste d'objectifs, en vue d'une pratique pédiatrique générale, demeurent imprécis pour les résidents. Cette étude visait à identifier les troubles de l'appareil digestif les plus importante à inclure à un cursus ciblé à l'intention des résidents en pédiatrie. MÉTHODOLOGIE: On a mené un sondage auprès de pédiatres des quatre provinces de l'Atlantique en leur envoyant un questionnaire par la poste. Les questions visaient à obtenir des données démographiques et leur demander de classer 14 troubles faisant actuellement partie de la liste du CRMCC, puis six autres après avoir recueilli des avis auprès de gastro-entérologues pédiatriques. RÉSULTATS: 132 (56 %) des 234 pédiatres sondés, dont 48 % étaient des pédiatres généralistes, ont répondu au questionnaire. La maladie cœliaque, le reflux gastro-œsophagien et l'obésité (maladie qui ne figure pas actuellement sur la liste du CRMCC) ont été jugés comme des troubles importants ou très importants à connaître par 94,4 %, 96,1 % et 96,0 % des répondants, respectivement. On n'a observé aucune différence significative entre le classement des pédiatres généralistes et celui des surs-spécialistes. Une grande majorité de répondants ont recommandé qu'un stage en gastro-entérologie devienne obligatoire durant la résidence en pédiatrie. CONCLUSIONS: Les pédiatres des quatre provinces de l'Atlantique ont recommandé une liste de troubles de l'appareil digestif à inclure au programme de résidence en pédiatrie. Il serait important de tenir compte de ces recommandations pour que le programme de formation reste adapté aux besoins de la réalité.

Performance of Black and Indigenous applicants in a medical school admissions process.

BACKGROUND: Diversity in medical schools has lagged behind Canada's growing multicultural population. Dalhousie medical school allows Black and Indigenous applicants to self-identify. We examined how these applicants performed and progressed through the admissions process compared to Other group (applicants who did not self-identify). METHODS: Retrospective analysis of four application cycles (2015-2019) was conducted, comparing demographic data, scores for application components (Computer-Based Assessment for Sampling Personal Characteristics (CASPer), MCAT, GPA, supplemental, discretionary, Multiple Mini Interview (MMI)), and final application status between the three groups. RESULTS: Of 1322 applicants, 104 identified as Black, 64 Indigenous, and 1154 Other. GPA was higher in the Other compared to the Indigenous group (p < 0.001). CASPer score was higher in the Other compared to the Black group (p = 0.047). There was no difference between groups for all other application components. A large proportion of Black and Indigenous applicants had incomplete applications. Acceptance rates were similar between all groups. Black applicants declined an admission offer substantially more than expected (31%; p < 0.001). CONCLUSIONS: Black and Indigenous applicants who completed their application progressed well through the admissions process. The pool of diverse applicants needs to be increased and support provided for completion of applications. Further study is warranted to understand why qualified applicants decline acceptance.

CONTEXTE: Les facultés de médecine ne reflètent pas la diversité croissante de la population multiculturelle du Canada. Celle de l'Université Dalhousie invite les candidats à déclarer s'ils se définissent comme une personne noire ou autochtone. Nous avons fait un examen comparatif du comportement et de la progression dans le processus d'admission des candidats qui ont déclaré leur appartenance à un de ces groupes et des candidats qui ne l'ont pas fait (groupe Autre). MÉTHODES: Nous avons fait une analyse rétrospective de quatre cycles de candidatures (2015-2019), en comparant les données démographiques, les scores des composantes de la candidature (examen assisté par ordinateur pour l'échantillonnage des caractéristiques personnelles ou CASPer, MCAT, MPC, renseignements complémentaires, décision discrétionnaire, mini-entrevues multiples (MEM)) et le statut final de la candidature des trois groupes. RÉSULTATS: Parmi les 1 322 candidats, 104 se sont définis comme étant Noirs, 64 comme Autochtones et 1 154 ont coché « Autre ¼. La moyenne cumulative du groupe Autre était plus élevée que celle du groupe Personne autochtone (p<0,001). Le score CASPer du groupe Autre était plus élevé que celui du groupe Personne noire (p=0,047). Pour tous les autres éléments de la candidature, il n'y avait pas de différence entre les groupes. Un grand nombre de candidats noirs et autochtones avaient des dossiers incomplets. Les taux d'acceptation des trois groupes étaient similaires. Le nombre de candidats noirs qui ont refusé une offre d'admission était beaucoup plus élevé que prévu (31 %; p<0,001). CONCLUSIONS: Les candidats noirs et autochtones dont le dossier était complet ont bien cheminé dans le processus d'admission. Il convient d'élargir le bassin de candidats de diverses origines et de leur proposer de l'aide pour remplir la demande d'admission. D'autres études sont nécessaires pour comprendre pourquoi les candidats sélectionnés refusent une offre d'admission.

Diagnostic Delay Is Associated With Complicated Disease and Growth Impairment in Paediatric Crohn's Disease.

BACKGROUND: Paediatric data on the association between diagnostic delay and inflammatory bowel disease [IBD] complications are lacking. We aimed to determine the effect of diagnostic delay on stricturing/fistulising complications, surgery, and growth impairment in a large paediatric cohort, and to identify predictors of diagnostic delay. METHODS: We conducted a national, prospective, multicentre IBD inception cohort study including 1399 children. Diagnostic delay was defined as time from symptom onset to diagnosis >75th percentile. Multivariable proportional hazards [PH] regression was used to examine the association between diagnostic delay and stricturing/fistulising complications and surgery, and multivariable linear regression to examine the association between diagnostic delay and growth. Predictors of diagnostic delay were identified using Cox PH regression. RESULTS: Overall (64% Crohn's disease [CD]; 36% ulcerative colitis/IBD unclassified [UC/IBD-U]; 57% male]), median time to diagnosis was 4.2 (interquartile range [IQR] 2.0-9.2) months. For the overall cohort, diagnostic delay was >9.2 months; in CD, >10.8 months and in UC/IBD-U, >6.6 months. In CD, diagnostic delay was associated with a 2.5-fold higher rate of strictures/internal fistulae (hazard ratio [HR] 2.53, 95% confidence interval [CI] 1.41-4.56). Every additional month of diagnostic delay was associated with a decrease in height-for-age z-score of 0.013 standard deviations [95% CI 0.005-0.021]. Associations persisted after adjusting for disease location and therapy. No independent association was observed between diagnostic delay and surgery in CD or UC/IBD-U. Diagnostic delay was more common in CD, particularly small bowel CD. Abdominal pain, including isolated abdominal pain in CD, was associated with diagnostic delay. CONCLUSIONS: Diagnostic delay represents a risk factor for stricturing/internal fistulising complications and growth impairment in paediatric CD. PODCAST: This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast.