Laura E. Targownik

Background: As the prevalence rates of inflammatory bowel disease (IBD) increase across Canada, it is imperative that persons living with IBD have timely and safe access to IBD-related care. Transgender and gender diverse (TGGD) individuals often experience fragmented care and a lower health-related quality of life often ascribed to past discrimination, stigmatization, and violence. The purpose of this patient-oriented, qualitative study was to explore the care experiences and expectations of TGGD individuals who live with IBD. Methods: Interpretive description was used to identify themes and patterns of the experiences and expectations of accessing and receiving care in TGGD individuals living with IBD. Purposive sampling was used to recruit and interview 16 Canadians who identified as TGGD, were living with IBD, and were over 18 years of age. Results: Of the 16 individuals interviewed, 10 people participated in individual interviews and 6 participated in group interviews. Four themes were identified: (1) The Intersections of Being TGGD and Living with IBD; (2) Barriers to TGGD IBD Healthcare; (3) Facilitators to TGGD IBD Healthcare; and (4) Improving TGGD IBD Care Experiences. A main strategy identified to overcome challenges related to the main themes is for healthcare providers and patients to build trusting relationships using open communication and ensure active participation in IBD-related healthcare decisions. Conclusion: There are several deficiencies in the process of care provided to TGGD individuals with IBD that are potential targets for improvement to facilitate a trauma-informed care approach.

Background: Gender biases in gastroenterology (GI) referrals have not been characterized. Aims: To assess for differences in the demographics or complexity of consultations referred to female vs male gastroenterologists. Methods: Our retrospective cohort study used health administrative data to identify all ambulatory luminal GI consultations in Ontario, Canada between 2002 and 2019. Our primary outcome was the difference in the proportion of female patients seen by female vs male gastroenterologists. Linear regression was performed to evaluate how this proportion changed over time and if this trend varied by physician gender. Crude odds ratios and their 95% CIs for the association of referral to a female gastroenterologist and being a female patient were calculated. We also examined the proportion of patients with mental health conditions. Results: We identified 4 620 691 GI consultations. In the early phase (2002-2007), 71.1% of consultations performed by female gastroenterologists were for female patients, compared to 55.9% of consultations performed by male gastroenterologists (crude OR 1.96, 95% CI [1.89, 2.03]); this discrepancy lessened over time based on trend tests. Female gastroenterologists also received a higher proportion of consultations for patients with mental health comorbidities in the early phase (41.3% vs 39.3%, P = .03); this proportion declined over time. The proportion of Ontario female gastroenterologists increased from 12.3% (28/227) to 24.4% (86/353) over the study period. Conclusions: There are systematic differences in the characteristics of consultations referred to female vs male gastroenterologists. Further research should explore the impact these gender-based differences have on patient outcomes.

Background: Inflammatory bowel diseases (IBDs), including Crohn’s disease (CD) and ulcerative colitis (UC), are increasingly prevalent. Ustekinumab (UST), a biologic therapy, has shown efficacy in treating CD and UC, but its real-world impact is less clear. This study assessed all-cause and IBD-specific healthcare resource utilization (HCRU) and costs, excluding medication costs, among patients with CD and UC initiated on UST. Methods: This retrospective cohort study in Ontario, Canada included patients initiating UST between January 2017 and September 2022. Patients were identified through the Johnson & Johnson (J&J) BIOADVANCE® patient support program and deterministically linked to ICES databases. Outcomes were compared between 1 year pre-initiation of therapy and each post-initiation year (up to 4 years). Results were reported for patients who were persistent on UST at each year of the analysis period, patients who were persistent vs. discontinued UST for the duration of Year 1, and patients who were biologic-naïve versus bio-experienced prior to index. Results: The study cohort included 2279 patients with CD and 626 patients with UC. UST initiation was associated with significant reductions (P < .001) in the number of all-cause HCRU events in each year of follow-up, including for CD patients who were biologic-naïve and persistent on UST. Non-medication costs were lower for both CD and UC patients in all years, and significant in Years 1-3 for CD and Year 2 for UC patients. Conclusions: In CD and UC patients, all-cause and IBD-specific HCRU and non-medication healthcare costs were lower in years following UST initiation.

Introduction: The urban environment increases the risk of inflammatory bowel disease (IBD). Specific environmental exposures involved in IBD etiology remain unknown. We examined the association between outdoor artificial light at night (ALAN) and IBD incidence, surgery, and health services utilization (HSU). Methods: Using population-based deterministically linked health administrative data from Ontario, Canada we conducted a birth cohort study (incidence), matched case-control study (incidence), and cohort study (surgery, HSU). Individuals with IBD were identified using previously validated algorithms. ALAN, the average digital number of lights consistently present, was a 3-level variable: 60. We used Cox proportional hazards models (birth cohort, surgery), conditional logistic regression (matched case-control study), and Poisson regression (HSU). Results: Among 3 929 374 individuals in the birth cohort, 5539 (0.1%) developed IBD; no association between ALAN at birth and IBD was observed (35-60: hazard ratio [HR] 1.03, 95% confidence interval [CI] 0.87-1.22; >60: HR 0.93, 95% CI 0.78-1.11). Among 32 176 IBD cases matched to 160 709 controls, high ALAN was associated with a lower IBD risk (>60: odds ratio [OR] 0.84, 95% CI 0.78-0.92); there was no association between IBD and the middle ALAN level. High ALAN was associated with fewer IBD-specific outpatient visits (rate ratio [RaR] 0.93, 95% CI 0.86-0.99) and hospitalizations (RaR 0.83, 95% CI 0.72-0.95) 1 year after diagnosis. ALAN was not associated with surgery or emergency department visits. Discussion: The association between ALAN and IBD is heterogeneous. Additional research is needed to understand how ALAN impacts IBD and identify other environmental exposures contributing to IBD etiology.

Background: Mirikizumab (MIR), a selective interleukin-23p19 inhibitor, has demonstrated efficacy in randomized trials for moderate-to-severe ulcerative colitis (UC). Real-world data remain limited. Here, we evaluated the effectiveness, durability, and safety of MIR in routine clinical practice. Methods: We conducted a retrospective, multicentre cohort study of adults with UC initiating MIR at two tertiary centres in Canada. Clinical, biomarker, endoscopic, and safety outcomes were assessed at weeks 12, 28, and 52. The primary outcome was corticosteroid-free (CSF) clinical remission at week 12. Secondary outcomes included CSF clinical remission at weeks 28 and 52, CSF clinical response, mucosal healing, treatment persistence, extended induction, and serious adverse events. Predictors of extended induction were evaluated using logistic regression. Results: Eighty-two patients were included; 94% were previously exposed to at least one advanced therapy. CSF clinical remission was achieved in 24% of patients at week 12, 35% at weeks 28, and 33% at week 52, with corresponding CSF clinical response rates of 45%, 53%, and 40%. Moreover, 40% of the cohort received extended induction. In the extended induction subgroup, CSF clinical remission was observed in 19% at week 28 and 22% at week 52, with CSF clinical response rates observed in 37% and 30%, respectively. Early CSF clinical response at week 12 was associated with treatment persistence. The incidence of serious adverse events was low, with no new safety signals. Conclusions: In this multicentre real-world Canadian cohort of predominantly treatment-experienced patients with UC, MIR demonstrated clinically relevant effectiveness, acceptable durability, and a favourable safety profile over 1 year.

Background and Aims: Studies show that corticosteroid use in inflammatory bowel disease (IBD) exceeds guideline recommendations. To better understand patterns of corticosteroid use and identify factors associated with excess exposure, we examined long‐term trends in corticosteroid prescribing practices in large IBD populations across 3 countries. Methods: This retrospective analysis used data from US administrative claims (2007–2018) and national registries from Sweden (2006–2022) and Denmark (1995–2018). The prevalent cohort included patients with ≥ 2 records of an IBD diagnosis since data collection. The incident cohort included patients with a new IBD diagnosis. Excess corticosteroid use was defined as ≥ 2 separate corticosteroid courses within 1 year and/or continuous corticosteroid exposure ≥ 3 months. We conducted multivariable logistic regression to identify variables associated with excess use. Results: In prevalent cohorts, including 257,359 (United States), 75,301 (Sweden), and 46,785 (Denmark) patients, annual rates of corticosteroid use and excess declined over the study period in the United States (use: CD [28.1 → 26.4%], UC [31.6 → 27.5%]; excess: CD [13.7 → 11.3%], UC [16.9% → 11.8%]), Sweden (use: CD [29.8% → 20.9%], UC [21.5% → 14.8%]; excess: CD [22.8% → 15.2%], UC [14.8% → 9.5%]), and Denmark (use: CD [15.5% → 10.0%], UC [12.1% → 8.5%]; excess: CD [6.8% → 3.2%], UC [4.9% → 2.5%]). In incident cohorts, including 106,845 (United States), 45,347 (Sweden), and 37,681 (Denmark) patients, corticosteroid use and excess were highest during the first year post‐diagnosis. During years 2‐4 post‐diagnosis, IBD complications, IBD‐related hospitalizations, and previous advanced therapy exposure (excluding CD Danish cohort) were associated with excess use. Conclusions: Corticosteroid use decreased over time, though exposure varied across countries. Corticosteroid use and excess were highest during the first year after diagnosis.

Background & Aims: Individuals with inflammatory bowel disease (IBD) may have worse obstetrical outcomes than those without IBD. We assessed the odds of severe maternal morbidity (SMM) among individuals with IBD compared to those without by IBD subtype (Crohn’s disease [CD] or ulcerative colitis [UC]), and whether the method of delivery impacted the odds of SMM. Methods: We conducted a retrospective, population-based matched cohort study of females aged 15-49 years in Ontario, Canada from 2003 to 2019 delivering at 20+ weeks’ gestation. The primary outcome was SMM occurring between 20 weeks’ gestation up to 42-days postpartum. We identified deliveries among individuals with IBD using health administrative data and matched them 1:5 to deliveries among individuals without IBD from the general population of Ontario residents. Multivariable regression models estimated the adjusted odds ratio (OR) of SMM in antepartum and postpartum periods. We tested for interactions between IBD status and delivery method. Results: 6833 deliveries in individuals with IBD (3800 CD and 3033 UC) were matched to 34 165 non-IBD deliveries. More individuals with IBD underwent C-section (36.5% vs 30.9%, standardized mean difference, SMD: 0.12). Compared with individuals without IBD, those with IBD had higher odds of antepartum SMM (OR: 3.5, 95% CI: 2.1-5.8) and postpartum SMM (OR: 1.3, 95% CI: 1.0-1.5). The odds of SMM among individuals with and without IBD was not modified by method of delivery (interaction term P = .17). Conclusions: Individuals with IBD were at increased risk of SMM, independent of delivery method. Pregnancy care should focus on optimization of other IBD-related risk factors.

This case reports a 35-year-old man with recurrent right lower quadrant (RLQ) pain initially suggestive of acute appendicitis who was diagnosed with functional abdominal pain syndrome after negative imaging and colonoscopy. Because of persistent pain, he underwent a diagnostic laparoscopy and appendectomy, where an appendiceal neuroma was diagnosed; this led to complete symptom resolution. This case highlights the importance of considering appendiceal neuroma in the differential for unexplained appendicitis-like RLQ pain, particularly when standard workups are inconclusive. The resolution of symptoms postsurgery suggests that exploratory surgery should be considered in patients with severe and persistent RLQ pain, even with negative imaging.

Background: Trends in extra‐digestive (ED) cancer incidence and mortality in inflammatory bowel diseases (IBD) may be changing with newer approaches to management. Aims: To study temporal trends and contemporary risks of ED cancers in individuals with and without IBD. Methods: Using population‐level administrative data from Ontario, Canada, we studied ED cancer rates among individuals with IBD and age‐sex‐matched controls (1:10) without IBD between 1994 and 2020. We modelled age‐sex‐standardised annual cancer incidence (per 100,000 person‐years) over time by first‐order linear autoregression, and standardised cancer incidence and mortality rate ratios (SIR, SMR) by quasi‐Poisson regression. Results: The average annual percentage change (AAPC) in ED cancer incidence was stable among 110,919 people with IBD (0.108%/year; 95% CI, −0.380, 0.599) but declined among 1,109,190 matched controls (−1.39%/year; 95% CI, −1.57, −1.21). Among those with IBD, AAPC was significant for non‐Hodgkin's lymphoma (1.48%/year; 95% CI, 0.161, 2.82), melanoma (1.77%/year; 95% CI, 0.781, 2.77), cervical (2.31%/year; 95% CI, 0.602, 4.10), uterine (4.41%/year; 95% CI, 0.045, 8.96) and thyroid (8.10%/year; 95% CI, 4.31, 12.0) cancers, and statistically greater than controls for cervical, ovarian, lung, and bladder cancers. During 2010–2020, ED cancer incidence was higher in those with IBD (SIR 1.20; 95% CI 1.15, 1.26), while ED cancer‐related mortality was specifically higher in those with Crohn's disease (CD; SMR 1.31; 95% CI 1.14, 1.51), as compared to matched controls. Conclusions: ED cancer incidence has not changed among those with IBD but has declined among matched controls. Beyond 2010, ED cancer incidence is higher among those with IBD and cancer‐related mortality is higher among those with CD, relative to matched controls.