bluuebunny/crossref_metadata_2025 huggingface dataset:
498 Objective Evidence of Gastrointestinal Disorders in Patients With 22q11.2 Deletion Syndrome
Authors: Kotcher Rebecca , Chait Daniel , Heckert Jason , Crowley T. Blaine , Ahuja Nitin K. , Mascarenhas Maria R. , McDonald-McGinn Donna , Reynolds James
Published: October 2019

INTRODUCTION:

22q11.2 deletion syndrome (22q11.2DS) is the most common chromosomal microdeletion syndrome (1:3000-6000 live births) and the most common cause of DiGeorge Syndrome (congenital heart disease, parathyroid hypoplasia, thymic hypoplasia). However, the 22q11.2DS phenotype varies markedly among patients. We previously studied a smaller subset of patients with 22q11.2DS (n = 72) and found that chronic gastrointestinal (GI) symptoms were common. Here we expand our previous observations to a larger cohort (n = 175) and also present objective study data in an effort to characterize these GI problems as structural versus functional.

METHODS:

Adult patients with 22q11.2DS were retrospectively assessed from our cohort of >1400 patients with a confirmed 22q11.2 deletion followed in the 22q and You Center at the Children's Hospital of Philadelphia. Included patients had at least one problem list, medication list, review of systems, and outpatient physician evaluation at ≥17 years of age. Broad clinical data were abstracted, including results of relevant imaging and laboratory studies. All available imaging studies were reviewed for radiologic and pathologic abnormalities. All routine laboratory studies were reviewed, and the lowest value was recorded for each test.

RESULTS:

672 consecutive charts were reviewed, of which 175 met inclusion criteria. Included patients (45% F) ranged from 17 to 59 years of age (mean 26.1; SD 8.1). Chronic GI symptoms were common from childhood through adulthood (Figure 1), but congenital GI malformations were rare (4%). Additionally, autoimmune GI disorders occurred at the frequency of the general population [celiac disease (1%); inflammatory bowel disease (0.6%)]. However, motility disorders were common and accounted for the vast majority of GI symptoms (Figure 2). Pertinent laboratory results were also reported and showed a high rate of anemia (Figure 3).

CONCLUSION:

Specialized GI studies were performed commonly in our study population, reinforcing our prior observation that GI disorders place a significant burden on patients with 22q11.2DS. In addition to the well-described palatal abnormalities affecting this population, these studies revealed a wide range of non-structural GI problems. We conclude that a large burden of GI illness in 22q11.2DS is functional. Finally, the known chromosomal microdeletions present in patients with 22q11.2DS may provide an explanatory framework for understanding the etiology of functional GI symptoms in the general population.
511 High Risk of Ionizing Radiation Exposure Among Patients With Irritable Bowel in the United States
Authors: Hadi Yousaf , Khan Adnan Aman , Khan Salman , Naqvi Syeda Fatima , Kupec Justin T.
Published: October 2019

INTRODUCTION:

Irritable bowel syndrome (IBS) is a functional gastrointestinal (GI) disorder. While ionizing radiation exposure, and its associated cancer risk, is well-studied in other GI disorders, there is a paucity of data in the IBS population.

METHODS:

After IRB approval, a retrospective cohort study at a tertiary care referral center was conducted. Radiologic studies performed between Jan 2008-Dec 2017 on patients diagnosed with IBS were retrospectively evaluated. Data from patients whose primary care physician and gastroenterologist were in our healthcare system were included. Analyses was performed by chi square and Mann Kendall trend test and multivariable logistic regression was applied to assess independent associations. Percentage of participants receiving more than a cumulative dosage of 50 mSv (consensus threshold for high cancer risk) in the study period was calculated

RESULTS:

The mean age of participants was 40.83 years (SD: 12.12 years). 35.24% participants had a smoking history. A vast majority of participants were female (77.53%) and 55.95% of participants had a co-morbid psychiatric diagnosis. Most participants (85.46%) were on pain medications in the outpatient setting. 16 patients (7%) did not undergo any radiological study during the study period. 56 patients (24.67%) received greater than 50 mSv of cumulative effective radiation dosage during the 10-year study period. Mean yearly effective radiation dosage was 3.75 mSv per year (SD: 5.67). Mean cumulative effective radiation dosage during the study period was 37.45 mSv. A mean dosage of 27.87 mSv was attributable to studies involving the abdomen. Participants received a mean dosage of 17.59 mSv before and 19.86 mSv after the definitive diagnosis by the digestive disease clinic. Female gender, comorbid depression and anxiety, and diarrhea predominant IBS phenotype was significantly associated with an increased risk of radiation exposure (P < 0.05). Mann Kendall trend test did not reveal any change in average ionizing radiation exposure in patients during the study period (P > 0.05).

CONCLUSION:

Previous limited data from Europe hinted at a low risk of radiation exposure in IBS but we finds that, contrary to popular belief, a significant proportion of IBS patients are exposed to high levels of ionizing radiation, which potentially poses a significant cancer risk. Nationwide cohort studies are needed to assess this risk and quality improvement initiatives are needed to decrease radiation exposure in this relatively young population.
520 Pre-Endoscopic Risk Stratification Scores Associated With Intubation for Emergent Endoscopy for Severe Gastrointestinal Hemorrhage
Authors: Duong Nikki , Woo Stephanie , Xi Rebecca , d'Aliberti Olivia , Jennings Joseph
Published: October 2019

INTRODUCTION:

Approximately 300,000 patients are admitted annually for gastrointestinal bleeding (GIB) in the US and many require emergent endoscopy. Many patients are prophylactically intubated to protect the airway in hopes of avoiding respiratory complications intra-operatively. Currently there are no guidelines to determine which patients should be intubated prior to endoscopy.

STUDY AIM:

To identify pre-procedural factors associated with intubation compared to those who undergo endoscopy without intubation and compare post-procedural outcomes.

METHODS:

Retrospective chart review from Sept 2017 to Dec 2018 of all emergent endoscopies for acute GIB. Data are presented as means with 95% ± t-test confidence intervals, or frequency (%). Analysis of variance (ANOVA), or univariate logistic regression was used for continuous variables, the Pearsons χ2 test was used for categorical variables.

RESULTS:

There were 210 procedures performed during this time frame. 142 patients were included in the final analysis after excluding endoscopies done for non-GIB indications. There was no statistically significant difference between the intubated and non-intubated groups for the following: gender, race, BMI, number of transfusions needed, or anticoagulation use [Table 1]. Mean Glasgow-Blatchford scores (GBS) and APACHE scores were higher in the intubated group than in the non-intubated group (12 vs. 10, P = .03 and 20 vs. 12, P < .01, respectively). In the intubated group, 28% of patients developed pneumonia (PNA) [Table 1]. The difference in cardiovascular outcomes trended towards significance (P = 0.07). The intubated group had higher cardiac arrest (5.7% vs. 0%) and mortality rates (24% vs. 11%) than the non-intubated group.

CONCLUSION:

We found that higher GBS and APACHE scores were associated with intubation. We also found that patients with cirrhosis or who were on pressors were more likely to be intubated. In our study, 28% of intubated patients developed pneumonia, whereas prior studies report a 14% incidence of pneumonia after intubation. The decision to intubate a patient is complex but gastroenterologists and intensivists must weigh the risks associated with intubation, such as PNA, ICU delirium, and increased length of stay in the ICU, and avoid reflexively intubating all patients. Our study shows significant differences in pre-procedure GBS and APACHE scores that could be useful for future studies as a possible tool to aid in this decision-making process.
528 A Patient-Centered Multidisciplinary Approach to Improve Inpatient Bowel Preparation for Colonoscopy
Authors: Shenoy Vinayak , Park Connie , Bhardwaj Richa , Ivanina Elena
Published: October 2019

INTRODUCTION:

The success of colonoscopy is largely dependent on the quality of bowel preparation. Inpatient colonoscopy preparations are often suboptimal, leading to missed lesions, increased complications and poor study quality. Several studies have shown improved outcomes with split-dose bowel preparation (SBDP). As such, we conducted a multidisciplinary approach to implement a universal prep protocol (UPP) for our hospitalized patients and assessed the intervention's impact on colonoscopy quality with the Boston Bowel Prep Score (BBPS).

METHODS:

We implemented a UPP for all our inpatient colonoscopy cases that met inclusion criteria. We initiated a patient focused multidisciplinary educational intervention to implement this UPP by administering SDBP (2L PEG at 5pm the night prior to colonoscopy and 2L at 5am the morning of colonoscopy). Educational interventions included holding multiple group meetings to educate house staff and floor nursing staff on how to order and administer the split doses. Patients and staff were educated on the benefits of split prep, how to pace bowel prep intake and dietary changes prior to colonoscopy. A universal pamphlet in English and Spanish reiterating these points was created and was provided to patients and staff for reference. Six months of prospective data, which included gender, ethnicity, indication for the procedure, and BBPS, were collected and compared to a historic pre-intervention (PI) cohort.

RESULTS:

A total of 155 patient records were reviewed, of these 107 eligible patients were identified. There was no statistical difference in age, ethnicity and indication between the two groups, but there was a difference in gender with 62% of PI patients being male compared to 35% males in the intervention group (IG). The gender was adjusted for in the Linear Mixed Model, which showed a statistically significant increase in BBPS in the IG (P = 0.019, OR 0.3948).

CONCLUSION:

Achieving adequate bowel preparation in the inpatient setting is challenging. Our study showed that a patient centered multidisciplinary approach to implement a UPP and emphasizing patient and staff education significantly improved the quality of colonoscopy, as demonstrated by the BBPS. This approach also highlights how patient engagement and patient comfort are key elements of patient focused care. Other institutions should consider this framework in improving inpatient colonoscopy quality and patient outcomes.
533 Effect of Pronase on Visibility Scores During Upper Endoscopy: Systematic Review and Meta-Analysis
Authors: Jayaraj Mahendran , Dhindsa Banreet , Mohan Babu P. , Ohning Gordon
Published: October 2019

INTRODUCTION:

Pronase is a proteolytic enzyme that helps in removal of mucous when used during the endoscopic examination by mucolytic activity. The increase in visibility during upper endoscopy and endoscopic ultrasound examination leads to identification of early cancerous lesions in the stomach.Different studies have reported varied results for using pronase as a pre-medication to improve visibility. We conducted a systematic review and meta-analysis to assess the improvement in visibility after pre-medication with Pronase in Upper endoscopy.

METHODS:

We performed a systematic search of multiple databases through May 2019 to identify studies reporting on the use of Pronase and outcomes in terms of visibility scores in upper endoscopy. Pooled visibility scores for different parts of the stomach were obtained. Heterogeneity was assessed by I2 statistics.

RESULTS:

Seven studies with a total of 2431 patients were included in the final analysis. The mean age ranged from 47 to 61 years with 44% males. majority of the studies were based out of single center data. The dose of pronase used was 20000 units in majority of the studies. Medication administration time varied. Four studies administered pronase 10 minutes before procedure, three studies administered it 20 minutes before procedure and one study used it 30 min before the procedure. Visibility scoring was done based on a scale of 1 to 4, 1 being best possible visualization. The pooled visibility score for the gastric antrum with pronase was 1.42 (95% CI: 1.2-1.6, I2 = 99); for fundus was 1.17 (95% CI: 1.1-1.2, I2 = 67.5); for lower gastric body was 1.46 (95% CI: 1.3-1.7, I2=94.5); and for upper gastric body was 1.68 (95% CI: 1.4-2, I2 = 97.3). Significant heterogeneity was noted in the analysis.

CONCLUSION:

Based on this meta-analysis the pooled visibility scores appear to be near one which is the ideal score.The optimal time of administration (pre-procedure drink or intraprocedural flushes) and the effect of pronase in improving detection of early cancerous lesion should be determined in future well controlled large studies.
544 Use of an Abdominal Compression Device in Colonoscopy Significantly Decreases Cecal Intubation Time as Compared to Conventional Colonoscopy: A Systematic Review and Meta-Analysis
Authors: Hamade Nour , Nutalapati Venkat , Chalhoub Jean M. , Chandrasekar Viveksandeep Thoguluva , Dasari Chandra , Kennedy Kevin , Kohli Divyanshoo , Sharma Prateek
Published: October 2019

INTRODUCTION:

Looping of the endoscope is a common issue encountered during colonoscopy. A number of tools and techniques including the use of abdominal pressure devices have been utilized as an aid to reduce looping and thereby decrease the cecal intubation time. We conducted a meta-analysis comparing outcomes of colonoscopy with and without abdominal pressure devices.

METHODS:

A comprehensive electronic database (PubMed, Cochrane, and Google Scholar) search was conducted to identify studies using abdominal pressure devices. Prospective randomized studies that reported colonoscopy outcomes with and without the use of abdominal compression devices were included in the analysis. The primary outcome was the difference in cecal intubation time (in minutes) between the intervention (colonoscopy using abdominal pressure devices) and control (colonoscopy without these devices) groups. Secondary outcomes assessed: need for manual pressure and patient position changes during colonoscopy. Review manager 5.3 and R version 3.5 were used for statistical analysis.

RESULTS:

A total of 6 prospective (4 randomized) studies were included in the final analysis. There were 673 patients in the intervention group as compared to 903 patients in the control group. The mean patient age was 56.2 years with 36.9% males. 3 studies used the ColoWrap device, one used an obstetric binder, one used a commercial elastic corset, and one used the N-Doe Pillow™. For the primary outcome, cecal intubation time was significantly shorter in the intervention group (colonoscopy with abdominal compression device) compared to the control group; -1.68 minutes (95% CI: -2.5 to -0.86, I2 = 86%). Similarly, the requirement for manual pressure during colonoscopy (OR: 0.17; 95% CI: 0.07-0.43, I2 = 91%) and need for patient position change (OR: 0.25; 95% CI: 0.15-0.42, I2 = 43%) was significantly lower in the abdominal compression devices versus the control group.

CONCLUSION:

The results of this systematic review and meta analysis demonstrate that the use of abdominal compression devices is associated with a significantly decreased cecal intubation time, need for manual pressure, and for patient position change during conventional colonoscopy. These devices should be considered for use during colonoscopy especially when looping of the endoscope is anticipated.
546 Inpatient Status Is Associated With Incomplete Capsule Endoscopy Examinations: A Systematic Review and Meta-Analysis
Authors: El Iskandarani Mahmoud , El Kurdi Bara , Aasen Tyler , Alomari Mohammad , Babar Sumbal , Haddad Ibrahim , Al Momani Laith , Young Mark
Published: October 2019

INTRODUCTION:

Capsule endoscopy (CE) has been increasingly used for the diagnosis of small bowel pathology, mainly, obscure gastrointestinal bleeding. Incomplete examination can lead to delayed intervention. Possible risks of incomplete examination have been extensively studied. We hypothesized that hospitalized patients might be at higher risk of incomplete examination due to acute illness. Therefore, we conducted a systematic review and meta-analysis to assess the effect of inpatient status on the completion of CE.

METHODS:

Unrestricted searches of MEDLINE, EMBASE, Cochrane bibliographic databases were performed inception through March 2019 for studies comparing CE completion rates in hospitalized vs. non-hospitalized patients. Results were screened for relevance and eligibility criteria. Relevant data was extracted and analyzed using Comprehensive Meta-Analysis software. The Begg and Mazumdar rank correlation test was utilized to evaluate for publication bias

RESULTS:

A total of 6 retrospective studies published between 2010-2018 were included examining 2,467 patients who underwent CE (702 inpatient vs 1,763 outpatient) were included. Outpatient CE completion rate was significantly higher compared to inpatient with an OR of 4.48 (95% CI 1.99-10.09; I2 = 85%). In three studies, small bowel transit time found to be shorter in the outpatient CE group with mean difference of -14.51 minutes (95%CI -34.87-5.84), however, this did not reach statistical significance. No publication bias was noted.

CONCLUSION:

Our findings suggests that outpatient CE was associated with higher completion rates than inpatient CE. This could be related to prolonged small bowel transit time in hospitalized patients related to acute illness, comorbidities, narcotic use, and bed rest which are more prevalent in hospitalized compared to non-hospitalized patients. Our findings suggest that it might be prudent to reserve CE examinations to the outpatient setting when possible.
552 Exploring the Role of Gastrointestinal Motility and Non-Acid Reflux in Lung Transplant Prognosis and Risk of Acute Rejection
Authors: Daniel Harrison , Gala Kushboo , Burlen Jordan , Stocker Abigail , Lorenz Doug , Ramirez Allan , Abell Thomas
Published: October 2019

INTRODUCTION:

Lung transplant patients are at risk of developing acute rejection leading to bronchiolitis obliterans syndrome (BOS). Lung transplant patients are also known to have and/or develop gastroesophageal reflux. Acid gastroesophageal reflux has been correlated with risk of acute rejection and consequently BOS. There is however a paucity of data correlating non-acid reflux with risk of acute rejection. Our study investigated the role of non-acid reflux with lung transplant rejection.

METHODS:

131 lung transplant recipients who had post-transplant evaluation between 2012 and 2019 were studied. A total of 64 lung transplant recipients had at least 3 months of post-transplant follow up consisting of 24 hour impedance pH testing, and high-resolution manometry (HREM). Patient characteristics were summarized with counts and percentages, means and SD, or medians and interquartile ranges (IQR) as appropriate to scale and distribution. The characteristics of those with and without rejection diagnoses was compared with Fisher's exact test for categorical variables and the Wilcoxon rank sum test for quantitative variables. Analyses were conducted in the open source R software environment.

RESULTS:

60 of 64 patients (94%) were alive at one-year post- lung transplant. The majority of patients had bilateral transplants and were Caucasian males with average age of 59 years. At one year there were 12 deaths. Patients with a diagnosis of acute rejection were less likely to exhibit gastroparesis (1% vs. 9%) and abnormal pH (28% vs. 45%). Acute rejection patients were more likely to exhibit GERD (53% vs. 45%), more non-acid episodes (median 19 vs. 15.5), higher reported symptom association (51% vs. 41%), on impedance pH; abnormal UES (56% vs. 45%), and abnormal body (86% vs. 77%) on HREM (Table 1). However, no differences were statistically significant (all P > .18), and conclusions cannot be generalized.

CONCLUSION:

Patients undergoing lung transplantation were found to have a high incidence of abnormal gastroesophageal motility studies, including both acid and non-acid reflux. Developing a protocolized pre- and post- transplant motility evaluation process for lung transplant patients may help identify those at greatest risk for acute rejection. Continued evaluation post-transplantation to establish therapeutic interventions in both acid and non-acid reflux patients to prevent lung transplant rejection appears warranted.
553 Exploring Methods to Reduce Colonoscopy Cancellations
Authors: Sheikh Akber , Chang Andrew , Godil Aslam , Foliente Roy , Hill Kevin , Brichler Benjamin
Published: October 2019

INTRODUCTION:

Colonoscopy cancellation negatively impacts endoscopy center efficiency and physician productivity. According to previous studies, the rates of colonoscopy cancellations within 24 hours were reported to be 2-4% (1,2). Using an automated call system to make reminder calls and informing patients of a cancellation fee, may be methods to reduce cancellations. Our aim is to evaluate the effectiveness of these methods in reducing late cancellations.

METHODS:

A prospective and retrospective study done at Sierra Nevada Gastroenterology Medical Associates and Sierra Endoscopy Center in Grass Valley, CA from Nov 2, 2018 to May 2, 2019. All enrolled patients had colonoscopy issues addressed by a physician at an office visit prior to scheduling. A reminder phone call was made by an automated calling system 48 hours prior to the colonoscopy. Results were compared to previous studies where a nurse gave the reminder call. Another group of patients were informed of a policy that a cancellation fee may be charged for late cancellation. Data was compared from this current study group to similar groups in 2009-11 and 2016-17 (1,2) to see if there were any significant factors that influenced colonoscopy cancellation rates.

RESULTS:

138 from a total of 2310 pts (6%) cancelled their colonoscopy within 24 hours of their scheduled procedure time when receiving the automated reminder phone call. 2-4% of pts cancelled their colonoscopy when receiving a personal reminder call from a nurse (1,2).Knowledge of a cancellation fee did not reduce the amount of cancellations.

CONCLUSION:

Using an automated phone call system to make reminder phone calls led to a higher cancellation rate (6%) when compared to a personal reminder phone call from a nurse (2-4%). Potential reasons are that the patient may not pick up the phone thinking it was a robocall, wrong phone numbers, deleted messages, and difficulty understanding automated messages. Even though no late fees were actually charged, just the knowledge of a potential cancellation fee was not a deterrent for cancellation. Type of insurance was the most significant factor influencing colonoscopy cancellation, as the rate of cancellation was directly related to the increase in Medicaid insured patients and inversely related to the number of privately insured patients. Personal issues were the most frequent cause for last minute cancellations. Anticipating and addressing these issues at the time of scheduling may be the most effective way of reducing cancellation rates.
559 Patients' Descriptions of Their Last Bowel Movement Before Colonoscopy, Converted to a Standardized Score, Shows Strong Correlation With Their Boston Bowel Preparation Scale (BBPS) Score
Authors: Akman Olgun , Chande Nilesh , Gregor James
Published: October 2019

INTRODUCTION:

Colorectal cancer is the third most common cancer worldwide. Early detection of adenomatous polyps and adenocarcinoma reduces mortality. The effectiveness of colonoscopy for colorectal cancer screening is reliant on the quality of bowel preparation. Patients with inadequate bowel preparation may require repeat colonoscopy; this exposes patients to further risks while placing financial stress on individuals and healthcare systems. The purpose of this study is to assess if a patient's description of their last bowel movement, converted to a standardized score, correlates to the quality of bowel cleansing.

METHODS:

This is a cross-sectional study performed at two hospitals with data collected over two months. On the day of the colonoscopy, prior to the procedure, outpatients were asked by a resident physician to describe their last bowel movement. The description was converted to a standardized score: “fully solid”, assigned a score of 0; “liquid with solid pieces”, assigned a score of 1; “brown liquid”, assigned a score of 2; and “clear / yellow liquid”, assigned a score of 3. Subsequently, each patient's total and segmental Boston Bowel Preparation Scale (BBPS) score was determined and recorded by the clinician performing the colonoscopy. The nurses and clinicians performing the procedure were blinded to the patient's last bowel movement description. Data analysis using bivariate Pearson's Correlation was used to assess the strength of correlation between the patients' descriptions and BBPS scores.

RESULTS:

Study population characteristics: N = 121, 66 F and 55 M; mean age 56.16 with Std. Dev. of 16.12; mean total BBPS 7.74 with Std. Dev. of 1.87. Bivariate Pearson's Correlation showed a strong correlation (r = 0.738; P < 0.001) between the patients' descriptions and total BBPS score. Patients' descriptions versus segmental BBPS scores showed: a strong correlation with Left Colon BBPS (r = 0.702; P < 0.001); a moderate correlation with Transverse Colon BBPS (r = 0.632; P < 0.001); and a moderate correlation with Right Colon BBPS (r = 0.667; P < 0.001).

CONCLUSION:

A patient's description of their last bowel movement, converted to a standardized score, shows a strong correlation with their BBPS score. One implication of identifying a patient with inadequate bowel preparation before a colonoscopy is potentially rescheduling the procedure. Alternatively, it may be possible to provide patients with extra time and medication for colon cleansing before the colonoscopy is attempted.
567 What's Taking so Long? Optimizing Efficiency in the Endoscopy Unit
Authors: Do Albert , Sayyar Mubarak , Macklin Jared , Lee Mindy , Pourmorady Jonathan , Masoud Amir
Published: October 2019

INTRODUCTION:

With the ongoing focus on value-based care, there has been greater emphasis on efficiency and cost-effectiveness of health services, including gastrointestinal endoscopy. Endoscopy unit optimization requires coordination of many providers, staff, equipment, and resources. We aimed to develop a value-stream map for performance of endoscopic procedures performed at a tertiary academic medical center, identify processes associated with delays, and assess if workflow process improved after recent redesign efforts were initiated.

METHODS:

Data were extracted from 13,663 endoscopic procedures from January 1st, 2018 to April 1st, 2019, at the Center for Advanced Endoscopy (CAE), a 5-room gastrointestinal and pulmonary endoscopy unit. The endoscopy workflow process was mapped (Figure 1) and potential processes associated with delays (lags) identified. We isolated patient process times through the CAE and compared those before and after clinical redesign initiatives were instituted. We additionally extracted clinical characteristics and performed logistic regression to identify potential predictors of delay ≥30 minutes, defined as delay in processes associated with patient transportation (lag 1 or lag 3).

RESULTS:

Patient clinical characteristics (Table 1) did not differ after implementation of clinical redesign though the proportion of inpatient procedures increased (33.9% vs 37.1%, P = 0.001). The rate of 30-minute delays was high and unchanged after clinical redesign implementation (25.9% vs. 25.9%, P = 0.99). Delays were noted at all three potential processes: procedure room availability (19 minutes), scheduled versus actual start time (49 minutes), and awaiting transport for inpatients to return to medical ward (34 minutes). Multiple logistic regression (Table 3) revealed male gender (OR 1.09, 95% CI: 1.00-1.19, P = 0.04) and inpatient status (OR 5.03, 95% CI: 4.60-5.51, P < 0.001) as significant predictors of delay in CAE workflow process.

CONCLUSION:

Patient hospitalization status is a contributing factor to delays in the CAE and. though prolonged monitoring of these patients is a logical practice, establishing benefit is needed to justify this action. Optimization of patient transportation services to procedure room and from post-procedure areas is one potential recommendation based on this analysis. This area for improvement is the center of our next optimization efforts and will be evaluated as part of this ongoing project.
572 Multi-Lingual Video Consent for Upper Endoscopy and Colonoscopy
Authors: Lawrence Zoe , Castillo Gabriel , Jang Janice , Tzimas Demetrios , Dikman Andrew , Williams Renee
Published: October 2019

INTRODUCTION:

Informed consent involves a thorough understanding of procedural risks, benefits, and alternatives. Among patients with Limited English Proficiency (LEP) it is difficult to ascertain comprehension even with the use of a certified medical interpreter. Prior studies have demonstrated that use of video during informed consent improves patient comprehension relative to traditional verbal consent. This quality improvement initiative aims to improve patient comprehension of endoscopy and colonoscopy though utilization of an educational video in the patient's primary language as a component of informed consent.

METHODS:

Short videos explaining the risks, benefits, and alternatives for endoscopy and colonoscopy were produced in English and Spanish. All patients underwent a traditional verbal consent process, with the use of a certified medical interpreter if indicated. A group also watched the educational video. Following either the video or the traditional verbal consent, the patients filled out a questionnaire in their preferred language to assess comprehension of the planned procedure and its risks, benefits, and alternatives.

RESULTS:

A total of 74 questionnaires were administered. Group 1 underwent traditional consent alone and group 2 watched the video prior to traditional consent. The colonoscopy cohort included 35 English-language and 11 Spanish-language patients; the endoscopy cohort included 21 English-language and 7 Spanish-language patients. The mean patient score on the colonoscopy questionnaire for group 2 was 77% compared with 54% for group 1 (P = 0.003). In the endoscopy cohort, group 2 also scored higher than group 1 (P = 0.0004). Among Spanish-speaking patients, group 2 had better comprehension scores than group 1 (86% vs 33%, P < 0.0005).

CONCLUSION:

Our results demonstrate a significant improvement in patient comprehension with the use of video education as part of the consent for colonoscopy and endoscopy. This difference was most notable for Spanish-speaking patients. Future directions include translation of the video into additional languages and incorporation into the standard pre-procedure consent at our institution in order to improve quality of care for patients who are both language concordant and language discordant with their providers.
574 Role of Prophylactic Endoscopic Clipping for Prevention of Delayed Post-Polypectomy Bleeding: Meta-Analysis of Randomized Controlled Trials
Authors: Gonzalez Zorisadday , Roy Neel P. , Kanth Rajan , Roy Praveen K.
Published: October 2019

INTRODUCTION:

Post-polypectomy bleeding is a common complication of colonoscopy. Several endoscopic techniques including prophylactic endoscopic clip placement are used for prevention of post-polypectomy bleeding. However, several studies have reported mixed results on the efficacy of this approach. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the efficacy of prophylactic endoscopic clipping for prevention of delayed post-polypectomy bleeding.

METHODS:

Several databases (Embase, Pubmed, Cochrane database, Google Scholar) and abstracts of gastrointestinal and surgical meetings were searched extensively for relevant articles. Studies comparing prophylactic endoscopic clipping alone to standard colonoscopy with no endoscopic clipping were included. Studies that combined prophylactic clipping with other hemostatic techniques were excluded. Data was extracted using a standard form by two reviewers. Data regarding patient characteristics, types of polyps resected, post-polypectomy bleeding and other complications were extracted. Effect sizes were computed either using the fixed effects or random effects model using the Comprehensive Meta-analysis software. Publication bias, quality of studies and heterogeneity were analyzed.

RESULTS:

Nine RCTs were included in this study. The studies recruited subjects from USA, Japan, Canada and Spain. There were 3762 controls and 3658 patients in the treatment arm. Studies evaluated both small (<20mm) and large polyps (>20 mm), sessile and pedunculated polyps. The polyps were predominantly removed with standard polypectomy or endoscopic mucosal resection (for larger polyps). Delayed post-polypectomy bleeding occurred in 2.4% of controls and 1.6% in patients with endoscopic clipping. On analysis of all polyps, prophylactic endoscopic clipping decreased the risk of delayed post-polypectomy bleeding (RR = 0.71: 95% CI 0.51-0.99, P = 0.04, I2= 20%). The risk reduction was seen mainly with larger polyps(>20 mm), RR = 0.53 (95% CI : 0.32-.90, P = 0.02, NNT 28) and with sessile polyps (RR = 0.52, 95% CI: 0.32-0.83, P = 0.006, NNT 100). The protective effect was not seen for small polyps (<20 mm) (P = 0.91, P = 0.7) or pedunculated polyps (RR = 0.58, P = 0.29). All studies were of high quality. No publication bias or heterogeneity was present.

CONCLUSION:

Prophylactic clipping decreased the risk of delayed post-polypectomy bleeding. The benefit was mainly seen in patients with sessile polyps or large polyps (>20 mm).
579 The Efficacy and Safety of Andexanet Alfa in Patients With Acute Gastrointestinal Bleeding While Taking Factor Xa Inhibitors: An ANNEXA-4 Sub-Analysis
Authors: Siegal Deborah , Beyer-Westendorf Jan , Yue Patrick , Souza Sonia , Nakamya Juliet , Connolly Stuart J. , Crowther Mark
Published: October 2019

INTRODUCTION:

Andexanet alfa is a recombinant modified human Factor Xa (FXa) decoy protein developed to reverse the anticoagulant effect of FXa inhibitors.

METHODS:

ANNEXA-4 was a prospective single-arm study of andexanet alfa in patients with acute major bleeding while taking a FXa inhibitor. Patients with major gastrointestinal (GI) bleeding were eligible if they had (1) signs/symptoms of hemodynamic compromise or (2) bleeding associated with a hemoglobin (Hb) drop ≥2 g/dL or baseline Hb ≤8 g/dL. Upon enrollment, patients were treated with one of two andexanet dosing regimens based on the type, timing, and dose of the most recent inhibitor intake. Efficacy was evaluated in all patients who met the bleeding criteria above and had a baseline anti-FXa activity ≥75 ng/mL (≥0.25 IU/mL for enoxaparin). Co-primary endpoints were the change in anti-FXa activity and the achievement of hemostasis, as adjudicated by an independent committee, at 12 hours after andexanet treatment. Hemostasis was defined as: excellent if the red blood cell transfusion-corrected Hb at 12 hours was ≤10% lower than baseline, good if Hb was 10-20% lower, and poor/none if Hb was >20% lower.

RESULTS:

Of 352 patients enrolled in the study, 90 had GI bleeding, of whom 62 were included in the efficacy analysis. Median age was 76 years (range 24-95); 51 (57%) were male. Patients were receiving rivaroxaban (n = 44), apixaban (n = 5), and edoxaban (n = 3) at study entry. Bleeding location was identified in 48 patients (upper n=27, lower n = 21) and unknown in 42 patients. 66 (73%) patients had some evidence of hemodynamic compromise, including 38 (42%) patients with hypotension. Mean Hb at the time of dosing was 4.9 ± 1.4 g/dL. In patients taking rivaroxaban, the baseline anti-FXa activity was 267 ± 168.5 ng/mL and the percent reduction with andexanet was 94% (95%CI 89-96). In apixaban patients, the baseline anti-FXa activity was 244 ± 215.0 ng/mL and the percent reduction with andexanet was 92% (95%CI 88-95). Excellent/good hemostasis was achieved in 85% of evaluable patients. 58 (94%) of 62 patients received red blood cell transfusions, 3 (5%) received platelet transfusion, and 2 (3%) received a coagulation factor product. 30-day rates of thrombosis and death were 6% and 13%, respectively.

CONCLUSION:

In patients with major GI bleeding treated with andexanet, a high rate of effective hemostasis was achieved. The thrombosis and mortality rates are consistent with prior studies in this patient population.
580 The Safety and Efficacy of Proton-Pump Inhibitors (PPI) Usage in Critical Care Patients for Stress Ulcer Prophylaxis: A Meta-Analysis of Randomized Controlled Trials
Authors: Abdel-Aziz Yousef , Ahmed Tamer , Renno Anas , Awad Mohammed , Assaly Ragheb , Ismail Mohammad , Howden Colin W. , Nawras Ali
Published: October 2019

INTRODUCTION:

There is some debate in current literature about the safety and efficacy of proton pump inhibitor usage in critical care patients. In this systematic review and meta-analysis we assessed the the Safety and efficacy of proton-pump inhibitors (PPI) usage in critical care patients for stress ulcer prophylaxis

METHODS:

We searched PubMed, Embase, Web of Science and Cochrane Central Register of Controlled Trials following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement from inception until January 2019. We included randomized controlled trials (RCTs) that examined the efficacy and safety of proton pump inhibitors (PPIs) vs placebo regardless of publication source, status and language with participants older than 18 year old and of any gender who were admitted to medical, surgical or neuro intensive care unit (ICU). We excluded studies in which participants were admitted to ICUs primarily for the management of GI bleeding. Seven eligible studies were included and relevant data was extracted and statistical analysis was performed using Rev Man 5.3.

RESULTS:

Of 57 potentially eligible studies, we included 7 trials enrolling 4021 patients. The results showed that PPIs are probably more effective for preventing non clinically significant gastrointestinal bleed (GI bleed) [Odds ratio (OR) 0.47; 95% Confidence interval (95% CI) 0.37, 0.6] and clinically significant GI bleed -reported in 4 studies- (OR 0.59, 95% CI 0.40, 0.86). PPIs did not increase the risk of developing infection [including pneumonia and Clostridium difficile infection (c-diff) ] compared with placebo (OR 1.02, 95% CI 0.86, 1.22) even with sub analysis: pneumonia (OR 1.03, 95% CI 0.86, 1.23) and c-diff (OR .80, 95% CI 0.45, 1.44) . Estimates of baseline risks of bleeding varied significantly across studies, only 4 studies reported clinically significant GI bleed, 5 studies reported pneumonia (Definitions of pneumonia varied) and two studies reported on Clostridium difficile infection.

CONCLUSION:

PPI decreases the clinically significant and non-significant GI bleeding in critical care patients. PPI did not increase the risk of developing infection [including pneumonia and Clostridium difficile infection (c-diff) ] compared with placebo (OR 1.02, 95% CI 0.86, 1.22) even with sub analysis: pneumonia (OR 1.03, 95% CI 0.86, 1.23) and c-diff (OR .80, 95% CI 0.45, 1.44).
598 Physicians Fail to Utilize Iron Supplementation After Discharge in Gastrointestinal Intestinal Bleeding
Authors: Baskharoun Marina , Goff Sara , Friedenberg Frank
Published: October 2019

INTRODUCTION:

A common cause of iron (Fe) deficiency anemia (IDA) is gastrointestinal bleeding (GIB). While treatment is aimed at the underlying cause of IDA, it is also targeted at replenishing Fe stores to reduce anemia progression and end organ damage. Our objective was to assess whether patients hospitalized with IDA secondary to GIB received appropriate Fe supplementation upon discharge and the effect of this therapy post-discharge.

METHODS:

Retrospective review of patients hospitalized with GIB between 1/2017 and 12/2017. Patients eligible for Fe on discharge had one or more of the following: ferritin ≤30, Fe saturation ≤10%, and/or ≥2-gram decrease from the patient's baseline hemoglobin (hgb) with a final hgb of <10.0 due to GIB. We excluded patients with active malignancy, prior abdominal surgery, hematologic disorders, hgb > 10 on discharge, or died during hospitalization. We recorded the hgb on admission, nadir, and discharge and whether blood transfusions and Fe supplementation were given. In addition, use of anticoagulants and antiplatelet agents prior to admission was recorded. A post-discharge period of 180 days was used to assess outpatient hgb levels and hospital readmission. A regression analysis was performed to identify significant variables associated with receiving appropriate Fe supplementation on discharge.

RESULTS:

From 992 records, 228 patients met inclusion criteria. There were 115 M, 113 F, with a mean age of 62.6y. Overall, 106 (46.5%) patients received Fe on discharge. In regression analysis, adjusted for multiple confounders, having received Fe (PO or IV) while inpatient was strongly predictive of receiving Fe on discharge aOR= 13.5 (CI 6.8-26.8). In addition, if admission hgb was <8.0, the aOR of receiving Fe on discharge was 2.21 (CI 1.10 – 4.45). Nadir and discharge hemoglobin were not associated with Fe supplementation. There was no statistical reduction in readmission rates for those discharged on Fe although a Type 2 error could not be excluded.

CONCLUSION:

Physicians fail to provide Fe supplementation on discharge to over 50% of patients eligible after a GIB. Fe supplementation during a patient's hospitalization is the strongest predictor of receiving Fe upon discharge. This may be due to the medication reconciliation performed by the EMR at time of discharge. The other predictor variable was admission hgb but not nadir or discharge hgb. Automated reminders built into the EMR may help reduce this widespread problem.
599 Assessing Adherence to ACG Guidelines on Restarting Low-Dose Aspirin After Upper Gastrointestinal Bleed Secondary to Ulcers
Authors: Wu Yi-Chia , Kim Urian , Chuang Philip , Rogers Steven
Published: October 2019

INTRODUCTION:

American College of Gastroenterology (ACG) guidelines in 2012 recommend that if low-dose aspirin (LDA) is used as secondary prophylaxis then LDA should be restarted as soon as possible with daily proton pump inhibitor (PPI) therapy in patients who achieve hemostasis after an upper gastrointestinal bleed (UGIB) secondary to an ulcer. It is not recommended to restart LDA for primary prophylaxis.

METHODS:

Retrospective chart review was performed on patients at our hospital center, Mount Sinai Beth Israel, who required an esophagogastroduodenoscopy (EGD) for UGIB secondary to ulcers during a hospital stay from February 2012 to December 2018. Patients were included if they were on LDA prior to EGD intervention. The percentage of included patients who were on LDA for primary prophylaxis and discontinued on discharge was calculated. The percentage of patients who were on LDA for secondary prophylaxis and restarted on LDA at discharge was calculated to assess the level of adherence to the guidelines. Subgroups within the secondary prophylaxis LDA group were also evaluated for adherence with chi-square tests to determine significance.

RESULTS:

155 patients who met the inclusion criteria were reviewed. The mean age was 73 years. Females (67, 43%). Caucasian (52, 33.6%), African American (12, 7.7%), Hispanic (35, 22.6%), Asian (51, 32.9%). 40 patients were on LDA for primary prophylaxis and 115 for secondary prophylaxis. Of those on LDA for primary prophylaxis, 28 (70%) were not restarted on LDA at discharge. Of those on LDA for secondary prophylaxis, 59 (51.3%) were restarted on LDA at hospital discharge. There was no significant difference in the decision to restart secondary prophylaxis LDA on discharge based on gender (P = 0.36) or race (P = 0.69). Additionally, there was no significant difference based on whether patients were taking another anticoagulant (P = 0.78), needed a second EGD (P = 0.09), required endoscopic hemostasis intervention (P = 0.71), or were indicated to receive blood transfusions (P = 0.83).

CONCLUSION:

This study showed that only about half of ulcer-related UGIB subjects on LDA for secondary prophylaxis were restarted on LDA and 70% on LDA for primary prophylaxis were not restarted on LDA at discharge based on suggested ACG guidelines at our institution. The decision to restart secondary prophylaxis LDA was independent of age, gender, and severity of gastrointestinal bleed. Therefore, greater awareness and education among hospital physicians is needed to improve adherence rates.
604 Outcomes of Long-Term Follow-Up in Patients With Iron Deficiency Anemia and Initial Negative Upper Endoscopy, Colonoscopy, and Video Capsule Endoscopy
Authors: Likhtshteyn Michelle , Arroyo-Mercado Fray Martin M. , Noel Jude , Chokshi Tanuj , Gupta Nikita , Aytaman Yasemin , Khudyakov Aleksandr , Lerer Renata , Grossman Jennifer , Tabone Sabrina , Frank David M. , Martinez Manuel
Published: October 2019

INTRODUCTION:

Iron Deficiency Anemia (IDA) occurs in 2-5% of adults and requires workup including upper esophagogastroduodenoscopy (EGD) and/or colonoscopy.1 However, in 10-41% of patients a source of bleeding is not identified,2–5 which requires investigation of the small bowel using video capsule endoscopy (VCE). This study aims to determine the long-term outcomes in patients with IDA and a pan endoscopy-negative IDA, which entails negative EGD, colonoscopy and VCE.

METHODS:

Medical records at the VA NY Harbor were queried for patients with IDA and having an EGD, colonoscopy, and VCE between 2005-2015. Anemia was defined as hemoglobin less than 13 g/dL in men and 12 g/dL in women; IDA was confirmed using serum ferritin less than 100 ng/mL. Exclusion criteria included underlying causes for IDA such as pre-menopausal women or history of ulcerative colitis. Biographical, laboratory and endoscopic data were obtained. Baseline hemoglobin and ferritin levels were recorded, and subsequently followed at 1, 3, and 6-year intervals.

RESULTS:

A total of 7,000 records were reviewed, 311 patients had EGD, colonoscopy and VCE; 67 of these patients were excluded. Of the remaining patients, 99 patients (13 females, 86 males) had a negative initial workup and were included in analysis. The mean age was 68.2 (±11.1). IDA resolved in 37 (37.4%) patients, 49 (49.5%) patients had persistent anemia, and 13 (13.1%) patients had recurrent anemia. Of the 99 patients with negative workup, 80 (80.8%) patients went on to have subsequent EGD, colonoscopy or VCE. 62 (62.6%) patients had subsequent EGD with 12 (19.4%) patients having positive findings such as gastric ulcers. 64 (64.7%) patients had subsequent colonoscopies, 7 (10.9%) of these patients had positive findings such as chronically bleeding hemorrhoids. 18 (18.2%) patients had subsequent VCEs, and 5 (27.8%) of these patients had findings such as angioectasias.

CONCLUSION:

Our findings are consistent with previous reports suggesting that the majority of elderly patients who have an initial negative workup for IDA tend to have favorable outcomes. 21 of 80 patients (26.25%) had some findings on subsequent workup to explain IDA, however those findings were benign. In addition to previous published data, our study highlights the significance of VCE as a tool for identifying a bleeding source. Our study also emphasizes the need for randomized control studies to determine the optimal workup strategy for patients with initially negative bidirectional endoscopy and VCE.