Mental Health Experiences of Adolescents and Young Adults with Inflammatory Bowel Disease During Transition to Adult Care: A Qualitative Descriptive Study.

OBJECTIVE: To explore the mental health experiences of adolescents and young adults (AYA) with inflammatory bowel disease (IBD) enrolled in a randomized controlled trial evaluating the impact of a multimodal transition intervention. STUDY DESIGN: Virtual semistructured interviews were held with 21 AYA aged 16 through 18 years with IBD. Guided by qualitative description, interviews were digitally recorded, transcribed verbatim, and analyzed using an inductive approach to reflexive thematic analysis. RESULTS: Three themes were generated from the data: (1) a continuum of integration between IBD and personal identity in adolescence and young adulthood; (2) manifestations of the mind-gut connection among AYA with IBD; and (3) hopes and priorities for addressing mental health in IBD care. CONCLUSIONS: AYA with IBD endorsed the criticality of incorporating mental health discussions into routine care during the transition to adult care, given the co-occurrence of psychosocial stressors throughout this period. A series of factors promoting and hindering the integration of IBD into one's identity were identified and could be explored in clinical encounters.

Multimodal intervention to improve the transition of patients with inflammatory bowel disease from pediatric to adult care: protocol for a randomized controlled trial.

BACKGROUND: Transition in care is defined as the "purposeful and planned movement of adolescents and young adults with a chronic medical condition from pediatric to adult-oriented healthcare systems/care providers." Currently, there are no Level 1 evidence-based interventions to improve the care of transitioning adolescents and young adults (AYAs) with inflammatory bowel disease (IBD). The development of a transition program using a biopsychosocial approach will improve the standards for healthcare delivery to transitioning IBD patients. This is a protocol for a structured randomized controlled trial (RCT) to assess the clinical and implementation effectiveness of a multimodal intervention focused on improving patient function, transition readiness and outcomes among AYA patients with IBD being cared for at pediatric centers in Canada. METHODS: This multi-center RCT is a type 1 hybrid effectiveness-implementation trial to evaluate effectiveness of the intervention and how it can be implemented more widely after the trial. We will include patients aged 16.0-17.5 years. The intervention program consists of 4 core components: (1) individualized assessment, (2) transition navigator, (3) virtual patient skills-building with a focus on building resilience, self-management and self-efficacy, and (4) a virtual structured education program. The control group will undergo standard-of-care defined by each participating center. The primary outcome will be the IBD Disability Index, a validated measure to assess patient functioning. Secondary outcomes include transition readiness and success, anxiety and depression scales, and health service utilization rates. Additionally, we will measure implementation outcomes and related barriers and facilitators for the intervention program. DISCUSSION: The type 1 hybrid effectiveness-implementation design will allow for the development of a feasible, sustainable, and acceptable final intervention model. The intervention will consist of modules that can be accessed in an online, virtual platform. The implementation will allow centralization of interventions and funding in order to minimize the impact on local clinical practice or hospital resources. The authors anticipate that the main study limitation will relate to study subjects not completely adhering to every component of the intervention, which will be evaluated and addressed using the implementation science approach. TRIAL REGISTRATION: NCT05221281. Registry: ClinicalTrials.gov. Date of registration: February 2, 2022. https://clinicaltrials.gov/ct2/show/NCT05221281 .

Gender differences in gastroenterology and hepatology authorship and editorial boards.

BACKGROUND AND AIMS: Women are numerically under-represented in the field of gastroenterology and hepatology. This study aims to characterize the gender distribution of first and senior authors and editorial board members across high impact factor journals in gastroenterology and hepatology. METHODS: Publications from January 1, 2019 to December 31, 2019 were reviewed from 29 journals. Gender of editorial board leadership, editorial board members, first, and senior authors was identified using publicly available data. Spearman correlation coefficients were calculated to assess for a relationship among editorial board, first author, and senior author gender and impact factor. RESULTS: Of 29 journals (median impact factor 5.55) with 357 journal issues and 8036 articles, there were 3 of 39 female chief editors (7.7%), 601 of 3455 female editorial board members (17.4%), 2547 of 8036 female first authors (31.7%), and 1390 of 7335 female senior authors (19%). No statistically significant correlations existed between impact factor and chief editor gender with gender distribution of editorial boards, first authors, or senior authors. Positive correlations existed between male-dominated editorial boards and male first (+.52, P = .005) and senior authorship (+.56, P = .002), whereas negative correlations occurred between male-dominated editorial boards and female first (-.51, P = .006) and senior authorship (-.56, P = .002). Positive correlations also existed between publication of first and senior authors of the same gender (+.57, men [P = .001]; +.58, women [P = .001]). CONCLUSIONS: Although gender distribution of female first authorship approaches current distributions in the field of gastroenterology and hepatology, editor-in-chief positions, editorial board membership, and senior authorship continue to be primarily men. Future endeavors to improve proportionate gender representation include improved journal leadership selection transparency, targeted diversity statements, and enhanced mentorship.

Prokinetics for Functional Dyspepsia: A Systematic Review and Meta-Analysis of Randomized Control Trials.

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

Health Services Use during Transition from Pediatric to Adult Care for Inflammatory Bowel Disease: A Population-Based Study Using Health Administrative Data.

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

Prokinetics for functional dyspepsia.

BACKGROUND: Dyspepsia is a common condition associated with gastrointestinal (GI) disease. Prokinetics are the treatment of choice for functional dyspepsia (FD). However, the role of prokinetics in FD treatment is still controversial. OBJECTIVES: We conducted a systematic review and meta-analysis of randomised control trials (RCTs) examining the efficacy of prokinetics in the treatment of FD. The primary outcome was overall absence of or improvement of symptoms and symptom scores at the end of treatment. We also evaluated quality of life (QoL) and adverse events as secondary outcomes. SEARCH METHODS: We performed a systematic search of MEDLINE, Embase, the Cochrane Library, and CINAHL, from 1946 until September 2017. RevMan 5.3 was used to calculate pooled risk ratios (RR) of symptoms persisting or without improved QoL or adverse events, mean difference (MD) or standardised mean difference (SMD) of post-treatment symptoms scores, changes of symptom scores, and QoL, when appropriate with 95% confidence intervals (CI), using a random-effects model. Quality of evidence was evaluated using GRADE methodology. SELECTION CRITERIA: We included studies that were parallel group RCTs comparing one prokinetic with either placebo or another prokinetic of the same or different class for the treatment of FD. Studies involved adults who presented with dyspepsia symptoms and who had negative or insignificant findings on endoscopy as well as no other organic and metabolic disorders. Studies only including participants with primarily reflux or heartburn symptoms were excluded. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study eligibility, study quality and performed data extraction. MAIN RESULTS: From an initial 1388 citations, we identified 43 studies in 40 papers. Of those, 29 studies with 10,044 participants compared six prokinetics with placebo for the outcome of absence of symptoms or symptom improvement. There was a statistically significant effect of prokinetic treatment in reducing global symptoms of FD (RR of remaining dyspeptic = 0.81, 95% CI 0.74 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) =7, very low-quality evidence) with considerable heterogeneity; I2 = 91% (P < 0.00001). After removing cisapride from the analysis, the effect of prokinetics in global symptom improvement still persisted, compared to placebo (RR 0.87, 95% CI 0.80 to 0.94), but was still based on very low-quality evidence. The result showed persistence of significant improvement in subgroups of studies at unclear or at low risk of bias (RR 0.86, 95% CI 0.80-0.92), and in subgroups by molecules of cisapride (RR 0.71, 95% CI 0.54 to 0.93; NNTB = 4), acotiamide (RR 0.94, 95% CI 0.91 to 0.98; NNTB = 20) and tegaserod(RR 0.89, 95% CI 0.82 to 0.96; NNTB = 14).Ten studies compared different types of prokinetics with each other and the most commonly used comparator was domperidone, 10 mg three times a day (eight of the 10 studies). There was a significantly better post-treatment symptom score in other prokinetics, compared to domperidone (SMD -0.19, 95% CI -0.35 to -0.03, very low-quality evidence), but no difference in reducing global symptom (RR 0.94, 95% CI 0.83 to 1.07), and mean difference symptom scores (SMD -0.13, 95% CI -0.31 to 0.05). We found five studies that assessed quality of life, but there was no benefit in improving quality of life with prokinetic treatment (SMD 0.11, 95% CI -0.10 to 0.33; participants = 1774). The adverse events in individual prokinetics was not different from placebo (RR 1.09, 95% CI 0.95 to 1.25; participants = 3811; studies = 17). However, when we looked at the adverse effects by each prokinetic, there were overall greater adverse effects in the active treatment group with cisapride (RR 1.31, 95% CI 1.03 to 1.65; P = 0.03). The most common side effects were diarrhoea, abdominal discomfort and nausea. The funnel plot was asymmetric (Egger's test, P = 0.02) implying reporting bias or other small-study effects may be, in part, driving the benefit of prokinetics compared to placebo in this meta-analysis. The GRADE assessment of the quality of the evidence in each outcome are mostly low or very low due to concerns around risk of bias in study design, unexplained heterogeneity and possible publication bias. AUTHORS' CONCLUSIONS: Due to low, or very low, quality of evidence, we are unable to say whether prokinetics are effective for the treatment of functional dyspepsia . We are uncertain which of the individual prokinetic drugs is the most effective as well as whether prokinetics can improve quality of life. Apart from cisapride, prokinetics are well-tolerated. Good quality RCTs are needed to verify the efficacy of prokinetics.

Increased Postoperative Mortality and Complications Among Elderly Patients With Inflammatory Bowel Diseases: An Analysis of the National Surgical Quality Improvement Program Cohort.

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

Factors associated with readmissions and outcomes of patients hospitalized for inflammatory bowel disease.

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

The 2023 Impact of Inflammatory Bowel Disease in Canada: The Influence of Sex and Gender on Canadians Living With Inflammatory Bowel Disease.

Sex (the physical and physiologic effects resulting from having specific combinations of sex chromosomes) and gender (sex-associated behaviours, expectations, identities, and roles) significantly affect the course of inflammatory bowel disease (IBD) and the experience of living with IBD. Sex-influenced physiologic states, like puberty, the menstrual cycle, pregnancy, and andropause/menopause may also impact and be impacted by IBD. While neither Crohn's disease nor ulcerative colitis is commonly considered sex-determined illnesses, the relative incidence of Crohn's disease and ulcerative colitis between males and females varies over the life cycle. In terms of gender, women tend to use healthcare resources at slightly higher rates than men and are more likely to have fragmented care. Women are more commonly prescribed opioid medications and are less likely than men to undergo colectomy. Women tend to report lower quality of life and have higher indirect costs due to higher rates of disability. Women are also more likely to take on caregiver roles for children with IBD. Women with IBD are more commonly burdened with adverse mental health concerns and having poor mental health has a more profound impact on women than men. Pregnant people with active IBD have higher rates of adverse outcomes in pregnancy, made worse in regions with poor access to IBD specialist care. The majority of individuals with IBD in Canada do not have access to a pregnancy-in-IBD specialist; access to this type of care has been shown to allay fears and increase knowledge among pregnant people with IBD.

Canadian Gastroenterology Career Pathway Experiences: Exploring the Gender Divide.

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