bluuebunny/crossref_metadata_2025 huggingface dataset:
245 Dietary Calcium and Vitamin D Intake and Colonic Mucosa-Associated Microbiome in Healthy Individuals
Authors: Chen Ellie , Ajami Nadim , Chen Liang , White Donna , Cole Rhonda , Hair Clark , Graham David Y. , El-Serag Hashem B. , Petrosino Joseph , Jiao Li
Published: October 2019

INTRODUCTION:

Studies have demonstrated antitumor or anti-inflammatory properties of calcium and vitamin D. Dietary calcium and vitamin D intake has been associated with lower risk of colorectal cancer. However, the effect of calcium and vitamin D intake on gut microbiota is not well understood.

METHODS:

This is a cross-sectional study of 99 colonic biopsies of 35 individuals (average age 62 years, 77% Caucasian and 1 woman) with poly-free colonoscopy between August 2013 and April 2017 at Michael E. DeBakey VA Medical Center. Microbial DNA was isolated and the V4 region of the16S rRNA gene was amplified then sequenced for microbiome profiling. A food frequency questionnaire was used to ascertain calorie-adjusted calcium and vitamin D intake. Median intake was used to dichotomize the intake to low vs. high. Sequencing data were analyzed using the UPARSE and SILVA database for operational taxonomic unit (OTU) classification. Alpha-diversity (Shannon index), beta-diversity (weighted UniFrac) and relative abundance of bacteria (Mann-Whitney test) were compared between low vs. high intake. Reported P-value was adjusted for multiple comparisons using false discovery rate (FDR).

RESULTS:

Compared with lower intake, higher dietary calcium and vitamin D intakes were both associated with greater richness and evenness (P value < 0.005). The community composition also differed by calcium and vitamin D intake (P = 0.001). In phylum level, the relative abundance of Verrucomicrobia was greater in individuals with higher calcium and vitamin D intake (P values < 0.005). In genus level, high consumption of both calcium and vitamin D were associated with a significantly higher relative abundance of Akkermansia, Faecalibacterium, Dialister, Haemophilus, Odoribacter, Fusicatenibacter, and Paraprevotella, but a lower abundance of Erysipelatoclostridium and Lachnoclostridium (FDR P values < 0.05). Higher intake of calcium, but not vitamin D, was also associated with lower abundance of Bacteroides and higher abundance of Parabacteroides (P values = 0.02).

CONCLUSION:

Higher intake of calcium and vitamin D was associated with a higher diversity of colonic microbiota and higher abundance of potentially beneficial bacteria and lower abundance of harmful bacteria in healthy individuals. Further metagenomics and metabolomics research are needed to understand whether and how the protective effect of calcium and vitamin D on colorectal cancer is partially mediated through gut microbiome.
263 Male Gastroenterologists Have Better High-Risk Adenoma Detection Rate (HRADR) in Male Patients
Authors: Alomari Mohammad , Al Momani Laith , Bratton Hunter , El Kurdi Bara , Khazaaleh Shrouq , Wadhwa Vaibhav , Thota Prashanthi N. , Sanaka Madhusudhan R.
Published: October 2019

INTRODUCTION:

High-risk adenomas (HRA) have been associated with a significant risk of interval colorectal cancer development. Recent literature suggests that high-risk adenoma detection rate (HRADR) can be used as a complementary screening colonoscopy quality metric. Being dependent upon the experience- and skill-level of the provider, we aimed in this study to investigate the impact of gastroenterologists' gender on HRADR among screened patients.

METHODS:

A retrospective review of all screening colonoscopies in patients ≥50 years of age performed at our center between 2012 and 2014 was done. Average risk patients who had a complete colonoscopy with excellent, good, and fair bowel preparation were included. Overall, gender-specific, and segment-specific adenoma detection rates (ADR), large adenoma detection rate and high-risk adenoma detection rates (HRADR) were calculated and compared using t-tests. HRADR defined as either ≥3 adenomas or at least one adenoma of ≥10 mm (big adenoma) or at least one tubule-villous adenoma, high grade dysplasia or cancerous polyp.

RESULTS:

A total of 2641 patients were included in the analysis. Average patient age was 58 ± 7.6 years and 53.2% were females (Table 1). Compared to female gastroenterologists, male gastroenterologists had better overall HRADR (9.8 ± 6.6 vs. 5.0 ± 4.0; P < 0.012) and overall Distal HRADR (4.6 ± 5.0 vs. 1.2 ± 2.2, 0.019). In male patients, male gastroenterologists had better proximal and distal HRADR (6.4 ± 7.0 vs. 1.8 ± 2.7; P < 0.021 and 6.3 ± 7.4 vs. 1.2 ± 3; P < 0.016, respectively). In female patients there was a non-significant trend toward better overall and segment-specific HRADR (P-value = 0.97, 0.56 and 0.30). Also, male gastroenterologists were better at detecting large adenomas (>1 cm) in male patients (7.4 ± 8.3 vs.1.7 ± 3.3; P < 0.016). All endoscopists met the nationally recommended ADR thresholds (25% overall, 20% for females and 30% for males).

CONCLUSION:

In this study, male gastroenterologists had better overall HRADR and overall Distal HRADR among all screened patients. In male patients, male gastroenterologists had better proximal and distal HRADR and were better at detecting large adenomas. This association was consistent across patient age, race, and level of colon preparation. These findings suggest that the differences in screening colonoscopy training and/or volume between male and female gastroenterologists may have important clinical implications in the detection of colon cancer and patient outcomes.
265 Beyond Polyp Detection: Novel Method to Track Individual Polyps Using Neural Networks
Authors: Requa James , Dao Tyler , Ninh Andrew , Karnes William
Published: October 2019

INTRODUCTION:

Polyp detection using neural networks (NNs) during colonoscopy shows promise for reducing adenoma miss rate. NNs are also being developed to document polyp features, including their pathology, size and shape, as well as procedure quality measures, including cecal intubation, withdrawal time and prep quality. Counting polyps of predicted size, shape and pathology is also critical for determining appropriate surveillance intervals at point-of-care. The latter requires NNs capable of “remembering” each polyp to avoid recounting at each re-encounter.

METHODS:

The polyp-tracking system includes 3 components: 1) Polyp Detection/Localization: YOLO-based Convolutional Neural Network architecture which identifies & localizes new polyps in the colon in real-time during colonoscopy procedure; 2) Polyp Future Positioning: Recurrent Neural Network Bi-directional LSTM (Long Short-Term Memory) that predicts polyp's future position based on temporal features across sequential video frames and 3) Polyp Re-Identification/Matching: one-shot learning Siamese Neural Network that outputs a “similarity score” expressing the likelihood that two polyps are the same.

RESULTS:

YOLO-based polyp detection algorithm was trained on 7000 polyp images (unique polyps), 7000 non-polyp images and can achieve a detection rate of over 99% on validation set of 3000 images. Both LSTM polyp future positioning algorithm & Siamese Net polyp re-identification algorithms were trained on sequences of detected polyps in video frames from 400 colonoscopy video clips and validated on 100 clips. For the LSTM, with objective to predict center-point coordinates for polyp in the next (future) frame, it achieved <0.001 validation loss (mean-squared-error) compared to ground truth center-point coordinates and can process inference at 1000 FPS. For polyp re-identification, we achieved 94.7% validation accuracy at re-identifying the same polyp across frames.

CONCLUSION:

Polyp tracking will provide many benefits to AI-assisted colonoscopy, including correct polyp counting, more accurate rendering of predictions of optical pathology, polyp size and polyp shape. Theoretically, the technology could be modified to assist in finding a lost polyp, in alerting the colonoscopist to unseen surfaces, and defining finding locations.
271 Higher Charlson-Deyo Score May Result in Delay to Colonoscopy in Veterans Subsequently Diagnosed With Colorectal Cancer
Authors: Khuc Thi , Jackson Christian
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) is the second most common cause of cancer deaths in the United States and expected to cause 51,020 deaths in 2019. Early detection with yearly fecal occult blood test (FOBT) has been proven to decrease CRC mortality. A 30-day delay from positive FOBT to colonoscopy has been shown to be associated with increased risk of CRC.
1
Currently, the Veterans Affairs Health System (VAHS) treats approximately 11% of CRCs in the United States. The compounding effects of an aging population, physician shortage, and increased military personnel entering the VAHS can increase demands on VAHS resources. The primary aim of this study was to determine risk factors that caused delay to colonoscopy.

METHODS:

We retrospectively reviewed records of 600 patients referred for colonoscopy between January 1999 and January 2009 and were subsequently diagnosed with CRC. Patients were excluded if a prior CRC diagnosis had been established. The final study cohort consisted of 530 patients. Using Chi square and Fisher's testing, we examined the relationship between 10 variables and delay in time from initial consultation to colonoscopy. Variables consisted of age, sex, race, ethnicity, CRC location, marital status, history of mental health diagnosis, tobacco use, substance abuse, Charlson/Deyo (C/D) score and season of referral for colonoscopy. A delay in time was defined as 30 days or greater. Further logistic regression analysis adjusted for age, race, CRC location and C/D score.

RESULTS:

A total of 87.17% of patients experienced a delay in time from initial consultation to colonoscopy. When analyzed with a predictive variable of delay to colonoscopy, C/D score of ≥2 versus 0, was associated with higher odds of delay in time to colonoscopy (OR = 2.18, P = 0.02). African American race and Hispanic ethnicity was associated with a higher odds of delay in time to colonoscopy, but was not statistically significant (OR = 1.47, P = 0.47, OR = 1.37, P = 0.48).

CONCLUSION:

Patients with a C/D score ≥2 were 218% more likely to have delay in time from initial consult to colonoscopy, resulting in a delayed CRC diagnosis. C/D score may be used to determine which patients should have more frequent reminders to schedule their colonoscopy to prevent delays in care. Randomized and prospective studies will need to be performed.
276 Low Rates of Colonoscopic Surveillance Among Patients With High Risk Adenomas
Authors: May Folasade , Corona Edgar , Yang Liu , Nguyen B. Sean , Lin Christina , Huang Marcela Zhou , Shao Paul , Mwengela Didi , Didero Michelle , Asokan Ishan , Bui Alex , Hsu William , Maehara Cleo , Naini Bita , Kang Yuna , Bastani Roshan
Published: October 2019

INTRODUCTION:

There have been a myriad of efforts to address suboptimal colorectal cancer (CRC) screening rates in the United States (US). Individuals with high-risk colon polyps detected during screening colonoscopy have 2- to 5-fold increased risk for the future development of CRC; however, there are few efforts directed towards optimizing risk reduction in this group. We examined surveillance uptake for patients with high-risk polyps in a large, academic healthcare system.

METHODS:

\We identified a cohort of patients: 1) age 50–75; 2) with a colonoscopic diagnosis of high-risk adenoma (HRA; 1 adenoma >1 cm, adenoma with villous histology, adenoma with high-grade dysplasia, or 3 or more adenomas) between January 2013 and January 2016; and 3) regular primary care (PC) at UCLA Health. We collected information from the electronic health record (EHR) on demographics, polyp histology, colonoscopy completion, and office visits. We determined the proportion of patients that completed surveillance colonoscopy each year and used Student's t-tests and chi-square tests to evaluate univariate associations between patient characteristics and colonoscopy completion.

RESULTS:

Our cohort included 203 individuals with HRA. Mean age was 62.5 (SD = 7.6), 62.6% were male, and 75.3% were White (Table 1). There were 153 (75.4%) patients who did not complete surveillance within 3 years. Surveillance completion increased from 24.6% to 40.4% by 3.5 years. 110 (54.2%) completed surveillance by the end of 5 years (Table 2). In all, 202 (99.5%) patients had documentation of a PC visit and 165 (81.3%) had documentation of a GI visit before surveillance was due. There were 121 (59.6%) patients with a documented history of adenoma in the EHR problem list. Patients with ≥1 GI visit after HRA diagnosis (165, 81.3%) were more likely to complete surveillance than patients without a GI visit after HRA diagnosis (38, 18.7%) (P < 0.001).

CONCLUSION:

Overall uptake of surveillance colonoscopy was low at 3 years for patients with HRA. There was notable improvement in follow-up by 3.5 years; however, adherence remained suboptimal at 40%. Clinical implications of this delay are unknown. Documentation of adenoma history was low. Individuals with HRA represent a group that has been largely neglected in CRC prevention/control research and that warrants evidence-based strategies to ensure appropriate follow-up to reduce CRC burden.
281 Elimination of Language Barriers as a Strategy to Decrease Colorectal Cancer Screening Disparities in Underserved Hispanics: Is This Enough?
Authors: Ajayi-Fox Patricia , Flocco Gianina , Romero-Marrero Carlos
Published: October 2019

INTRODUCTION:

Despite the overall increase in colorectal cancer screening (CRCS) rates, disparities are still observed in minority groups, such as Hispanics. Suggested reasons for this are poor health literacy, different cultural attitudes about health and language barriers. To determine the impact of eliminating language barriers among Hispanics in CRCS, we analyzed differences in CRCS rates between Hispanics served at a bilingual underserved clinic to African Americans and Hispanics served at other non-bilingual clinics.

METHODS:

A retrospective review of CRCS rates of selected minority patients seen at our institution between 1/1/13 and 12/31/18 was conducted. Three outpatient primary care clinics were included: a clinic located at our Main Campus (GC), one with predominantly African American patients (AC), and a Hispanic clinic (HC) at an alternate location. While GC and AC had only English-speaking providers, the Hispanic clinic (HC) had exclusively bilingual providers. For GC, only Hispanic patients were included. Variables analyzed included general demographics, CRCS rates, screening method, quality of bowel preparation and adenoma detection rates.

RESULTS:

A total of 3963 patients were included in the study. Sixty percent were female. Average age of screening was 58, 57 and 58 at HC, GC and AC respectively (p 0.093). Overall, the predominant method of CRCS was colonoscopy (45.1%), however AC had a high rate (13.6%) of FIT utilization. 65.7% of patients had good or excellent bowel preparation quality, and there was a 37.2% adenoma detection rate (ADR). When comparing clinics, there was a statistically significant difference in CRCS rates (43.4% HC, 58.7% GC and 59.5% AC, P < 0.001), good bowel preparation quality (53.6% HC, 68.5% GC and 69.2% AC, P < 0.001) and adenoma detection rates (29.8% HC, 29.3% GC and 40.3% AC, P < 0.001).

CONCLUSION:

Our study shows that, despite the elimination of language barriers, disparities affecting underserved Hispanic patients remain in colorectal cancer screening rates, bowel preparation quality and adenoma detection rates. Language alone may not be all that is needed for improving CRCS in underserved Hispanic populations and a multifactorial approach is needed for this. The higher CRCS at AC could be attributable to their high number of FIT tests. One potential intervention would be increasing FIT at the HC as an initial screening method.
286 Colonoscopy Outcome Similarities and Differences Between GI Providers and Non-GI Providers in Patients Who Undergo Colonoscopy Following a Positive Stool DNA Test
Authors: Huq Nadia , Fahed Gracia , Inaganti Anupama , Affi Aboud , Fahed Julien
Published: October 2019

INTRODUCTION:

Previous stool DNA studies published aggregated results of colonoscopy outcome in patients who had a positive stool DNA test. In this study, we compare the outcome of colonoscopy based on the specialty of the provider who performed the procedure.

METHODS:

Review of charts of 1413 patients who had a positive stool DNA followed by documented colonoscopy was done. At total of 4 patients were excluded. Two patients were excluded because of finding of “other carcinoma” aside from adenocarcinoma while the other 2 were excluded because the provider type was unknown. Attention was given to the specialty of the provider performing the procedure. Patients were divided in 2 groups. Group 1 included patients who had their colonoscopy done by a GI provider while group 2 included patients who had their colonoscopy done but a Non-GI provider. Only the index lesion was recorded. Advanced adenoma was defined as an adenoma that is larger than 10 mm or had high risk features such as villous transformation or high grade dysplasia. Nonadvanced adenoma was defined as an adenoma that is smaller than 10 mm and had no high risk features. Statistical analysis with Chi-square and Fisher exact was done to compare the proportions. A P-value < 0.05 was considered to be statistically significant.

RESULTS:

Out of the 1409 patients included in the study, colonoscopy was performed by a gastroenterologist in 1180 (83.75%) of the patients, by a general surgeon in 198 (14.05%) of the patients, and by a primary care provider (internal medicine or family medicine) in 31 (2.2%) of the patients. The findings in group 1 and group 2 were compared. “adenocarcinoma” was found in 2.03% vs. 0% respectively (P = 0.02). “Advanced adenoma” was found in 23.98% vs. 22.27% respectively (P = 0.58). “10 mm adenoma” was found in 7.71% vs. 4.37% respectively (P = 0.07). Non advanced adenoma was found in 30% vs. 26.64% respectively (P = 0.31). Finally, no adenomas were found in 36.27% vs. 46.72% respectively (P = 0.003).

CONCLUSION:

This study shows similarities and differences in outcomes of colonoscopies in patients who have positive stool DNA test between high volume and low volume providers. GI providers and non GI providers had a difference in their findings of non advanced adenoma and adenocarcinoma. Further prospective studies are needed to validate these results.
295 Colonoscopy Use Among Dominicans: An Analysis of the New York City Community Health Survey (2003–2016)
Authors: Glenn Matthew , Xia Yuhe , Ng Sandy , Lin Kevin , Nagpal Neha , Liang Peter S.
Published: October 2019

INTRODUCTION:

Screening for colorectal cancer (CRC) reduces incidence and mortality. Latinos are more likely to be diagnosed with late-stage CRC than non-Latino whites, a disparity that may be partially attributed to lower rates of screening among Latinos. New York City (NYC) has the fourth largest Latino population in the U.S., with Dominicans comprising the largest subgroup (41%). The current study examines predictors of up-to-date colonoscopy use among Dominicans using the NYC Community Health Survey (NYCCHS).

METHODS:

The NYCCHS is an annual population-based telephone survey of New Yorkers aged 18 and older. We included all Dominicans aged 50 and older who participated in the survey from 2003–2016. The outcome of interest was up-to-date colonoscopy use, defined as having completed a colonoscopy within the past 10 years. To evaluate sociodemographic and medical predictors of colonoscopy uptake, we entered age, sex, and all factors with P < 0.10 on univariate analysis into multivariable models for each of four consecutive time periods: 2003–2008, T1; 2009–2012, T2; 2013–2014, T3; and 2015–2016, T4. The final models were determined using stepwise backward selection.

RESULTS:

Results for 3,237 Dominican participants are shown in Table 1. On multivariable analysis, two variables were significantly associated with colonoscopy use in three of the time periods: age ≥65 (T1, T2, T4) and having received a flu vaccine in the prior year (T1, T3, T4). Two variables were significantly associated with colonoscopy uptake in two time periods: foreign birth (T1, T4) and longer duration of residence in the US (T2, T3). Variables associated with up-to-date colonoscopy use in only one time period included having a primary care provider (T2), being unemployed (T2), self-rated poor health status (T2), residence in Queens (T3), and not drinking sugar-sweetened beverages (T3).

CONCLUSION:

Among Dominicans living in NYC, older age, foreign birthplace, longer duration of residence in the US, and receiving the flu vaccine were the most consistent factors associated with up-to-date colonoscopy use.
299 Obesity Is Risk Factor for Colorectal Cancer Recurrence: A Systematic Review and Meta-Analysis
Authors: Lin Kevin , Jaspan Vita , Wilder Evan , Chang Steven , Popov Violeta
Published: October 2019

INTRODUCTION:

There is a wealth of epidemiologic evidence supporting the association between weight parameters and colorectal cancer incidence. However, how these variables affect colorectal cancer (CRC) recurrence is still a topic of debate. In our study, we hypothesized that there would be increased risk of recurrence of colorectal cancer with obesity and higher visceral fat.

METHODS:

A systematic review of electronic databases was performed through April 2019, including NCBI, Embase, Cochrane, and Web of Science. Screening was performed using Covidence and each article was screened independently by two authors. Included were retrospective and prospective studies reporting CRC outcomes of at least 2 months after cancer diagnosis. The primary outcome was CRC recurrence in obese compared to normal weight subjects, and high vs. normal visceral fat. Weight parameters tested were body mass index (BMI) categories of underweight, normal, overweight, and obese; visceral fat as measured by CT scan into categories of normal and high visceral fat. Odds ratios (OR), risk ratios (RR), and 95% confidence intervals (95% CI) are reported. Random effects analysis was performed for all outcomes, with heterogeneity assessed by the I2 statistic.

RESULTS:

484 citations were reviewed of which 9 were included in the final analysis. In total, 7 studies analyzed CRC recurrence data in terms of BMI, and 2 in terms of visceral adiposity. Most were retrospective cohort studies. These studies comprised 5777 patients, with an average age of 61.4 years and with mean follow-up time of 58.4 months, range (52 months–77 months). Both overweight and obese BMI were associated with significantly increased risk of cancer recurrence compared to normal BMI individuals (Figure 1), OR 1.41 (95% CI 1.18–1.69), P = 0.00, I2 = 0%, N = 4295, and OR 1.47 (95% CI 1.02–2.12), P = 0.04, I2 = 45%, N = 3637, respectively. There was no association between being underweight and colorectal cancer recurrence compared to normal BMI or overweight BMI. High visceral adiposity was also not associated with increased CRC recurrence, although only two studies were included in our meta-analysis (Table 1).

CONCLUSION:

Obese and overweight BMI are both associated with increased risk of CRC recurrence compared to normal weight. However, being underweight was not associated with CRC recurrence compared to being normal weight. Patients with CRC would likely benefit from active interventions to prevent obesity.
311 Colorectal Neoplasm in Patients With Cryptogenic Pyogenic Liver Abscess, Do They Need Routine Screening Colonoscopy: A Systematic Review and Meta-Analysis
Authors: Mohan Babu P. , Aravamudan Veeraraghavan Meyyur , Khan Shahab R. , Chandan Saurabh , Ponnada Suresh , Asokkumar Ravishankar , Navaneethan Udayakumar , Adler Douglas G.
Published: October 2019

INTRODUCTION:

Patients with cryptogenic pyogenic liver abscess (PLA) do not have a definite source of infection and it could be a manifestation of compromised colonic mucosal barrier due to colorectal cancer (CRC). Association of PLA and CRC is unclear. Evidence is weak and limited to small sized studies. As a result, the need for screening colonoscopy in PLA patients is subject to debate and currently not established.

METHODS:

We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through January 2019) to identify studies that reported on the prevalence of CRC in PLA patients. Our goal was to evaluate the pooled rate of prevalence of CRC in patients with cryptogenic PLA. Heterogeneity was measured by I2 statistics and funnel-plot was used to assess publication bias.

RESULTS:

12 studies were included in the analysis. Majority of them were from East Asian countries. 18,607 patients were diagnosed with PLA in study group and 60,130 patients were in control group. 63% were males in the age range of 56 to 94 years. 90.5% of the lesions were left sided and 93.1% were positive for Klebsiella pneumoniae. A total of 18,607 PLA patients were reported, of which 17,906 patients underwent screening colonoscopy. A total of 713 colorectal lesions were found, of which 648 were diagnosed with CRC. 60,130 patients were used as control, of which 509 patients were diagnosed with CRC. The pooled rate of prevalence of CRC was 7.9% (95% CI 5-12.1, I2 = 92.4, relative risk = 6.6) in patients with PLA, as compared to 1.2% (95% CI 0.3-5.7, I2 = 93.4) in control, with statistical significance (P = 0.001). Relative risk = 6.6. Publication bias was present.

CONCLUSION:

In conclusion, our meta-analysis demonstrates that patients with cryptogenic PLA have a 7-fold risk of having CRC, when compared to people without PLA. Although limited by heterogeneity, our results support the need for a screening colonoscopy in patients diagnosed with cryptogenic PLA, especially if positive for Klebsiella pneumoniae.
314 In Patients With an Overall Cleansing Success the 1L Polyethylene Glycol NER1006 Achieves More High-Quality Cleansed Segments per Patient Than Three Standard Bowel Preparations
Authors: Epstein Michael S. , Halonen Juha , Amlani Bharat , Hassan Cesare
Published: October 2019

INTRODUCTION:

In pre-colonoscopy colon cleansing, the presence of removable stool is currently considered a success for reliable adenoma detection. The phase 3 trials of 1L polyethylene glycol (PEG) NER1006 (trials DAYB, MORA and NOCT) are the largest to date joint prospective study on colon cleansing quality. Split dosing with NER1006 achieved a higher or at least as high cleansing success as sodium picosulfate/magnesium citrate (SPMC), 2L PEG + ascorbate (2LPEG), or oral sulfate solution (OSS). NER1006 also improves high-quality (HQ) cleansing in whole treatment groups, but patient level benefits are unclear.

METHODS:

This post hoc analysis of DAYB, MORA and NOCT examined if NER1006 increases the number of HQ segments per patient vs SPMC, 2LPEG or OSS, and if that could improve the adenoma detection rate (ADR) or mean number of adenomas per patient (MAP). Treatment-blinded central readers used the Harefield Cleansing Scale (HCS) to assess cleansing quality. Site endoscopists detected polyps; adenomas were confirmed by histology. Patients with full HCS scoring and adenoma counts were included. In overall cleansing successes, (HCS Grades A-B; have segments with removable stool), the number of HQ segments (HCS scores 3-4; stool-free) per patient was assessed. One-sided t-tests compared treatments. Per-patient regression analyses assessed whether HQ segments per patient improves ADR (logistic; LogR) or MAP (linear; LinR), in all patients and in cleansing successes. Odds ratios or average increments are presented with 95% CI. Trend curves were plotted with data points for group means ± SD.

RESULTS:

A total of 1749 patients were included, 1471 (84%) with overall cleansing success (Figure 1). In cleansing successes, NER1006 achieved more HQ segments per patient than SPMC (1.13 ± 1.29 vs 0.76 ± 1.07; P = 0.005), 2LPEG: (2.52 ± 1.76 and 2.65 ± 1.81 vs 1.65 ± 1.71; P < 0.001 for both) and OSS (2.61 ± 1.8 vs 2.30 ± 1.81; P = 0.032). More HQ segments per patient showed positive odds for ADR in all (OR 1.09 [1.03-1.16]; Ptrend = 0.003) and successfully cleansed patients (OR 1.11 [1.04-1.18]; Ptrend = 0.001) [Figure 2]. With LinR, more HQ segments per patient increased MAP in all (average increment 0.05 [0.01-0.09]; Ptrend = 0.012) and successfully cleansed patients (average increment 0.05 [0.01-0.10]; Ptrend = 0.025) [Figure 3].

CONCLUSION:

NER1006 delivered more HQ segments per patient than SPMC, 2LPEG or OSS. More HQ segments per patient may increase ADR and MAP and thus protect patients against colorectal cancer.
321 Factors Associated With Up-to-Date Colonoscopy Use Among Puerto Ricans in New York City, 2003-2016
Authors: Ng Sandy , Xia Yuhe , Glenn Matthew , Lin Kevin , Nagpal Neha , Liang Peter S.
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) is a leading cause of cancer death among Hispanic Americans. Puerto Ricans are the second largest Hispanic subgroup in the United States and the largest in New York City, but little is known about predictors of CRC screening uptake in this population. We used the New York City Community Health Survey (NYCCHS), a population-based telephone survey, to investigate predictors of up-to-date colonoscopy use over time among Puerto Ricans aged ≥50 in NYC.

METHODS:

We assessed the association between sociodemographic and medical factors and up-to-date colonoscopy use (defined as colonoscopy in the last 10 years) over four time periods: 2003-2008, 2009-2012, 2013-2014, and 2015-2016. We entered age, sex, and any additional factors with P < 0.10 on univariate analysis into a multivariable model and reached the final model for each period using stepwise backward selection.

RESULTS:

On univariate analysis, factors including age ≥65, having a primary care provider, and receiving the flu shot were associated with colonoscopy use in the last 10 years. After adjusting for multiple sociodemographic and medical factors (Table 1), age ≥65 [OR 1.41 (2003-2008), OR 1.76 (2013-2014), OR 1.82 (2015-2016)] and receiving the flu shot [OR 2.14 (2003-2008), OR 1.52 (2009-2012), OR 1.95 (2013-2014), OR 1.62 (2015-2016)] were two factors positively associated with up-to-date colonoscopy use over most time periods. Those without a primary care provider [OR 0.53 (2003-2008), OR 0.38 (2013-2014)] were significantly less likely to have an up-to-date colonoscopy.

CONCLUSION:

Older age, having a primary care provider, and receiving the flu shot are independent predictors of up-to-date colonoscopy use among Puerto Ricans in NYC. Targeted interventions to improve CRC screening should be considered for Puerto Ricans aged 50-64 and those who do not have a primary care provider.
329 Quality Assessment of Appropriate Follow-Up for Positive Fecal Immunochemical Tests at a Large Federal Healthcare Facility
Authors: Sadowski Brett , Humes Ross , Tritsch Adam , Laczek Jeffrey T. , Singla Manish
Published: October 2019

INTRODUCTION:

Annual fecal immunochemical testing (FIT)—a first tier screening test for colorectal cancer—has the potential to help achieve wider compliance with screening recommendations, including in vulnerable populations. The impact of FIT is dependent on the ability to follow up a positive test with a colonoscopy. National guidelines provide recommendations regarding targets for appropriate follow up. We sought to study practice patterns and performance of FIT follow up at our multi-level care medical center (which includes an on-site patient centered medical home).

METHODS:

The study was performed at the Department of Defenses’ largest military treatment facility with primary care and gastroenterological (GI) services located on the same campus. All FIT orders between January 2013 and December 2017 were identified through electronic test identification codes. Retrospective chart review was performed to evaluate the indication for testing, patient notification of a positive test, GI referral, and completion of colonoscopy.

RESULTS:

A total of 979 tests were ordered with 246 positive tests. The majority of patients (169, 70.2%) had appropriate follow up or an alternative explanation of a positive test (e.g. infectious colitis). 77 patients (29.8%) had inadequate follow up. 33 of 83 patients (39.7%) ages 50-75 and 69 of 198 patients ages 18-75 did not receive adequate follow. Patients without adequate follow up were offered expedited evaluation in GI.

CONCLUSION:

We found that despite being on the same campus and sharing an electronic record, patients seen in primary care clinics utilizing an opportunistic screening strategy had appropriate follow up just over 60% of the time in the screening age cohort (50/83), falling below the 80% threshold recommended by national guidelines. Due to our findings, we embarked on plans to alter the way patients with positive FIT are routed between primary care providers and GI clinic. Interventions to improve follow-up of positive FIT include expedited colonoscopy scheduling and automatic patient notification of FIT results. We have adjusted our electronic ordering system to require providers to specify an indication when ordering FIT so that patients with positive screening tests are automatically referred in a highly reliable fashion. These findings support the use of a programmatic screening program when utilizing a FIT test as a screening modality; systems must allocate resources to ensure patients with positive tests successfully navigate the medical system.
347 Successful Removal of Anal Condyloma With Endoscopic Submucosal Dissection (ESD): A Novel Indication for ESD
Authors: Gajula Prianka , Othman Mohamed
Published: October 2019

INTRODUCTION:

Endoscopic submucosal dissection (ESD) is a novel procedure that utilizes advanced surgical techniques to remove gastrointestinal tumors without the invasive nature of surgery. While there are many advantages to this procedure, one limitation that remains is that the standardization of ESD technique is yet to be well-defined, particularly in Western nations. Here, we present a case of a patient with a 30-mm anal condyloma who had complete resection of the pre-malignant lesion through ESD.

CASE DESCRIPTION/METHODS:

A 73-year-old female presented for screening colonoscopy. She was found to have an anal lesion on exam, biopsies showed anal condyloma with low-grade dysplasia. Given the extension of the lesion to the distal rectum, the decision was to perform dissection of the anal condyloma from the anorectal canal. Initially, the lesion was marked 5-6 mm away from its border, to allow for dissection with clear margins. In the next step, a 25-gauge needle was used to inject a solution containing Hetastarch and methylene blue. This was done to raise the lesion away from the muscularis propria layer. A circumferential incision was made, beginning at the anal aspect of the lesion. To make the final dissection, a dissection knife with an insulated ceramic tip was used in the forward view. This allowed for secure separation of the lesion in one piece, without any tissue injury.

DISCUSSION:

A 30 mm anal condyloma was procured. Pathology showed an anal condyloma with anal intraepithelial neoplasia grade I (AIN1). The lesion was negative for any high-grade dysplasia or carcinoma. Peripheral and deep margins were free of the lesion. The patient had mild rectal pain for three days after the procedure, which completely resolved with the application of lidocaine gel. ESD is a highly effective resection tool and should be considered for treatment of rectal condylomatous lesions.

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352 Volumetric Laser Endomicroscopy Feature Discovery and Diagnostic Performance Optimization for Barrett’s Esophagus Dysplasia Using Laser-Targeted Biopsies With Histopathologic Correlation
Authors: Leggett Cadman , Trindade Arvind , McKinley Matthew , Chang Kenneth J. , Samarasena Jason , Singh Satish , Mashimo Hiroshi , Smith Michael S. , Béchard Vincent , Vieth Michael , Odze Robert , Tearney Gary J. , Wang Kenneth K.
Published: October 2019

INTRODUCTION:

Volumetric laser endomicroscopy (VLE) is a high-resolution imaging modality used in Barrett’s esophagus (BE) surveillance. Established VLE scoring systems use a combination of features to guide BE dysplasia diagnosis but it remains unclear whether these features are sufficient to reach optimal VLE diagnostic performance. This study explores an exhaustive list of VLE features using one-to-one imaging to pathology correlation to develop optimal VLE diagnostic models for BE dysplasia.

METHODS:

In this prospective, multi-center (5 sites) study, patients with dysplastic BE underwent VLE with laser targeted regions of interest (ROIs), followed by standard surveillance endoscopy and biopsy directed to laser-marked sites. Histology was reviewed by two GI pathologists (MV, RO) who achieved a consensus diagnosis (gold-standard). ROIs were dysplastic if low-grade dysplasia (LGD), high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC) was present. Two VLE experts (CLL, GJT) reviewed ROIs and corresponding endoscopic images to identify and define a set of VLE features associated with BE dysplasia. A multi-variable logistic regression model based on least absolute shrinkage and selection operator (LASSO) method was developed to determine the optimal diagnostic performance of these features. A decision tree model with high clinical usability also was developed to evaluate VLE diagnostic performance for real-time image interpretation.

RESULTS:

A total of 461 VLE ROIs with matching histology were obtained from 150 patients (Table 1). A final dataset of 55 neoplastic (LGD, 12; HGD, 24; IMC, 19) and 56 randomly selected non-dysplastic ROIs were reviewed. Twenty-eight VLE features were identified describing layering, signal intensity, surface topography, and glandular characteristics. LASSO logistic regression modeling identified 5 VLE features which when utilized optimized diagnostic performance with an area under the curve (AUC) for BE dysplasia of 0.95 (Figure 1). To improve clinical usability, a decision tree model was optimized to three levels with an AUC of 0.90 (Figure 2).

CONCLUSION:

This study represents the most comprehensive review of VLE features associated with BE dysplasia to date. The proposed high-performing diagnostic models suggest that VLE can be used efficiently and effectively to enhance BE surveillance by identifying ROIs for targeted biopsy. Further validation of the proposed VLE models will determine their clinical utility.
355 Endoscopic Submucosal Dissection vs. Endoscopic Mucosal Resection for Treatment of Barrett’s Related Superficial Esophageal Neoplasia
Authors: Mejia Perez Lady Katherine , Alaber Omar A. , Jawaid Salmaan , Chua Tiffany , Kudaravalli Praneeth , Khoshknab Milad Pourmousavi , Mehta Neal , Ngamruengphong Saowanee , Vargo John , Jang Sunguk , Dumot John , Gabr Moamen , Aihara Hiroyuki , Fukami Norio , Draganov Peter V. , Chak Amitabh , Bhatt Amit
Published: October 2019

INTRODUCTION:

The difference in long-term outcomes of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for Barrett’s related superficial neoplasia remains unclear. We aimed to compare the rates of local and metachronous recurrence of ESD and EMR in patients with clinically staged BE-associated high-grade dysplasia (HGD) and T1a esophageal adenocarcinoma (EAC).

METHODS:

Multicenter study at six academic hospitals in the U.S. including patients who underwent ESD for BE-HGD or T1a EAC. Primary outcome was a composite of metastasis and local recurrence rate. A time-to-event analysis was performed to evaluate recurrence. A Kaplan-Meier plot was constructed, and a log-rank test was used to compare the groups. A Cox hazard ratio regression analysis was performed to identify predictors of recurrence.

RESULTS:

A total of 241 patients were included. 154 underwent EMR, while 84 underwent ESD (Table 1). ESD had higher en bloc (96% vs 33%, P < 0.0001), R0 (76% vs 54%, P = 0.0009) and curative resection rates (75% vs 32%, P < .0001) when compared to EMR. The 24-month local recurrence rate for EMR and ESD was 43% and 11%, respectively (P = 0.0007) (Figure 1). Significantly more endoscopic resection procedures were required to treat recurrence after EMR compared to after ESD (Table 1). EMR, piecemeal resection, positive margins, and non-curative resection were identified as predictors of recurrence on univariate analysis. En bloc resection remained significant after multivariate analysis (Table 2).

CONCLUSION:

This multicenter study showed that ESD results in more definitive treatment of BE-associated early neoplasia than EMR, with significant lower recurrence rates and less need for repeat endoscopic therapeutic procedures than EMR.
367 Epidemiology of Barrett’s Esophagus in Cirrhosis in the United States: A Population-Based Study
Authors: Sanghi Vedha , Saleh Mohannad Abou , Alkhayyat Motasem , Rouphael Carol , Mansoor Emad , Thota Prashanthi N. , Chak Amitabh
Published: October 2019

INTRODUCTION:

The risk of progression of Barrett's Esophagus (BE) increases with worsening liver function. Cirrhosis has high rates of GERD, but data are limited on the prevalence of BE in cirrhosis. We aimed to study the epidemiology of BE in cirrhosis and the underlying associations

METHODS:

We queried a commercial database (Explorys Inc, Cleveland,OH) that contains an aggregate of electronic health record data from 26 major integrated US healthcare systems. We identified patient cohort between 2014-2019 with a Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT). Patients with BE in the absence of cirrhosis were the control group. Patients with a new diagnosis of BE after at least 1 year of cirrhosis were the study group. We performed analyses to describe age, gender and race-based distributions and potential associations

RESULTS:

Of the 36,893,970 patients in the database between 2014-2019, 208,630 (0.57%) patients with cirrhosis and 179,610 (0.49%) patients with BE were identified. One year after the diagnosis of cirrhosis, 1,500 (0.72%) patients were diagnosed with BE for the first time. When compared to patients without cirrhosis, those with cirrhosis were 1.5 times more likely to develop BE [Odds Ratio (OR) 1.5, 95% confidence interval (CI) 1.46-1.61; P < 0.0001]. The odds of developing BE in patients with cirrhosis was higher in males vs females [OR 1.4, 95% CI 1.26-1.55; P < 0.0001], African American vs Caucasians [OR 1.36, 95% CI 1.08-1.70; P < 0.0082] and young adults (age < 65years) vs elderly (age > 65years) [OR 1.43; 95% CI 1.29-1.58; P < 0.0001] as compared to patients without cirrhosis. When compared to patients without cirrhosis, patients with cirrhosis and BE were more likely to have a history of smoking, Helicobacter pylori infection, GERD, non-steroidal anti-inflammatory use, obstructive sleep apnea and be in the 6th decade of life. Body mass index carried an increased risk of developing BE in cirrhosis [ORs in Table]. Prevalence rates of BE in cirrhosis over the past 5 years is noted in Figure 1.

CONCLUSION:

Limitations-Endoscopic and histology data are unavailable. Logistic regression analysis was not performed, thus the risk of confounding bias remains. Conclusion-This is the largest study to evaluate BE in cirrhosis. We found a rising trend over the past 5 years in the prevalence of BE in cirrhosis with 1.5 times increased occurrence. This may be a true association or attributed to increased health utilization by patients with cirrhosis or increased endoscopic evaluation by physicians
373 Routine EGD Has Minimal Impact on Refractory GERD Management
Authors: Kwak Ye Eun , Coleman Madeleine , Sanchez Mayra , Masoud Amir
Published: October 2019

INTRODUCTION:

Routine diagnostic esophagogastroduodenoscopy (EGD) is recommended for refractory gastro-esophageal reflux disease (GERD) symptoms despite lack of evidence that it impacts management or outcomes. This study aims to determine if diagnostic EGD impacts management in patients with refractory GERD compared to esophageal manometry, pH testing and intra-luminal impedance.

METHODS:

We performed an observational study of patients with refractory GERD who underwent EGD from 2013 to 2018 at a tertiary hospital. Among 1,213 patients with GERD, we strictly excluded patients with alarm features such as dysphagia, dyspepsia; history of gastroesophageal surgery, or EGD done for other diagnostic procedures, and identified 339 patients who underwent EGD solely for persistent reflux symptoms. We then identified those who had esophageal manometry or pH-impedance studies for further evaluation of GERD, as well as if the findings of these tests resulted in a change in management (medication change or de-escalation, referral for Nissen fundoplication, etc).

RESULTS:

Among 339 patients with refractory GERD, 80.5% of patients were taking PPIs prior to and/or at the time of EGD. The majority of patients had completely normal (163/339, 48.1%) or solely benign or incidental findings (106/339, 31.3%) on EGD. Only 10.6% of patients had esophageal manometry or pH-impedance studies for refractory reflux symptoms, of those, 6.2% followed EGD and only 7 patients had these studies after a completely normal EGD. The majority of patients undergoing manometry had normal studies or minor abnormalities (23/32, 71.8%). All patients who had been ordered for intraluminal impedance or 24 hr pH testing alone could not tolerate the procedure. Six of 15 patients (40%) undergoing 24 hr pH-impedance testing had findings leading to a change in management. Undergoing pH-impedance testing after EGD was associated with a change in management (OR 7.33, P = 0.018). PPI use was not associated DeMeester score or with results of manometry, impedance, or pH testing.

CONCLUSION:

Most patients who underwent EGD for refractory GERD symptoms alone did not have pathological findings prompting a change in management. There were no demographic variables that predicted pathologic findings on EGD. Very few patients underwent subsequent or concomitant esophageal manometry, impedance or pH testing. pH-impedance after EGD was associated with a change in management, and may be a better first step in evaluating patients with refractory GERD symptoms, than EGD.