Abstract Background Severe restrictions on in-person encounters and endoscopic procedures for digestive care have occurred as a result of the COVID-19 pandemic. This has exacerbated pre-existing barriers in access to gastroenterology (GI) care across Nova Scotia (NS) for patients and primary healthcare providers (PHCPs). In response, a provincial PHCP-GI consultative service (GUT LINK) was implemented at a single tertiary care center with the goal of supporting PHCPs in the management of non-urgent GI referral conditions. Aims To implement and evaluate the acceptability, feasibility, appropriateness, and early effectiveness of the GUT LINK PHCP-GI consultation service. Methods This is an ongoing prospective observational cohort study. All referrals received through the EMR-based referral and triage management system between May and November 2020 that were deemed to be amenable to management within primary care with specialist support were returned to the PHCP with the suggestion to arrange a GUT LINK telephone consultation. GUT LINK appointments were scheduled through an administrative support telephone line with the PHCP and a GI specialist. A post-consultation e-questionnaire was distributed to PHCPs who consented to participate. Feasibility (number of and indication for referrals, PHCP participation rates), acceptability and appropriateness (satisfaction, future use, likelihood to recommend) metrics and outcomes (case resolution, re-referrals, proportion requiring endoscopic investigations) were recorded. Patient charts were reviewed to determine whether the patient ultimately required GI speciality care. Analyses were descriptive and expressed as frequencies, means (+/-SD), medians (+/-SE), and proportions (%). Results A total of 45 GUT LINK consultations were completed between May and November 2020. Of these, 20% required GI specialist care and 80% have remained within primary care, with a median follow-up of 101 (+/-9.1) days. The indications for GUT LINK consultation included lower GI symptoms (64%), abnormal imaging or investigations (17%), and upper GI symptoms (19%). To date, 21 PHCP agreed to be contacted for the post-consultation survey and 10 have been completed. All PHCPs reported that GUT LINK consultation was easy to access, while 90% found the advice helpful and 80% reported that that it resolved the issue. Following the GUT LINK appointment, 80% felt they would not need to refer their patient to GI. Conclusions The implementation of GUT LINK was acceptable, feasible, and improved access to specialist support for management of undifferentiated GI symptoms. Future research will focus on comprehensive stakeholder engagement in order to design, implement, and evaluate GUT LINK PHCP care pathways. Funding Agencies CAG

Abstract Background Nova Scotia has provincial colorectal cancer (CRC) screening for asymptomatic, average risk individuals age 50–74 using fecal immunochemical testing (FIT) every 2 years. However, individuals with 1 or more first degree relatives (FDR) diagnosed with CRC by age 60 have a 2–4 fold increased risk for developing CRC. For these high risk individuals, current guidelines recommend CRC screening with colonoscopy rather than FIT testing. Annually, the Division of Digestive Care & Endoscopy (DCE) at Dalhousie University receives many referrals for patients with a family history of CRC but the percentage of patients who require this procedure is unclear. Aims The objectives of this quality assessment study were to review patients referred to DCE for a family history of CRC to (1) better understand the indication for referral; and (2) determine the percentage of patients undergoing colonoscopy Methods This was a retrospective cross sectional review of a prospectively updated database. The study population was patients referred to DCE from 2012–2019 based on a family history of CRC, as indicated on the referral. Family history of CRC was defined as 1 or more FDRs diagnosed with CRC. High risk patients were those with 2 or more FDRs with CRC or 1 FDR diagnosed by age 60. All patients were reviewed by a single gastroenterologist in clinic. Results A total of 107 referrals from 2012–2019 were reviewed. Of patients age 50 or older, 51/78 (65.4%) had performed at least 1 FIT. The indications for referral were 2 or more FDR diagnosed with CRC for 6/107 (5.6%) patients, 1 FDR diagnosed with CRC by age 60 for 37/107 patients (34.6%) and 1 FDR diagnosed with CRC over age 60 for 33/107 patients (30.8%). The remaining 31/107 patients (29.0%) had no FDR with CRC. Of the 43/107 patients (40.2%) considered high risk based on family history alone, 34/43 (79.1%) underwent colonoscopy and 8/43 (18.6%) opted for FIT testing. Of the 64/107 patients (59.8%) considered average risk based on family history alone, 26/64 (40.6%) had another indication for colonoscopy and 35/64 (54.7%) resumed FIT testing. Conclusions The majority of patients (71.0%) referred to the DCE for a family history of CRC had at least 1 FDR with CRC. Just over half of patients (55.1%) referred to the DCE for a family history of CRC underwent colonoscopy. Strategies to improve the referral process by better capturing high risk individuals are needed. Funding Agencies None

Quality indicators are used to evaluate the effectiveness of colon cancer screening programs. The most commonly reported quality indicator is the Adenoma Detection Rate (ADR) since increased ADR correlates with reduced risk of colorectal cancer and death. Another quality indicator that is gaining popularity is the Serrated Adenoma Detection Rate (SADR) since serrated adenomas are precursors to colorectal cancer and can easily be missed. The utility of reporting SADR is unclear. The objectives of the study are to (1) determine the SADR; and (2) investigate the relationship between SADR and APC for all screening endoscopists in the Nova Scotia colon cancer program as a means of quality assurance. This was a retrospective cross sectional review of a prospectively updated colonoscopy database. The study population was asymptomatic, average risk adults age 50–74 who had a screening colonoscopy after a positive fecal immunochemical test (FIT) from 2016–2017 as part of the Nova Scotia Colon Cancer Prevention Program (NSCCPP). ADR was defined as the number of colonoscopies in which one or more adenomas was removed divided by the total number of colonoscopies performed. SADR was defined in a similar manner using serrated adenomas. Pearson correlation coefficients were used to evaluate the relationship between ADR and SADR. A total of 8379 colonoscopies were performed by 42 endoscopists on FIT positive patients over the study period. The mean number of colonoscopies per endoscopist was 200 (range 51–615). The mean SADR for all endoscopists, those with ADR ≥ 50% and those with ADR ≥ 60% are shown in Table 1. There was a significant positive correlation between ADR and SADR (R=0.52; P<0.001). In the NSCCPP, there was a significant positive correlation between ADR and SADR for screening endoscopists, supporting the use of SADR as a quality indicator. The target SADR for endoscopists screening FIT positive patients needs to be determined. Table 1. SADR for endoscopists classified by ADR Table 1. SADR for endoscopists classified by ADR None

Quality indicators are used to evaluate endoscopist performance in colon cancer screening programs. Adenoma detection rate (ADR) is currently the most commonly used quality indicator. However, ADR has potential limitations prompting other quality indicators to be proposed. Adenoma per case (APC) appears to correlate with ADR and may better differentiate endoscopist performance. However, the relationship between APC and ADR is not fully established and the ideal target for APC remains unknown. The objectives of the study are to (1) determine the APC; (2) investigate the relationship between ADR and APC; and (3) explore target APC based on ADR for all screening endoscopists in the Nova Scotia colon cancer program as a means of quality assurance. This was a retrospective cross sectional review of a prospectively updated colonoscopy database at Dalhousie University. The study population was asymptomatic, average risk adults age 50–74 who had a screening colonoscopy after a positive fecal immunochemical test (FIT) from 2016–2017 as part of the Nova Scotia colon cancer screening program. Adenoma detection rate (ADR) was defined as the number of colonoscopies in which one or more adenomas was removed divided by the total number of colonoscopies performed. The number of adenomas per case (APC) was determined by dividing the total number of adenomas removed by the total number of colonoscopies performed. Pearson correlation coefficients were used to evaluate the relationship between and ADR-APC. A total of 8379 colonoscopies were performed by 42 endoscopists on FIT positive patients over the study period. The mean number of colonoscopies per endoscopist was 200 (range 51–615). The mean APC for all endoscopists, those with ADR ≥ 50% and those with ≥ 60% are shown in Table 1. There was a significant positive correlation between ADR and APC (R=0.88; P<0.001). In the Nova Scotia Colon Cancer Prevention Program, there is a significant positive correlation between ADR and APC for screening endoscopists. A mean APC of 1.4 may be a useful target for endoscopists screening FIT positive patients. Table 1. APC for endoscopists classified by ADR Table 1. APC for endoscopists classified by ADR None

Patients with inflammatory bowel disease (IBD) require lifelong medical and surgical management of their disease. Globally, many institutions have adopted integrated collaborative care models to improve patient care. Studies of these dedicated IBD services have shown they improve patient outcomes and quality of life. Little is known, however, what models of care for the management of patients with IBD are currently used across Canada. The objectives of this study are to 1) determine the structure and processes used in clinics providing care for patients with IBD across Canada, 2) understand how IBD patients access IBD clinics across Canada, 3) identify the IBD practitioners and allied health professionals working with IBD clinics across Canada, and 4) determine the process and structure of referral pathways and clinical visits for IBD patients. Evidence-based survey development methods were used to develop a peer-reviewed and piloted, web-based questionnaire to survey Canadian gastroenterologists who provide care for IBD patients. The questionnaire was developed using Novi Survey software. The contact information for each gastroenterologist in Canada was acquired using a database provided by Scott’s Directories. Participants’ lists were finalized after cross-referencing the Scott’s database with gastroenterologists listed by the Royal College of Physicians and Surgeons. In October 2017, the entire target population was invited to participate in the survey using the Dillman’s Tailored Design methodology. This work is in progress. To date, 14/583 (3%) survey questionnaires have been received from 7 provinces. Nine (65%) respondents are male and the mean age is 45 (SD=10) years. Working in or affiliated with most respondent IBD clinics are gastroenterologists specializing in IBD (71%), medical residents (71%), medical students (64%), gastroenterology residents (64%), IBD nurse non-practitioners (64%), research nurses (64%) general gastroenterologists (57%), IBD nurse practitioners (57%), dieticians (57%) and radiologists (57%). Few respondent IBD clinics have nurse educators (36%), general surgeons (36%), colorectal surgeons (36%), ophthalmologists (36%), social workers (36%), nurse navigators (29%) or psychiatrists (21%) working in or affiliated with them. IBD in Canada represents a significant burden of illness. Most of the respondents to date work in IBD clinics comprised of gastroenterologists, trainees, IBD nurses, research nurses and dieticians while few work with nurse educators or navigators, surgeons, social workers or psychiatrists. Given the limited number of responses to date the sample thus far is likely not representative and the final results of this survey will be presented once the survey distribution process is complete. None

Hepatitis C virus (HCV) has been the main indication for liver transplantation (LT) with universal recurrence after transplantation and significant morbidity and mortality post LT. The newer interferon-free direct acting antiviral agents have been effective in achieving sustained viral response (SVR). To document the efficacy, safety and tolerability of interferon-free direct acting antiviral agents in the treatment of HCV recurrence in all genotypes in liver transplant patients from Atlantic Canada. As part of quality improvement audit, we searched the AMOTP liver transplant database for all patients with HCV who had undergone LT. We then specifically extracted data on the LT patients who had direct acting antiviral agents initiated to assess efficacy of therapy. Post treatment SVR was determined by HCV RNA levels at week 12. Between July 1985 and June 2016, 583 liver transplants were done within the Atlantic Multi-Organ Transplant Program (AMOTP). Of those 119 (20%) recipients were HCV-Antibody positive at time of liver transplant. By end of study period, 62 with HCV-Antibody were still alive. Between July 2014 and August 2016, 24 liver transplantation recipients from across Atlantic Canada with HCV recurrence [defined as positive HCV-RNA by PCR and liver biopsy proven disease showing at least grade 2 (inflammation) and/or stage 2 (fibrosis)] were started on interferon-free orally direct acting antiviral. Most patients (88%) received sofosbuvir (SOF) based regimes (sovaldi + ribavirin (RBV), n=5; SOF + RBV, n=5; SOF + ledipasvir + RBV, n=13; SOF + sovaldi, n=1). The mean age of these patients was 62.8 ± 4.9 years with the majority being genotype 1 (75%) and male (79%). Eighteen of twenty-two (82%) patients have undetectable HCV RNA viral loads at the end of treatment, with two patients still undergoing evaluation. Thirteen of seventeen (76.5%) patients have achieved SVR with 2 non-responders, 1 relapse and 1 early discontinuation due to non-compliance. The remaining 5 patients are still undergoing evaluation. Treatment of HCV infected patients with interferon-free regimens after liver transplantation appears efficacious and well tolerated. None

Trimethoprim-sulfamethoxazole (TMP-SMX) is commonly prescribed for skin and soft tissue infections. While generally well tolerated in HIV-negative patients, TMP-SMX can lead to drug-induced liver injury (DILI). Most cases are self-limited and resolve quickly with drug discontinuation, but prolonged, severe injury and liver failure can occur. Upon onset of acute liver failure, prognosis is poor without liver transplantation. Currently, there are no specific therapies to prevent progression to acute liver failure in patients with TMP-SMX induced liver injury. We hope to help raise awareness on DILI due to TMP-SMX and provide evidence for the use of N-acetylcysteine (NAC) to treat acute drug induced liver dysfunction. We report a case of a young male on TMP-SMX for a purulent soft tissue infection who developed acute liver dysfunction and was successfully treated with NAC. A 17 yo male was prescribed oral TMP-SMX (80 mg/400 mg) for a purulent soft tissue infection and after 30 days of treatment developed jaundice and a rash. He presented to the emergency department with accompanying malaise, weakness, nausea, vomiting and fever. He had no risk factors for viral hepatitis, no history of liver disease, took no other medications and did not drink alcohol or use recreational drugs. Laboratory tests showed elevated total bilirubin (139 µmol/L), transaminases (AST 280 U/L, ALT 1378 U/L), alkaline phosphatase (295 U/L), and lactate dehydrogenase (1162 U/L), with normal white blood cell count (9.6 x 109/L), serum albumin (38 g/L) and INR (1.1). Tests for hepatitis A, B and C were negative. Abdominal ultrasound found no evidence of biliary obstruction. His TMP-SMX was stopped but his condition worsened and he was transferred to our centre for urgent hepatology assessment. Physical examination revealed scleral icterus and a morbilliform rash over his trunk, back and upper extremities, but no asterixis. Repeat laboratory tests showed increased bilirubin (229 µmol/L), transaminases (AST 1498 U/L, ALT 2045 U/L), lactate dehydrogenase (5302 U/L) and INR (3.2). He underwent a transplant work-up, which did not reveal an alternative cause for his liver dysfunction. He received IV NAC for 72 hours and 4 doses of 10 mg IV vitamin K. NAC was dosed according to our standardized 20-hour protocol and the final infusion rate was continued until his INR was less than 1.5. After 4 days, his INR normalized, his rash and jaundice resolved and he was feeling well enough to be discharged home. Clinicians prescribing TMP-SMX should monitor patients for signs and symptoms of DILI. In the event of acute liver dysfunction due to TMP-SMX, use of NAC may improve outcomes by preventing progression to liver failure, but further research is needed. None