bluuebunny/crossref_metadata_2025 huggingface dataset:
509 Burden of IBS-Diarrhea Symptoms Tracked With Daily Journals for 12 Weeks in a Randomized, Double-Blind, Placebo-Controlled Study of Lactobacillus AcidophilusCL1285, L. Casei LBC80R and L. Rhamnosus CLR2
Authors: Ship Noam , Mallais Cynthia , Carrière Serge
Published: October 2019

INTRODUCTION:

The burden of symptoms in Irritable Bowel Syndrome is chronic and fluctuates from day to day, yet most research studies rely on scheduled clinical interviews. Daily symptom journals may provide better precision of the burden of illness. The diarrhea-predominant presentation of IBS (IBS-D) is particularly disruptive to Quality of Life.

METHODS:

Subjects with a history of IBS were randomized, double-blind, to oral capsules of a probiotic comprised of Lactobacillus acidophilus CL1285, L. casei LBC80R and L. rhamnosusCLR2, 100 billion CFU daily, or placebo in a 2:1 ratio (Preston 2018). In addition to the clinical interviews, subjects kept daily records of each stool with the Bristol Stool Scale (BSS), and, scored their abdominal pain on a 10-point visual analog scale (VAS). Scores were pooled for weeks 1 through 6 and weeks 7-12. Liquid stools had BSS ratings of 6 or 7. Missing journal entries were imputed with the Last Observation Carried Forward. A regression was performed for IBS-related Quality of Life scores at clinical interviews and journal data for abdominal pain and the proportion of liquid stools.

RESULTS:

Daily journals were available for 38 subjects with IBS-D (N = 26, active, N = 12, placebo). The active treatment group had significantly more liquid stools at baseline relative to placebo, RR = 1.2, P < 0.001. Both groups decreased vs. baseline for weeks 1-6 but the ratio remained the same, RR = 1.2, P < 0.001. For weeks 7-12 the number of liquid stools for placebo plateaued but the active group continued to improve, RR = 0.7, P < 0.001. The number of days of abdominal pain, 6 or greater on the VAS, in each arm was similar at baseline, RR = 0.9, but there were significantly fewer days of pain with probiotic treatment vs. placebo for weeks 1-6 and 7-12, RR = 0.6, 0.5, respectively, P < 0.001. For weeks 7-12, the probiotic group experienced fewer weeks with any pain rating of 6 or greater, RR = 0.6, P = 0.02. Better Quality of Life was correlated with fewer days of abdominal pain, 3 or greater on the VAS, and, a lower proportion of liquid stools (R2 = 0.16, P < 0.001).

CONCLUSION:

There was an important decrease in the burden of IBS-D symptoms in both treatment arms. Compared to placebo, subjects taking the probiotic capsules had fewer liquid stools and fewer days of abdominal pain. Despite variability among the subjects with IBS-D, fewer days of pain and a lower proportion of liquid stools correlated with improved IBS-related Quality of Life. Preston K, et al. Beneficial Microbes, 2018, 9(5):697-706.
510 Ginger, Paullinia Cupana, Muira Puama, and L-citrulline (COMP-4) as a Novel Natural Treatment for Severe Constipation
Authors: Gisi Catherine , Reicher Sofiya , Hou Linda A. , Fleischman Wayne , Eysselein Viktor E.
Published: October 2019

INTRODUCTION:

Epidemiologic studies report that about 15% of adults and 30% of people older than 60 years suffer from constipation in the United States. The actual prevalence is likely greater as many people believe their bowel habits are normal and underreport symptoms of constipation. Moreover, most recent surveys assessing current medical management of constipation show that patients are dissatisfied and believe that conventional treatments, like laxatives and colonic stimulants, are suboptimal since they can cause explosive bowel movements which are difficult to control. COMP-4, a combination of ginger, Paullinia cupana, muira puama, and L-citrulline is a novel nutraceutical that has been shown to stimulate the production of nitric oxide and cGMP in smooth muscle cells resulting in smooth muscle relaxation and possibly increases intestinal secretion. In this study, we aim to demonstrate that treatment with COMP-4 is an effective treatment for severe constipation.

METHODS:

Seventeen patients with constipation were treated COMP-4 (2-4 capsules per day) for 2-4 weeks. Constipation was defined as two or more of the following: the sensation of incomplete evacuation, Bristol stool score 1-2 (hard, lumpy nut or sausage-shaped bowel movements), and straining during the majority of defecations. Patients were surveyed before and after the treatment regarding their approximate number of bowel movements per week, their typical Bristol stool score, the presence of abdominal pain, and the feeling of incomplete evacuation. Statistical analysis was performed using the Wilcoxon rank test with a P < 0.05 considered significant.

RESULTS:

Following treatment with COMP-4, the average weekly number of stools significantly (P < 0.0001) increased from 2.7+/-0.68 to 7.3+/- 1.11 (Figure 1). Prior to COMP-4, 16/17 patients reported incomplete bowel evacuation during bowel movements. After COMP-4, 10/17 patients reported complete bowel evacuation. The mean Bristol Stool Score significantly (P < 0.0001) increased from 1.5+/- 0.15 to 3.4+/-0.29 with softer and more formed stools (Figure 2). Patients also experienced a significant (P < 0.0001) decrease in abdominal pain (Figure 3).

CONCLUSION:

The combination of ginger, Paulinia cupana, muira puama, and L-citrulline improves the frequency and consistency of stools and helps relieve symptoms of constipation. The nutraceutical may be a novel agent used to treat severe constipation not responding well to other conventional treatments.
515 Are All Endoscopic-Related Musculoskeletal Injuries Created Equal?: Results of a National Gender-Based Survey
Authors: Pawa Swati , Banerjee Promilla , Kothari Shivangi , D'Souza Sharlene , Martindale Sarah L. , Gaidos Jill , Oxentenko Amy S. , Burke Carol A.
Published: October 2019

INTRODUCTION:

Endoscopy- related injury (ERI) is common in gastroenterologists. This study aimed to evaluate the prevalence of self-reported ERI, patterns of injury and knowledge of ergonomic strategies in endoscopists who are ACG physician members.

METHODS:

A 38-item survey was developed and initially piloted at three academic medical centers. Through the ACG Women in GI Committee and ACG Governing Board sponsorship, the survey was administered to ACG physician members. Statistical analysis was performed using SAS Enterprise Guide 7.0 (SAS Institute Inc., Cary, NC); chi-square tests and descriptive analysis evaluating associations between multiple variables and ERI.

RESULTS:

Of the 14759 total surveys sent, 5940 were opened, and only completed surveys were included (n = 1133). ERI was reported by 71% of the respondents including 49% of trainees. More than half of the respondents reported pain in the thumbs (64%), hand/fingers (59%), neck (57%), and lower back (54 %). The most common causes of ERI reported were torqueing with the right hand (64%), adjusting tip angulation with left hand (53%), standing for prolonged periods of time (59%), and standing in awkward positions while supporting an endoscope (58 %). While no differences were noted in characteristics associated with overall ERI, including sex (P = 0.77), performance of interventional endoscopy or a focus in another GI domain (P = 0.55) women were more likely to have upper extremity pain and upper back pain (see Table 2). There were statistically significant differences between genders in the mechanisms of ERI (see Table 3). Most respondents did not receive training during fellowship (68%), or discuss ergonomic strategies in their current practice (63%). Those without training in ergonomics were more likely to report ERI (P = 0.02). 81 % of respondents noted a desire for more training in ergonomic strategies to reduce ERI.

CONCLUSION:

The results of this study show an overwhelming occurrence of ERI in all GI physicians and in nearly half of the trainee respondents. Preliminary analysis shows a significant difference between men and women with regards to specific areas of ERI and contributing mechanisms. Results strongly support training and a desire for continued education in ergonomic strategies as a preventative strategy. Education and prevention of ERI represent rich opportunities for improving key aspects of clinical practice, reducing burden on physicians, and decreasing interruptions to clinical care.
516 The Impact of In-Hospital Palliative Unit on Percutaneous Gastrostomy Practice, Volume, and Outcomes
Authors: Patel Harish , Makker Jasbir , Tariq Hassan , Ahmed Rafeeq , Kumar Kishore , Chime Chukwunonso U. , Ravi Madhavi , Abbas Hafsa , Baiomi Ahmed , Shaikh Danial , Mehershahi Shehriyar , Balar Bhavna , Chilimuri Sridhar
Published: October 2019

INTRODUCTION:

Per-cutaneous gastrostomy (PEG) is often preferred for enteral feeding of patients with terminal and critical illness. Implementation of the palliative care often avoids the futile procedures in patients with short life expectancy. Inpatient palliative units have the potential to reduce placement of PEG in terminally ill patients.

METHODS:

In retrospective review, we analyzed all patients who underwent PEG from 2006 to 2015. The research protocol was approved by Institutional Review Board at our institution. The study population was divided into two groups based on the establishment of in-hospital palliative care unit at our institution in August of 2010. The demographic data including age, gender and ethnicity were reviewed. Endoscopy reports and patient charts were reviewed for the indication of PEG and post-procedural complications. The categorical variables were analyzed with chi-square and continues variable with student t-test. The annual procedural number were extrapolated from our endoscopy EMR.

RESULTS:

There were 780 PEGS placed on 721 unique patients from 2006 to 2015. Majority of them (62% n = 483) were placed before establishment of in-hospital palliative care unit (August 2010) and the remaining (38% n = 297) were done after Aug 2010. There was no significant difference in total number of hospitalizations or discharges during the study period. After implementation of palliative unit, number of PEGS decreased from 97/year to 52/year (Figure 2). The mean age of patient undergoing PEG was 69 years in both group. There was slight females preponderance (53% vs 50%). African American patients were predominant in both groups. Establishment of in-house palliative care unit led to statically significant decrease (34% to 7%) in number of Hispanic patients and an increase in white Caucasian (from 9% to 42%) undergoing PEGs (Figure 1). There was substantial change noted in the indication of the PEG (Figure 3) after inpatient palliative care unit services, with the predominant decrease for the PEG requirement in patients with dementia (from 42.9% to 24%, P-value < 0.001). There was a statistically significant decrease in the overall mortality (23.3% to 7.4%) and 30-day mortality (9.7% to 4%) for patients undergoing PEGS after the initiation of the palliative unit. However, overall PEG related complications were unaltered.

CONCLUSION:

The in-house palliative care units impact practice of PEG placement by decreasing procedural volume, lower overall and 30-day mortality after PEG placement.
517 A Survey of Peri-Colonoscopy Management of Anti-Diabetic Medications
Authors: Lee Byeori , Jain Deepanshu , Rajala Michael
Published: October 2019

INTRODUCTION:

Currently, no standardized recommendations exist for management of antidiabetic medications in diabetes mellitus type II (DMII) patients undergoing bowel cleansing for colonoscopy. This study aims to find real-world practices of gastroenterology providers in the management of anti-diabetic medications in peri-colonoscopy period for DMII patients.

METHODS:

An online survey was created using Google Survey and sent to thirty-three providers who are routinely involved in planning colonoscopy for patients at our tertiary medical center. Survey questions were designed to know provider practices regarding the management of anti-diabetic medications on the day before and morning of colonoscopy in DMII patients. Questions specific to six non-insulin medications and four insulins (short, intermediate, long-acting, and mixed) for each meal were framed. Two expert endocrinologists were consulted to give best practice recommendations regarding management of same anti-diabetic medications in the peri-colonoscopy period. The answers from each provider were collected and summarized.

RESULTS:

Among 33 providers, 24 providers (72.7%) answered the survey. Of them, 12/24 were attending physicians, 6/24 were fellow in training, 6/24 were nurse practitioners/physician assistants). Table 1–3 summarize the cumulative numbers (and percentages) for each response specific to each anti-diabetic medication and time of day.

CONCLUSION:

Our survey shows marked disparity amongst gastroenterology providers (attendings, fellows, and nurse practitioners/physician assistants) and with regards to endocrinologist recommendations. Lack of consensus leads to confusion at the patient level, often leading to mismanagement and sometimes even clinically significant hypoglycemic and hyperglycemic events. Gastroenterologists should team up with endocrinologists to come up with practice guidelines to standardize peri-colonoscopy management of anti-diabetic medications among DMII patients.
521 Developing and Validating a Prediction Model to Identify Patients at High Risk for Failing Standard Sedation for Routine GI Endoscopy
Authors: Adams Megan A. , Saini Sameer D. , Gao Yuqing , Wiitala Wyndy , Rubenstein Joel
Published: October 2019

INTRODUCTION:

In recent years, use of anesthesia-assisted (AA) sedation for routine GI endoscopy has increased markedly. One factor contributing to this increased use is clinical uncertainty about which patients are most likely to benefit from AA. We aimed to develop a prediction model to help providers identify patients who require AA due to high-risk of failing standard sedation (SS).

METHODS:

This was an IRB-approved retrospective longitudinal study of national Veterans Affairs (VA) data of all patients who underwent an EGD and/or colonoscopy in 2009-13 (during which AA was used for 4.1% of routine GI endoscopy in VA). Using step-wise logistic regression, we developed a model to predict the primary outcome of failed sedation using potentially predictive patient and procedure-level variables (Table 1). Failed sedation cases were identified electronically as patients who had a routine procedure (without polypectomy, dilation, or injection) with AA within 3-months of a prior similar SS procedure. All cases were manually validated by chart review (index endoscopy report or other records) documenting patient discomfort/agitation and/or medical instability resulting in either an incomplete procedure or specific mention of need for AA for future procedures. 10-fold cross validation was used to validate the final model.

RESULTS:

Of 710,252 SS procedures, there were 398 cases of failed sedation (173 EGD, 225 colonoscopy; prevalence = 0.06%). None of the factors found to be significant predictors of failed sedation (e.g., high-dose opioid use, younger age) had an odds ratio > 3; factors NOT associated with failed sedation included body mass index, obstructive sleep apnea, functional GI disorders, and others (Table 1). 10-fold cross-validation yielded a mean area under the curve (AUC) of 0.67 (range 0.63-0.71). The model was well-calibrated, but patients in the top decile of risk had a failed sedation prevalence of only 0.16% (Table 2).

CONCLUSION:

Failed sedation among patients undergoing routine outpatient GI endoscopy with SS is very rare, even among patients in the highest decile of risk. This suggests that concerns regarding failed sedation due to commonly cited factors such as chronic opioid use, obesity, or increased comorbidity do not justify forgoing SS in favor of AA in most patients. It also suggests that use of AA is generally unnecessary, since failed sedation is very uncommon even in VA where overall use of AA is much lower than in the private sector.
522 Is the Future of Gastroenterology Being Prepared to Prevent Work Related Injuries and Allow for a Long Healthy Career: Question Answered
Authors: Craig Cassandra , Owen S. Craig , Acharya Priyanka , Kedia Prashant
Published: October 2019

INTRODUCTION:

Gastroenterologists practicing in the United States perform on average 12 endoscopies and 22 colonoscopies per week and spend 43% of their time performing endoscopy. 39-89% of endoscopists report pain and/or injuries related to performing procedures. Recently, there has been an emphasis on optimizing physician trainee mental health, while education and training on managing the physical strain associated with endoscopy is lacking. We hypothesized that gastroenterology fellows are receiving insufficient training in the ergonomics of endoscopy.

METHODS:

A survey consisting of nine questions was distributed to all gastroenterology fellowship coordinators and program directors to distribute to their fellows. Primary outcome targets were the percentage of fellows having undergone any ergonomics training as well as the number of hours of instruction received. Secondary outcomes included the type of work-related injury and the responder's opinion on the need for additional training. Demographic data obtained included age, sex, year in training and overall physical fitness level.

RESULTS:

Ninety-nine fellows completed the survey. The average age was 32.9 years old, 74.8% male, and first/second/third years were equally represented (28.3% vs 34.3% vs 32.3%) with only 5.1% being advanced fellows (5.1%). 53.5% reported good overall health. Only 45.5% have received any training in ergonomics, 8.1% reported more than 2 hours and 92.9% felt they would benefit from additional training. Procedurally related injuries were reported in 27.3% of fellows. Despite a trend towards more females reporting work related injuries it was not statistically significant (P = 0.098). Once again, a trend was seen in second and third years reporting more injuries (P = 0.076). There was no significant difference in perceived health of respondents reporting injuries (P = 0.864) or amount of training received (P = 0.232).

CONCLUSION:

Despite a limited sample size clear trends in endoscopic ergonomics training were identified. The majority of fellows have received no or minimal training and an overwhelming amount believe that they would benefit from additional instruction. With more than 25% of fellows reporting an injury as a direct result of endoscopy, if no changes are made in training curriculum we can assume this number will grow as their careers progress. Our survey demonstrated a need and desire for more formal training in the ergonomics of endoscopy.
526 The Efficacy and Safety of Device-Assisted Enteroscopy and Push Enteroscopy in Cirrhosis Patients
Authors: Al Yassin Altaib , Alazzawi Yasir , Sapho Lidia , Kheder Joan , Cave David
Published: October 2019

INTRODUCTION:

Small bowel Push enteroscopy (PE) and device-assisted enteroscopy (DAE); including double balloon, single balloon or spiral enteroscopy are modalities that used in evaluating and treating obscure gastrointestinal bleeding and small bowel lesions. Limited data are available on the safety and efficacy of these procedures in the cirrhotic population. The aim of this study is to assess the efficacy and the safety of DAE and PE in cirrhotic patients.

METHODS:

A retrospective chart review of cirrhotic patients from a single center between January 2006 and January 2016 who had device-assisted enteroscopy or PE procedure. Success rate, duration of the procedure, anesthesia time, and procedure complications were collected. Patients' age, sex, MELD score, child-Pugh score (CTP) were also reviewed and analyzed.

RESULTS:

A total of 42 procedures, including 22 PE and 20 DAE, in 33 cirrhotic patients were reviewed. The mean age was 59.3 years (range: 29-86 years). The most common findings were angioectasias followed by ulcers and inflammatory changes. A longer duration time was associated with the device-assisted enteroscopy when compared to the PE group, the mean time was 58 minutes and 37 minutes respectively (P-value of 0.03). The anesthesia time was longer in the DAE with an average of 83 minutes while in the PE , it was 53 minutes (P-value of 0.03). No difference in the time of the procedure was found between the compensated cirrhosis when compared to the decompensated cirrhosis. The device-assisted enteroscopy success rate was 90% versus 100% in PE. No adverse events were seen in both groups. More therapeutic interventions were performed in DAE compared to PE especially bleeding cauterizations and biopsy of lesions while more diagnostic procedures were performed in the PE (Table 1).

CONCLUSION:

Device-assisted enteroscopy and push enteroscopy are safe procedures in cirrhotic patients with a high success rate. Decompensated cirrhosis does not carry an increased risk of a longer procedure time or complication when compared to the compensated cirrhosis.
531 Patients Undergoing Outpatient Upper Endoscopy and Colonoscopy on the Same Day (Double Procedures) Are at Increased Risk for Adverse Respiratory Outcomes
Authors: Saltzman Steven , Weinstein Michael , Ali M. Aamir
Published: October 2019

INTRODUCTION:

Between 11-15 million colonoscopies and 6-7 million upper endoscopies are performed in the United States annually, with over half the cases occurring in an ambulatory setting (1,2). Recent claims-based data has suggested that infectious complications may be increased when upper endoscopy and colonoscopy are performed together compared to when they are performed separately (3). The purpose of this study is to determine endoscopic and anesthesia variables that increase the risk of periprocedural respiratory complications.

METHODS:

Medical records from 2000 consecutive upper endoscopies and colonoscopies performed at five high volume ambulatory surgery centers were reviewed. Patient characteristics were recorded, along with endoscopic and anesthesia variables. End points chosen to serve as surrogates of aspiration risk were intra-procedure cough, desaturation, placement of a nasal or oral airway, and use of oral suction.

RESULTS:

In 2000 cases, desaturation occurred in 3.25%, cough in 3.5% cases, need for suction in 2.45%, and need for oral airway / nasal trumpet in 0.4%. Multiple logistic regression analysis demonstrated supine position, double procedure, bowel prep taken as a single dose, NPO time of less than 3 hours, BMI >35 kg/m2 and Propofol dose >300 mg, and supine position to be independent risk factors for adverse respiratory events.

CONCLUSION:

Supine position during procedures, double procedures, bowel prep taken as a single dose, NPO duration of less than 3 hours, high BMI and high propofol dose are risk factors for adverse respiratory outcomes during endoscopic procedures.
532 Reduction of Inpatient Non-Emergent GI Procedure Utilization
Authors: Sandhu Naemat , John-Keating Krysta , Platt Alison , Wambold Christine , Barash Eric , Navarro Victor J.
Published: October 2019

INTRODUCTION:

Non-emergent gastrointestinal (GI) procedures performed on inpatients increase costs in a diagnosis related group (DRG) reimbursement system. They prolong periods of inanition due to preps, interrupt patient rest and disrupt the flow of outpatient procedures. This study involved delivery of an educational intervention for gastroenterologists intended to reduce the number of non-emergent inpatient GI procedures at Einstein Medical Center Philadelphia.

METHODS:

The baseline rate of non-emergent inpatient GI procedure performance was determined for a 6-week period in 2018. Potential barriers contributing to performance of non-emergent inpatient GI procedures were assessed via a survey of twenty gastroenterologists. Total inpatient esophagogastroduodenoscopies (EGDs) and colonoscopies was collected, non-emergent procedures were identified during a 6-week pre-intervention phase A 30 minute didactic to brief all twenty on the American College of Gastroenterology guidelines on emergent GI procedure indications was delivered as the intervention. Post-intervention data was collected for total and non-emergent inpatient GI procedure performance for a 6-week period immediately following the intervention.

RESULTS:

Fear of patients not following up followed by fear of litigation were the most common reasons that caused providers to perform non-emergent inpatient GI procedures (Figure 1). The rate of non-emergent EGDs and colonoscopies dropped from baseline to post-intervention periods; 31% to 8% (Figure 2), and 49% to 20% (Figure 3) respectively. The rate of non-emergent EGDs dropped further from pre to post-intervention, but rose slightly for colonoscopies.

CONCLUSION:

The process of measuring non-emergent GI procedure performance led to a reduction in utilization (Hawthorne effect), in keeping with guidelines. An educational intervention led to a further reduction in inpatient EGD utilization. Implementing steps to eliminate potential barriers may improve non-emergent inpatient GI procedure performance rates.
535 Peppermint Oil Decreases Colonic Spasm Without Significantly Affecting Cecal Intubation Time and Adenoma Detection Rate: A Systematic Review and Meta-Analysis
Authors: Nehme Fredy , Al Momani Laith , Alomari Mohammad , Zafar Yousaf
Published: October 2019

INTRODUCTION:

Peppermint oil, an essential oil well known as a flavoring agent, is also known to have a relaxation effect on smooth muscles in the colon. Peppermint oil was reported to reduce colonic spasm and is commonly used for symptomatic relief in irritable bowel syndrome. Whether these effects lead to clinically relevant advantages in practice during routine colonoscopy is controversial.

METHODS:

We included randomized controlled trials comparing peppermint oil administered during colonoscopy to placebo. We searched Medline, Google Scholar, and Cochrane through May 2019. Eligible studies were searched for variables of interest including inhibition of peristalsis cecal intubation time, and adenoma detection rate (ADR). All statistical analyses were performed using the R Programming Language. Pooled rates of variables were reported as Odds ratio (OR) and standardized mean difference with 95% confidence interval and heterogeneity was reported as I2 statistics.

RESULTS:

A total of 5 trials were eligible and included in the analysis. Dosage and route of administration were variable, peppermint oil was administered via oral dose pre-procedure in 2 studies and locally during the procedure in 3 studies. There was a total of 623 subjects in the peppermint oil group and 239 in the placebo group. Complete inhibition of colonic peristalsis was significantly more common in the peppermint oil group (OR = 6.12, 1.85-20.26). Cecal intubation time and ADR were comparable between the 2 study groups. There was substantial heterogeneity.

CONCLUSION:

Administration of peppermint oil reduces colonic spasm during colonoscopy. Despite the theoretical benefits of improving mucosal inspection and increasing the ease of colonoscopy insertion with peppermint oil, objective measurements including ADR and cecal intubation time did not differ. However, these studies were limited by the low number of subjects, significant heterogeneity in dosage, route and timing of administration. Given the heterogeneity of the results, larger randomized controlled trials are needed.
537 A Simple Step for Better Prep: The Impact of Nurse Driven Telephone Education on Colonoscopy Bowel Prep
Authors: Mann Sarabdeep , Ahmed Shifat , Al-Jashaami Layth , Alishahi Yasmin
Published: October 2019

INTRODUCTION:

Bowel preparation affects the completeness, duration, and safety of colonoscopy, as well as the detection of neoplastic lesions. Guidelines have proposed a goal of >85% to achieve adequate bowel cleansing during colonoscopy. However there remain challenges to achieve this metric, as factors including patient health literacy, socioeconomic status, language barriers, and complex instruction tools can influence the quality of bowel prep. Recognizing a period of time when the adequacy of bowel prep at our institution was <85%, a nurse driven telephone education protocol was developed to improve bowel prep at the Phoenix VA Health Care System.

METHODS:

The nurse education team assigned a GI nurse to call patients one week prior to their colonoscopy. During this phone visit, patients were educated to eat a low residue diet one week prior to their procedure. They were further instructed to maintain a clear liquid diet the day prior to the colonoscopy. During the phone encounter, education was given regarding the timing of the bowel prep. Prior to our education initiative, to prevent confusion all patients were instructed to take the first dose of MoviPrep at 6 pm the evening before the exam, and the 2nd dose at midnight the day of the colonoscopy. With the nurse driven telephone education protocol patients received individualized plans for split dose prep, with the 1st dose at 6pm the evening prior to the colonoscopy and the 2nd dose four hours before the colonoscopy. We evaluated the quality of bowel prep seven months prior to and six months after our quality improvement initiative, and collected data on overall impression of bowel prep deemed by the performing gastroenterologist. Statistics were performed with univariate analysis and statistical significance was set at P < 0.05.

RESULTS:

For the preceding seven months prior to our quality improvement initiative, 2115 out of 2569 (82%) colonoscopies achieved adequate quality bowel prep. Following implementation of a nurse driven telephone education initiative, 2271 out of 2384 (95%) colonoscopies achieved adequate prep. This improvement from 82% to 95% was statistically significant (P = 0.0001).

CONCLUSION:

We demonstrate improved bowel prep through nurse driven telephone education. Where resources allow, this can be a simple yet effective tool to improve bowel prep, in turn reducing cost. Further studies are needed to determine the precise cost effectiveness of such interventions, as well the role other ancillary staff may play in education.
543 Analysis of Variation in Pre-Procedural Fasting Duration for Common Inpatient Gastrointestinal Procedures
Authors: Sakulsaengprapha Vorada , Daniel Michael , Cai Jiarui , Martinez Diego , Mathews Simon C.
Published: October 2019

INTRODUCTION:

Guidelines from the American Society of Anesthesiologists (ASA) recommend no intake of clear liquids and solid food 2-4 hours and 6-8 hours respectively prior to endoscopic procedures. Because excessively long pre-procedural fasting while inpatient can negatively impact a patient's experience and clinical outcomes, our study analyzed the typical fasting duration for patients undergoing colonoscopy, esophagogastroduodenoscopy (EGD), or endoscopic retrograde cholangiopancreatography (ERCP) at a large tertiary care hospital and determined how these wait times varied across multiple variables.

METHODS:

Inpatient data for colonoscopy, EGD, and ERCP was extracted as part of a quality improvement evaluation using administrative data and information from the electronic medical record at The Johns Hopkins Hospital between July 2016 and January 2018. The duration of nil per os (NPO) status was calculated from time the NPO order went into effect to the time “Patient in Procedure Room” order was entered. Patients who were NPO greater than 72 hours were excluded as NPO status was more likely secondary to non-procedure factors. Kruskal-Wallis Test/Wilcoxon Test/Pearson Test were used in analysis depending on the outcome type and data distribution.

RESULTS:

During the study period, there were 753 colonoscopies, 1325 EGDs, and 550 ERCPs performed on inpatients. The median NPO wait time for colonoscopy was 11.9 hours; 12.6 hours for EGD; and 13.1 hours for ERCP (median for all procedures was 12.6 hours; interquartile range 9.6-16.1 hours). Hispanic patients spent more time NPO than non-Hispanic patients (median of 13.9 hours vs. 12.4 hours, P-value = 0.018). There was no statistically significant associations between NPO duration and patient sex, total number of comorbidities, intensive care unit days, length of stay, inpatient unit location, inpatient team, or type of provider placing the orders (physician vs. non-physician).

CONCLUSION:

The duration of pre-procedural inpatient fasting was between 9.6-16.1 hours for the majority of patients, which consistently exceeds ASA guidelines for pre-procedural fasting. There are many scenarios where longer fasting is clinically indicated particularly for safety; however, these data suggest that for many patients there may be an opportunity to liberalize NPO duration and keep within recommended guidelines. This change may contribute to improved patient experience and minimize potential clinical impact of prolonged fasting.
550 Discordance in Colorectal Polyp Size Determination Between Colonoscopy and Pathology Reporting
Authors: Corona Edgar , Bastani Roshan , Yang Liu , Shao Paul , Mwengela Didi , Didero Michelle , Asokan Ishan , Bui Alex , Hsu William , May Folasade
Published: October 2019

INTRODUCTION:

National guidelines recommend that patients with colorectal adenomas ≥1cm undergo surveillance colonoscopy to prevent colorectal cancer. Polyp size is often assessed twice, once during colonoscopy and again during pathology examination. It remains unclear whether these measurements vary and which should govern surveillance intervals.

METHODS:

We retrospectively analyzed a random sample of primary care patients who underwent polypectomy between January 1, 2013 and January 1, 2016 in a large academic healthcare center. Chart abstractors reviewed electronic health record data for colonoscopic polyp descriptors and measurements, corresponding pathology measurements, and histology. We excluded cases with normal histology, missing pathology, fragments, unreliable polyp matches between reports, and >5 polypectomies. We performed a paired t-test to assess polyp size discordance between reports and calculated Cohen's kappa coefficient to assess agreement whether the size was ≥1 cm.

RESULTS:

We reviewed 1,528 patient charts, and 831 (54.4%) met inclusion criteria, representing 1,532 polyps. Sizes ranged from 0.1-3.0cm on colonoscopy and 0.1-2.7cm on pathology reports. On colonoscopy report, the majority (881, 57.5%) used only a descriptive term rather than a numeric value to describe size (Table 1). Descriptive size terms were diminutive (513), tiny (39), small (328), and large (1). Only 2.8% of polyps described as diminutive, small, or tiny on the colonoscopy report were ≥1cm on the corresponding pathology report. Among the 367 (24.0%) polyps with discrete numeric sizes on both reports, size discordance varied by >0.2 cm for 50% of polyps (Figure 1). More of these polyps were ≥1 cm on colonoscopy (70) than on pathology (51) report, and there was remarkable clustering at 1 cm by colonoscopy report estimation (Figure 2). There was moderate agreement (kappa = 0.52) on size ≥1 cm. Among tubular adenomas (TA) ≥1 cm on colonoscopy or pathology report (36), 10 (27.8%) were ≥1 cm on both, 18 (50.0%) were ≥1 cm on colonoscopy only, and 8 (22.2%) were ≥1 cm on pathology only.

CONCLUSION:

There is considerable discordance between colonoscopic and pathology polyp size measurements, with more polyps sized as ≥1 cm by colonoscopic estimation compared to pathology, which has implications for surveillance frequency. Future studies should investigate the implications of discordant measurements on clinical outcomes and inform guidelines on surveillance intervals.
551 Comparing Advanced Adenoma Detection Rate of Water Exchange, Cap, and Endocuff Colonoscopy: Pooled Data of Randomized Controlled Trials With Air Insufflation as the Common Comparator
Authors: Shao Paul , Bui Aileen , Jia Hui , Leung Felix
Published: October 2019

INTRODUCTION:

Advanced adenomas, defined as adenomas ≥10mm, significant villous features (>25%), or high-grade dysplasia, are important targets for colorectal cancer screening. They represent the subpopulation of adenomas that are most likely to progress into carcinoma and are associated with increased risk for future CRC incidence. Advanced adenoma detection rate (AADR) is therefore an important measure in assessing new screening methods. Water exchange (WE) colonoscopy has been shown to improve AADR consistently while modern accessories, such as cap and endocuff, have variable impacts on AADR. We assessed the impact on AADR between WE, cap and Endocuff by indirect comparison with standard air insufflation (AI) as the common comparator.

METHODS:

A literature search was done to identify all relevant RCTs comparing WE, Cap and Endocuff with AI colonoscopy published since 2000 as full text in English and included AADR among the outcomes. EMBASE, Medline, SCOPUS, and Cochrane Library were searched systematically using the following terms in their titles, abstracts, or keyword lists: colonoscopy, and water exchange, cap, or Endocuff. Two investigators screened the articles manually and separately. The results were compared, and a discussion was held with a third investigator to resolve any discrepancies.

RESULTS:

1,453 articles resulted from keywords search and were manually screened. 14 RCTs met criteria and were included in the analysis. A total of 12,085 subjects underwent AI, WE, cap (CC) or Endocuff-assisted (EC) colonoscopy. AADR of WE, CC, and EC were compared against AI. Table 1 shows that WE significantly increases AADR compared to AI (8.1% vs 6.0%, P = 0.0001, Fisher exact test). CC does not significantly change AADR compared to AI (8.7% vs 8.2%, P = 0.585). No significant difference in AADR exists between EC and AI (16.6% vs 17.0%, P = 0.815). AADR in WE, CC, and EC as a percentage change of AI are 35.0%, 6.1% and -2.4%, respectively. While WE significantly increases AADR, CC and EC do not significantly impact AADR. Compared to CC and EC, WE has a higher percentage increase in AADR (vs the common comparator of AI). This may be related to the low AADR in the AI group in the WE trials.

CONCLUSION:

WE appears to significantly increase AADR, especially in patient cohort with lower AADR. Cap and Endocuff does not have significant impact on AADR.
560 Bowel Preparation Quality Improvement Using Multimedia and Visual Aids in Hospitalized Patients
Authors: Tang Thinh , Gohar Hamza , Villano Svetlana , Sharma Vishvinder , Attri Priyanka , Carlson Brian
Published: October 2019

INTRODUCTION:

Bowel preparation is one of the most important factors affecting diagnostic yield and reaching the cecum in colonoscopy. Poor bowel preparation is encountered in up to 25% of colonoscopies. Hospitalized patients typically have poorer bowel preparation compared to outpatients due to factors such as acute illness and narcotic use. In this study, a new bowel preparation process using multimedia and visual aids was introduced with the goal of decreasing suboptimal and incomplete colonoscopy in hospitalized patients.

METHODS:

The study was conducted at a single community hospital in Las Vegas, Nevada. Nurses and nursing assistants completed an online educational module consisting of interactive written and video materials. All patients scheduled for colonoscopy received a brochure and watched a short 10 minutes video detailing the colonoscopy process. This new process was implemented on February 1, 2019. Post-implementation data were collected from February 1, 2019 to March 31, 2019. This was retrospectively compared to pre-implementation timeframe from December 1, 2018 to January 31, 2019. In the post-implementation period, 46 patients were included while 13 patients were excluded due to colonoscopy aborted or not performed for reasons unrelated to bowel preparation. During the pre-implementation period, 48 patients were included and 10 patients were excluded.

RESULTS:

In the post-implementation period there was a decreased in the number of colonoscopies aborted due to poor bowel preparation (19% to 7%). Of the number of completed colonoscopies, the average Boston Bowel Preparation Score are comparable (6.00 versus 5.95). The percentage of adequate bowel preparation, defined as Boston bowel preparation score of 6 or greater, are also similar (58% versus 57%).

CONCLUSION:

There was a significant decline in the number of colonoscopies aborted due to poor bowel preparation after the new process was implemented. The educational materials likely benefited those patients with poor initial understanding of the bowel preparation who would have inadequate preparation for successful colonoscopy otherwise. In patients with adequate initial understanding, the educational materials are less likely to be beneficial or change the outcome of the colonoscopy. This is evidenced by similar average Boston Bowel Preparation Score and percentage of adequate bowel preparation in both timeframes. These findings emphasize the importance of patient advocacy and education.
568 Polyp Detection and Histology by Colon Cleansing Quality With a Ready-to-Drink Low Volume Bowel Preparation: Subgroup Analysis From a Randomized, Assessor-Blinded, Multicenter Study
Authors: Bertiger Gerald , Hookey Lawrence , Johnson Kenneth L. , Ando Masakazu , Stong Laura , Chacar Christelle , Dahdal David N.
Published: October 2019

INTRODUCTION:

High-quality bowel preparations are essential for polyp detection. In a recent meta-analysis, patients with adequate bowel preparation by the Aronchick Scale (AS) (defined as those with “excellent,” “good,” or “fair” ratings) had sufficient adenoma detection rate (ADR) for follow-up at guideline-recommended intervals. Here, we examine polyp and adenoma detection, grouped by AS rating, from a study of a ready-to-drink preparation of sodium picosulfate, magnesium oxide, and citric acid (SPMC oral solution).

METHODS:

A phase 3, randomized, assessor-blinded, multicenter study compared the efficacy and safety of low volume, split-dose SPMC oral solution to a powder formulation for colon cleansing in adults undergoing elective colonoscopy for screening, surveillance, or diagnosis. The study protocol was approved by Schulman IRB (protocol #000253). The primary efficacy endpoint assessed overall colon cleansing quality using a modified AS. Any polyps found during the colonoscopy were removed, recorded as AEs, and all polyps were sent for histological analysis. A post-hoc analysis examined polyp detection and histology by AS rating group. Polyp detection rate (PDR) and ADR in this study were defined as the percentage of any participants who had ≥1 polyp or adenoma, respectively (NCT03017235).

RESULTS:

A total of 448 patients received SPMC oral solution. For patients with an “excellent” rating by AS (n = 241), the mean (standard deviation, SD) age was 56.5 (12.2) years. In this group, PDR was 46.1% (111/241), and ADR was 30.3% (73/241), with a total of 122 adenomas identified across all participants (Figure 1, Table 1). For patients with a “good” rating by AS (n = 152), the mean (SD) age was 57.3 (9.4) years. In this group, PDR was 46.7% (71/152), and ADR was 33.6% (51/152), with a total of 104 adenomas identified in the group. For patients with a “fair” rating by AS (n = 43), the mean (SD) age was 60.8 (9.5) years. In this group, PDR was 41.9% (18/43), and ADR was 34.9% (15/43), with a total of 23 adenomas identified across all participants in this group. There were 4 (0.9%) patients who received an “inadequate” rating by AS, with a mean (SD) age of 51.0 (10.7) years.

CONCLUSION:

In patients receiving SPMC oral solution who had “excellent”, “good”, or “fair” ratings by AS, PDR and ADR were above guideline-recommended levels. Detection of sessile polyps was higher for those with “excellent” or “good” ratings by AS, compared to those with “fair” ratings.
570 Improving Endoscopy Staff Professional Satisfaction and Employment Retention Through Clinical Educational Didactic
Authors: Palmer William , Chris-Olaiya Abimbola , Hodge David , Lesser Elizabeth , Cangemi David , Lewis Michele
Published: October 2019

INTRODUCTION:

High nursing turnover has long been recognized as a fiscally and emotionally costly phenomenon in gastrointestinal (GI) endoscopy units. Previous studies suggest high turnover may be partly attributed to job-related stress in GI endoscopy units and lack of educational opportunities. A retrospective review of nursing turnover rate in 2016 at Mayo Clinic Florida GI endoscopy unit found the turnover rate to be 25%, which is twice the average of other departments at the clinical site. We aimed to reduce endoscopy staff turnover rate to less than 25% and improve job satisfaction by improving knowledge of GI diseases through structured didactic sessions.

METHODS:

A descriptive correlational study of the impact of a six-month long optional educational curriculum on professional quality of life and employee turnover was performed. All endoscopy nurses and technicians employed at Mayo Clinic in Florida were recruited, but both study enrollment and participation were blinded and voluntary. Data on clinical gastroenterological knowledge and surveys on professional satisfaction and team cohesion were collected at the initiation of the curriculum and at one month after completion. Pre and post intervention knowledge scores were compared using the Wilcoxon signed rank test. The annual percentage of turnover was estimated by the Wilson score confidence interval.

RESULTS:

All available GI nurses and endoscopy technicians (n = 71) were invited to participate. 40 (56.3%) participants completed only the initial survey, 30 (42.3%) only the second survey, and 16 (22.9%) both surveys. Of those who completed both surveys, median quiz scores improved by 2 questions for those that attended 6 or more lectures (P = 0.017). There was a trend towards increased professional satisfaction on the modified perceived cohesion scale in participants who attended 6 or more lectures (P = 0.095). For participants who have worked in the unit for less than 1 year, the estimated turnover is 14% (6 – 38%, P > 0.05) and 24% (11 – 45%, P >0.05) for those who have worked longer than 1 year.

CONCLUSION:

Though limited by sample size, there is a trend towards improved job satisfaction for participants that completed all surveys and a reduction in turnover rate for staff who have worked in the unit for less than one year. This study suggests potential benefit in knowledge, professional satisfaction, and turnover for those offered voluntary education.