bluuebunny/crossref_metadata_2025 huggingface dataset:
138 Multiplex Gastrointestinal Pathogen PCR Testing in HIV/AIDS Patients: The Relationship Between Enteric Infection and CD4 T-Cell Count
Authors: Hine Ashley M. , Lebwohl Benjamin , Axelrad Jordan E.
Published: October 2019

INTRODUCTION:

Diarrhea is a common complication of HIV/AIDS. Although non-infectious enteropathy may be attributed to HIV infection, enteric pathogens are frequently detected in episodes of diarrhea. The objective of this study was to investigate the relationship between CD4 count and enteric infection as detected by multiplex gastrointestinal PCR stool testing in HIV/AIDS patients.

METHODS:

We performed a cross-sectional analysis of adult inpatients and outpatients who underwent stool testing with a FilmArray multiplex gastrointestinal pathogen PCR panel (GI PCR panel) during an acute episode of diarrhea from December 2015 to February 2019. Our primary endpoint was the detection of any enteric pathogen. Patients were stratified by the presence of HIV infection and CD4 count at time of stool testing.

RESULTS:

Of 80 HIV+ patients who underwent a GI PCR panel, 45 (56%) tested positive for an enteric pathogen (Table 1). HIV+ patients with CD4 counts >500 (n = 26) were more likely to have a pathogen detected (19, 73%) compared to patients with a CD4 count <200 (n = 30) consistent with AIDS (12, 40%; P = 0.03; Figure). Patients with a CD4 count between 201 and 499 (n = 24) had a positivity rate that was in between that of patients with low and high CD4 counts (14, 58%). Of 30 AIDS patients, 9 (30%) had a GI infection not detected by GI PCR including CMV, HSV, LGV, MAI, and syphilis. Among this subset of 9 AIDS patients, 4 (44%) tested negative on GI PCR. AIDS patients were less likely to be adherent to antiretroviral therapy, and more likely to be on opportunistic infection prophylaxis compared to HIV+ patients with CD4 counts >200 (P = 0.03 and P = 0.002 respectively.) Compared to patients with CD4 counts >200, those with AIDS were more likely to receive empiric antimicrobial therapy at stool testing (P < 0.001), and in the 30 days following stool testing, as likely to visit an emergency room (P = 0.24), require hospitalization (P = 0.31), or undergo endoscopic procedures for continued GI symptoms (P = 0.67).

CONCLUSION:

Enteric infections were common in HIV+ patients who underwent a GI PCR panel for an episode of diarrhea, with the highest proportion of positive results in patients with CD4 counts >500. Based on historical data, this rate of positivity is considerably higher than in the general population of patients with an episode of diarrhea. These data suggest that AIDS patients may be more likely to have a pathogen not included on the GI PCR panel, or a chronic cause of diarrhea such as HIV-enteropathy.
140 Traditional Serrated Adenomas (TSA) and the Company They Keep: TSA Presence Predicts Synchronous Advanced Lesions
Authors: Duh Erica , Sowa Piotr , Roberts Mary B. , Karnes William
Published: October 2019

INTRODUCTION:

The serrated group of colorectal polyps include hyperplastic polyps (HPs), sessile serrated polyps (SSPs), and traditional serrated adenomas (TSAs). HPs are generally non-precancerous whereas SSPs and TSAs are considered precancerous. TSAs are associated with high risk of subsequent (metachronous) advanced neoplasms, suggesting that TSAs reflect a predisposition for neoplastic progression. If true, the presence of one or more TSAs should be associated with synchronous advanced neoplasms.

METHODS:

Data was extracted from UCICQD—a prospectively collected database (2012–2019) inclusive of locations, sizes and pathology of all polyps and masses. A “neoplasm” was defined as carcinoma, adenoma, SSP, or TSAs regardless of size. Cases with advanced neoplasm were defined if any neoplasm was malignant, ≥1 cm, contained villous features or high grade dysplasia, or if ≥3 neoplasms of any size were found. TSAs cases were compared to cases of other lesions for rates and odds ratios of synchronous neoplasms and advanced neoplasms.

RESULTS:

A total of 6023 procedures with at least one HP, adenoma, SSP or TSA were included, of which 70 had one or more TSAs (TSA cases). No significant differences in age, body mass index, or gender were seen between TSA and non-TSA cases. TSA cases had a mean of 2.44 neoplasms compared to 1.72 in non-TSA cases (IIR = 1.42 [CI 1.05–1.92] P = 0.022) and were associated with increased numbers of SSPs (IIR = 1.83 [CI 1.04–3.22] P = 0.038) (Table 1). The fraction of cases with synchronous advanced neoplasia was significantly higher in TSA cases (0.786 ± 0.115) compared to cases with one or more adenomas (0.487 ± 0.016), HPs (0.327 ± 0.019) or SSPs (0.592 ± 0.034), P = 0.0002. Relative to cases with one or more HPs, odds ratios for advanced neoplasia were 1.95 (1.75–2.17), 2.98 (2.54–3.5) and 7.54 (4.23–13.44) for cases with adenoma, SSP and TSA, respectively (Table 2).

CONCLUSION:

Prior studies have shown that one or more index TSA(s) predict later risk for metachronous advanced neoplasms, more so than an index colorectal carcinoma. We show that the presence of one or more TSAs is also associated with higher risk for synchronous neoplasms and advanced neoplasms, especially SSPs. This suggests that TSA presence may reflect an unknown genetic predisposition and/or intestinal field defect that promotes tumor initiation and malignant progression. Regardless of underlying mechanisms, our data support an aggressive surveillance strategy for patients with one or more TSAs.
149 Gastrointestinal Pathogen Distribution for Patients With Immunosuppressive States and Acute Diarrheal Illness
Authors: Ziv Yonatan , Ho Tai Hang , Szymczak Wendy A. , Gendlina Inessa , Kwah Joann
Published: October 2019

INTRODUCTION:

Up until recently, identification of gastrointestinal (GI) pathogens in patients with an acute diarrheal illness (ADI) was limited. The introduction of a new GI pathogen PCR panel now offers a quick, reliable way to identify specific GI pathogens. It has been established that patients with immunosuppressive states are more susceptible to opportunistic GI pathogens, but the prevalence of these pathogens remains unknown. This study aims to compare the pathogen distribution in ADI in patients with immunosuppressive states versus patients without immunosuppressive states.

METHODS:

A database of patients was identified who presented to Montefiore Medical Center with an ADI and a positive GI pathogen PCR panel from April 2018 to November, 2018. Data collected included patient demographics, toxic habits, and previous antibiotic and steroid use within 6 months prior to the ADI. Immunosuppressed patients were identified as having either HIV/AIDS, organ transplant, active hematologic malignancy, primary immunodeficiency disease or current use of immunosuppressive medications. If C. difficile was identified, the patient was included if a confirmatory C. difficile test was positive. The primary outcome was the pathogen identified on GI pathogen PCR panel.

RESULTS:

Of 551 patients identified for this study, 130 patients (23.6% of the cohort) were immunosuppressed. A total of 88 patients had a positive GI pathogen PCR panel for C. difficile and 472 patients had a positive GI pathogen PCR panel for organisms other than C. difficile. The most common pathogen in both the non-immunosuppressed and the immunosuppressed patients was Enteropathogenic E. coli (EPEC) (184 cases, 35.3% and 26.9%). The most common viral pathogen was Norovirus (47 cases, 6.6% and 14.6%), and the most common parasitic pathogen was Giardia lamblia (21 cases, 2.4% and 8.5%). Immunosuppressed patients were more likely to be positive for Norovirus (14.6% vs. 6.6%, P = 0.008), Cryptosporidium (5.4% vs. 0.7%, P = 0.002), Giardia (8.5% vs. 2.4%, P = 0.004), Enteroinvasive E. coli (EIEC) (13.1% vs. 4.5%, P = 0.001) and C. difficile (23.1% vs. 13.7%, P = 0.011). No other differences in pathogen distribution were identified between the two groups.

CONCLUSION:

Patients presenting with ADI with immunosuppressive states were more likely to have Norovirus, Giardia, Cryptosporidium, EIEC or C. difficile identified on GI pathogen PCR panel. Further studies are needed to better define these findings and their clinical implications.
152 Fair Colonoscopy Bowel Preparation Is Not Adequate for Effective Colonoscopy
Authors: Alomari Mohammad , Al Momani Laith , Sarmini Muhammad Talal , Khazaaleh Shrouq , Nehme Fredy , Wadhwa Vaibhav , Thota Prashanthi N. , Sanaka Madhusudhan R.
Published: October 2019

INTRODUCTION:

Adenoma detection rate (ADR) is an established colonoscopy quality metric with higher rates associated with reduced interval colorectal cancer. Adequate colon visualization and hence sufficient bowel preparation are crucial for effective colonoscopy. Due to inconsistency in the adequate bowel preparation definition using the Aronchick scale, we aimed in this study to investigate the impact of bowel preparation on overall and segment-specific ADR and polypectomy rates (PR).

METHODS:

A retrospective review of all screening colonoscopies in patients ≥50 years of age performed at our institution between 2012 and 2014 was done. Average risk patients who had a complete colonoscopy with excellent, good and fair bowel preparation as per the Aronchick scale were included. Overall, gender-specific and colon segment-specific ADR and PR were calculated and compared using t-tests. All analyses were done using SAS (version 9.4, The SAS Institute, Cary, NC) and a P-value < 0.05 was considered statistically significant.

RESULTS:

A total of 4151 patients were included in the analysis. Average patient age was 60.0 ± 7.7 years and 53.2% were females. A total of 652 (15.7%) had excellent preparation, 2675 (64.4%) had good preparation and 824 (19.9%) had fair preparation (Table 1). Overall ADR was significantly lower in patients with fair preparation (21.1 ± 27.0) than in those with good preparation (27.6 ± 12.8; P  <  0.012). Overall PR, proximal PR, and distal PR were significantly lower in patients with fair bowel preparation (38.0 ± 34.1, 25.0 ± 29.9 and 25.0 ± 29.9, respectively) compared to those with good bowel preparation (45.9 ± 19.8; P  = 0.048; 28.1 ± 16.4; P  = 0.042; 29.4 ± 14.3; P  = 0.044, respectively) (Table 2).

CONCLUSION:

The Aronchick Scale is one of the most commonly used validated bowel preparation quality scales in clinical practice. However, to date, there is no uniform definition of the adequate bowel preparation as some use a composite of “excellent,” “good” and “fair” preparation while others define it as a composite of “good” and “excellent” preparation. In our study, patients with fair standards of preparation had significantly lower overall and segment-specific ADR and PR than those with good bowel preparation. Moreover, in patients with fair colonoscopy preparation, endoscopists didn't reach their recommended overall and gender-specific ADR benchmarks. Thus, an earlier surveillance colonoscopy may be considered in those patients.
158 No Cure, No Comfort: An Urban Center Experience With Palliative Care for Hospitalized Colon Cancer Patients, 2010–2017
Authors: Jamorabo Daniel S. , Renelus Benjamin D. , Kancharla Pragnan , Briggs William M.
Published: October 2019

INTRODUCTION:

Palliative care is integral to cancer treatment. Our goal was to investigate the frequency of palliative care service contact for colon cancer patients and factors associated with their involvement.

METHODS:

We carried out a retrospective analysis of all colon cancer patients diagnosed at our university-affiliated hospital between 1/1/2010 and 12/31/2017. We used Fisher's exact test to find statistically significant differences in proportions of patients seen by the palliative care service based on sex, race, insurance type, cancer stage, surgical intervention, and chemotherapy administration, hospitalization history, and vital status. Bayesian univariate logistic regression models were fit to each variable to give the probability of palliative care use for each.

RESULTS:

We identified 655 patients diagnosed with colon cancer at our institution, including 361 (55%) women, 280 (43%) with Stage III or IV disease, and 156 (25%) dead at time of last contact. Most were diagnosed as inpatients (385/655; 59%) and hospitalized for any cause (612/655; 93%). Those diagnosed as inpatients had poorer survival for the first 6 years after diagnosis compared to their counterparts (Figure 1). Only 105/612 (17%) admitted for any cause were evaluated by the palliative care team—regardless of sex, race, insurance type, or cancer stage—while 484/612 (79%) underwent surgical intervention and 151/612 (25%) received chemotherapy. Most patients with Stage III and IV disease were more likely to undergo surgery (214/285; 75%) than not, yet were less likely to receive chemotherapy (150/285; 53%) and palliative care team contact (214/285; 75%). Results are summarized in Tables 1 and 2.

CONCLUSION:

The lack of contact with palliative care teams is concerning given both the poorer survival among those diagnosed as inpatients as well as the rate of all-cause admissions. Additionally, the preponderance of surgical interventions without chemotherapy or palliative care in Stage III to IV disease is inconsistent since aggressive treatments typically involve the former while conservative plans should include the latter. The underutilization of palliative care teams may be rooted in lack of staffing, misconceptions that providers and patients have about palliative care, or lack of coordination among specialists. Providers must be mindful of the utility of palliative care specialists and aim to include them earlier in the care of patients at all stages of disease.
161 Optimizing Clinical Assessment and Diagnostic Evaluation in Patients With Chronic Constipation Based on Systematic Analysis of 97 Articles in the Literature
Authors: Brandler Justin , Camilleri Michael
Published: October 2019

INTRODUCTION:

There is still controversy surrounding the use of symptoms, history, and tests for diagnosis of rectal evacuation disorders (RED) and slow transit constipation (STC). We performed a comprehensive literature-based analysis to ascertain pooled prevalence, sensitivity (SN), specificity (SP), and likelihood ratios (LR) for clinical parameters to determine pre- and post-test probabilities of diagnosing RED and STC without RED.

METHODS:

Using MEDLINE and PUBMED, we examined systematic and clinical reviews, meta-analyses, primers, guidelines, and consensus statements since 1999 to determine the diagnostic utility of history, symptoms, and testing for RED and STC. Studies were included if binary data were available to assess true/false positives or negatives to pool and calculate SN/SP/LR. Given there are no “gold standard” diagnostic criteria for RED or STC, designation of “true” RED or STC was based on confirmation by at least one objective anorectal or colonic transit test. Controls varied across studies; all had normal anorectal and/or transit tests by the specific protocol used in each study. We assessed STC alone (associated with normal anorectal testing).

RESULTS:

We reviewed 97 articles involving studies from many different countries, and 63 articles for RED and 61 articles for STC met inclusion/exclusion criteria. The prevalence of disease phenotypes among 4160 patients with chronic constipation based on objective testing was RED alone 23.3%, normal transit constipation (NTC) alone 31.9%, STC alone 16.2%, and RED + STC 14.3%. To diagnose RED (Figure 1, Table 1), the most clinically significant symptoms included hard/lumpy stools (+LR 269.6, n = 1583) and urinary symptoms (100% specificity, n = 58). The strongest digital rectal exam (DRE) findings were poor anal relaxation (+LR 5.3, n = 529) or increased anal squeeze (+LR 8.4, n = 395). The most predictive anorectal tests were balloon expulsion time >120 s (+LR 5.5, n = 551) and rectoanal pressure gradient < −40 mmHg with high anal pressure on straining on anorectal manometry (100% specificity, n = 101). For STC alone, the most predictive symptom was a call to stool (+LR 10.5, n = 75). Patients without abdominal distension/fullness/bloating were less likely to have RED (−LR 0.2, n = 324) or STC alone (−LR 0.2, n = 93).

CONCLUSION:

Symptom assessments and DREs are critical in the evaluation for RED and STC. RED is highly prevalent in patients presenting with chronic idiopathic constipation.
163 High Incidence of Early Onset Colon Cancer in Ethiopia: Clinical and Therapeutic Evaluation With Genetic Mutational Analyses
Authors: Mohammed Abdulsemed , Sultan Amir , Braimoh Grace , Debes Jose D.
Published: October 2019

INTRODUCTION:

Colon cancer has been reported to occur early in certain African regions, but the understanding of genetic modifications leading to early disease is incomplete. We aimed to study cases of early colon cancer and genetic modifications leading to these tumors in Ethiopia.

METHODS:

We evaluated all colon masses detected between 2015 and 2018 at Black Lion Hospital, Addis Ababa. Clinical, endoscopic and pathology descriptions were assessed for all cases in 30-year-olds or younger. Subsets of pathology block-tissues were evaluated for genetic modifications via Multiplex Ligation-dependent Probe Amplification.

RESULTS:

A total of 38 cases of colon cancer ages 30 or earlier were identified. These represented 13% of all cases of colon cancer in the 3-year period. The median age was 27 years (IQR 27–30), and 50% of individuals were female. None of the cases reported a family history of colon cancer or had evidence of inflammatory bowel disease (IBD). The most common presenting symptom was rectal bleeding (57%) followed by a change in bowel habit (22%). All but one sample were identified as adenocarcinoma, 78% were confined to the rectum, and 65% had distant metastasis or locally advanced disease at the time of diagnosis. Longer duration of symptoms correlated with the presence of metastasis on diagnosis (P = 0.035). Surgery (23%) and chemotherapy (15%) were the most frequently used treatments. We performed genetic analysis of biopsy tissue in a subset of 3 individuals: a) 21 y/o-male showed decrease copies of APC, increase in K-ras, v600f mutation in BRAF and decrease in MSH2 and MLH1; b) 21 y/o-female showed duplication of exon 4 APC, decrease in K-ras and decreased copies of MSH-2; c) 30 y/o-female showed decreased copies of APC, decreased copies of K-ras and BRAF and decreased copies of MSH2 and MLH1.

CONCLUSION:

We report a high incidence of early colon cancer in Ethiopia with no family history or IBD. Most patients presented with rectal bleeding. Genetic analyses in a subset of patients showed APC and K-ras alterations as well as modifications of mismatch repair pathways.
166 Is Prophylactic Clipping Necessary After the Resection of Large (≥1 cm) Colorectal Lesions? If So, at What Cost?
Authors: Mohan Babu P. , Asokkumar Ravishankar , Yu Jessica X. , Kaltenbach Tonya , Soetikno Roy
Published: October 2019

INTRODUCTION:

Published data on the risk of delayed bleeding (DB) after endoscopic resection of large colorectal lesions (≥1 cm) are conflicting. Prior systematic analyses were underpowered. We systematically reviewed the current data, focusing on randomized studies, to compare the risk of DB with and without clipping, and to determine its cost-effectiveness. We hypothesized that prophylactic clipping is the preferred strategy.

METHODS:

We conducted a systematic search in PubMed and the Cochrane library to identify RCTs that compared the DB outcomes of prophylactic clipping vs. no clipping after resection of large polyps. We estimated pooled odds ratios (ORs with 95% CIs). Using the 2016 CMS reimbursement rates for procedure and hospitalization and price of clips estimated from the VHA system, we created a decision tree to model the cost: the initial procedure was estimated to be the cost of a colonoscopy with EMR and three clip placement or no clip. We assumed that some patients who had DB required repeat colonoscopy. Our primary outcome is the total cost. We sought to determine the cost of clips that would make the strategies equal.

RESULTS:

Six studies, which included 2002 patients with 3736 polyps in the clipping arm and 1996 patients with 3717 polyps in the no clipping arm met eligibility criteria for the meta-analysis. Prophylactic clipping of large polyps had a reduced risk of DB compared to those without clipping: OR 0.60 (95% CI: 0.38–0.92) with the random effects and OR 0.59 (95% CI: 0.39–0.89) with the fixed effects models. There was no significant heterogeneity (I2 = 7%, P = 0.37). The pooled risks of bleeding with clipping was 2.3% (95% CI: 0.8–6.1%) and 3.6% (95% CI: 1.2–10.3%) without clipping. In the meta-regression analysis, there was no significant difference based on antithrombotic use (P = 0.57) or lesion size (P = 0.79). Using a base case of 3 clips placed in the clipping arm (cost = $522), we found that the strategy of prophylactic clipping cost $1517.91 compared to $1179.69 for no clipping. The prophylactic clipping strategy cost $11,274 for each rebleed prevented. The two strategies however became equivalent in cost if the total cost of clipping is lower than $183.

CONCLUSION:

Our analysis suggests that prophylactically clip placement after resection of large (≥1 cm) polyp reduces the risk of DB. Such a strategy is cost-effective if the cost of the clip(s) used is less than $183.
173 Retrospective Study Correlating Bowel Wall Thickening to Colonoscopy Findings
Authors: Alsheikh Mira , Daneshvar Danial , Gurala Dhineshreddy , Ngu Sam , El Douaihy Youssef , Mulrooney Stephen
Published: October 2019

INTRODUCTION:

Colonic bowel wall thickening (BWT) on computed tomography (CT) scan is a common but nonspecific finding. It can correspond to an early pathological change, a mere artifact or may be due to inadequate distention of the colorectum (CR). The pattern of BWT can be indicative of malignant, inflammatory, or infectious process. However, the clinical relevance of colorectal thickening on CT is unclear, and if an endoscopic examination is warranted is yet to be determined. The main objective of this study is to assess the sensitivity (Sn) and specificity (Sp) of BWT on CT scan in identifying colorectal cancer (CRC) and to provide evidence to inform a cost-effective and clinically relevant diagnostic strategy.

METHODS:

This was a retrospective cohort chart review of 300 consecutive patients who had BWT described on CT scan of the abdomen (with or without oral contrast) AND who subsequently underwent a colonoscopy. The primary outcome was the Sp of BWT on CT in diagnosing CRC. Ratios of distributions were used to describe the cohort at baseline. The distribution of BWT was also calculated to describe the location of BWT in the different sections of the CR: Ascending (including the cecum), transverse, descending, sigmoid and rectum. The area under the curve (ROC) analysis was conducted to assess for the Sn and Sp of CT's bowel wall thickening in predicting colorectal masses. This was extrapolated to predict any pathology, including colitis, polyps, and diverticulosis.

RESULTS:

The mean age at diagnosis was 61.6. Only 3 patients (1.7%) reported a positive family history (hx) of CRC. 7 (4.1%) reported a prior hx of partial bowel resection and 11 patients (6.4%) reported a hx of IBD. The distribution of the BWT was as follows: Ascending colon 29.1%, Transverse colon 34.3%, descending colon 45.9%, sigmoid colon 61.0%, and rectum 18%. The CT ROC value in predicting a mass seen on endoscopy ranged between 0.491 and 0.524 in all 5 studied sections of the colon. This study suggests that the CT carries a very low accuracy as a diagnostic test for colorectal masses.

CONCLUSION:

In conclusion, this study demonstrates that despite common practice, the CT finding of bowel wall thickening remains a poor indicator of colorectal masses. Nonetheless, Gastroenterologists feel obliged to pursue endoscopic visualization of all CT scans with the finding of BWT for a variety of reasons, including defensive medical practices. Further studies might clarify which subgroups warrant further investigation.
176 Increased Mortality in Patients With Acute Diverticulitis and History of Inflammatory Bowel Disease
Authors: Castaneda Daniel , Hasan Badar , Melendez-Rosado Jose , Charles Roger
Published: October 2019

INTRODUCTION:

Patients with acute diverticulitis have a benign disease course when antibiotic treatment is provided. Risk factors for poor outcome include extensive disease, age and nutritional status. Notably, underlying background inflammation can predispose to severe disease, such as in patients with inflammatory bowel disease (IBD). The aim of this study is to compare the inpatient outcomes for patients with acute diverticulitis with and without IBD.

METHODS:

This was a retrospective cohort study using the 2014 National Inpatient Sample, the largest publicly available inpatient database in the United States. Inclusion criteria were age older than 18 years and a primary ICD-9 CM code for any diagnosis of acute diverticulitis. There were no exclusion criteria. The primary outcome was in-hospital mortality. The secondary outcomes were morbidity measured by intensive care unit (ICU) admission, shock, multi-organ dysfunction syndrome (MODS), malnutrition and need for partial/total colectomy, and resource utilization measured by length of hospital stay (LOS), total hospitalization charges, need for ultrasound (US), and CT abdomen. Patients with acute diverticulitis were classified as having or not IBD diagnosis using ICD-9 CM codes. Odds ratios and means were adjusted for the following confounders using multivariate regression analysis models: age, sex, race, median income in the patient's zip code, hospital region, rural location, size and hospital teaching status.

RESULTS:

218,720 patients with acute diverticulitis were included in the study, from which 1,835 (0.84%) had a diagnosis of IBD. Mean age was 60.4 years and 58% of patients were female. The population was predominantly Caucasian (76.9%). The in-hospital mortality was higher among IBD patients (1.4 vs 0.4%), with an overall mortality of 0.41%. On multivariate analysis, patients with IBD had higher in-hospital mortality risk compared to patients without IBD (OR 2.77, 95% P = 0.05). When evaluating morbidity and resource utilization, only the length of stay was longer in patients with IBD 0.64 days (P = 0.024). All adjusted odds ratios, adjusted means and p values are shown in Table 1.

CONCLUSION:

Patients with a history of inflammatory bowel disease tended to have increased mortality after an episode of acute diverticulitis. However, no differences on morbidity and inpatient resource usage was seen in comparison to the general population.
178 Short and Long-Term Outcomes of Patients With Severe Complicated Clostridioides (Clostridium) difficile Infection Treated With Fecal Microbiota Transplant
Authors: Park Sa Ra , Wang Patty , Hays R. Ann
Published: October 2019

INTRODUCTION:

Severe complicated Clostridioides difficile infection (SC-CDI) has mortality rates of 20–80%. Standard treatment for SC-CDI refractory to antibiotic therapy includes colectomy with end ileostomy and more recently diverting loop ileostomy, which have mortality rates of 19–57%. Fecal microbiota transplantation (FMT) is a well-established treatment for recurrent CDI, but its use for SC-CDI has not been well-studied. Here, we present short-term and long-term outcomes of patients who underwent FMT for SC-CDI.

METHODS:

An IRB-approved retrospective cohort study was conducted on patients with SC-CDI who received FMT at a single academic center between 2015–2018. SC-CDI was defined by the 2013 American College of Gastroenterology guidelines. Two patients who underwent both surgery and FMT were excluded. We obtained: WBC count, heart rate (HR), pressor requirement pre-FMT then 24, 48, and 72 hours (h) after FMT, mortality, cause of death, re-admission rate, and re-admission diagnoses.

RESULTS:

Total 8 patients were identified. Regarding short-term outcomes of FMT, we observed that patients showed clinical improvement within 72 h of FMT. We found that WBC count was significantly decreased at 72 h compared to pre-FMT (9.6 vs 12.9, P = 0.025). Heart rate (HR) was also significantly decreased at 72 h post-FMT (91.6 vs 79.6, P = 0.022). One patient was on vasopressor pre-FMT (norepinephrine 16 mcg/min), and it was discontinued by 72 h post-FMT. Regarding long-term outcomes, 1 patient died 564 days after FMT due to chronic leg infection. All other patients were alive at the time of chart review. All patients had survived at least 1-year post-FMT, 6 for 2-years post-FMT, 5 for 3-years post-FMT, and 3 for 4-year post-FMT. No patient had post-procedural complication from FMT. Average number of FMTs that patients received was 3. Within 1 year of FMT, 3 patients had recurrent admission due to CDI. There were no admissions for CDI beyond 1-year post-FMT.

CONCLUSION:

Our study showed that patients with SC-CDI had significant clinical improvement within 72 h of FMT. Their long-term survival up to 4 years after FMT was unexpectedly high. FMT is a promising modality for treatment of SC-CDI. Prospective studies are needed to identify the appropriate clinical setting for this promising treatment in patients with SC-CDI (e.g., adjuvant or neoadjuvant to surgery, replacement of surgery, or patients without acute abdomen but refractory to antibiotic therapy).
182 A Comparison of the Mucosal Defects and Healing by Hot Snare Polypectomy (HSP) vs. Cold Snare Polypectomy (CSP) for Endoscopic Removal of Colorectal Polyps
Authors: Fukushima Hirofumi , Sakamoto Naoto , Murakami Takashi , Ueyama Hiroya , Matsumoto Kenshi , Shibuya Tomoyoshi , Nagahara Akihito
Published: October 2019

INTRODUCTION:

Screening colonoscopy with polypectomy of small polyp substantially reduces colorectal cancer incidence and mortality. CSP and HSP are two major methods for polypectomy. The basic difference of CSP and HSP is the use of a high frequency generator of HSP. HSP may damage deeper vessels with increased risk of delayed healing, thereby post-polypectomy bleeding and even perforation. For this reason, CSP is usually considered safer, in recent years, CSP has increasingly been used for the removal of colorectal polyps. On the other hand, CSP is concerned associate with a rate of incomplete resection. So far few studies have confirmed endoscopically the early condition after treatment. In this study, through a randomized controlled study, we evaluated to compare mucosal defects and healing one week after treatment, from polypectomy using CSP vs. HSP.

METHODS:

The 52 patients has tumor size under 10 mm were randomly divided into two groups using opaque envelopes: CP (n = 27) and HP (n = 25). We compared the mean tumor size, ulcer diameter one week after endoscopic treatment, exposed blood vessels, residual recurrence and contingencies for CSP and HSP. Pathological diagnosis of complete resection was defined as no evidence of adenomatous tissue in the biopsied specimens, among all pathologically confirmed adenomatous polyps.

RESULTS:

The overall the mean tumor size did not differ between the two groups (CSP vs. HSP: 5.44 mm vs. 5.32 mm). Ulcer base diameter one week after treatment is CSP group had a smaller compared to the HSP group (2.7 mm vs. 4.84 mm; P < 0.001). And the CSP group had a lower exposed blood vessels compared to the HSP group (7.4% vs. 36.0%; P < 0.05). Delayed perforation or bleeding was not recognized in any patient during the one weeks after treatment. One case of residual recurrence was admitted to CSP group.

CONCLUSION:

Our study findings show that although there is no difference tumor diameter between the two techniques, the size of ulcer diameter one weeks after treatment, resection time and the rate of post-polypectomy bleeding is lower with CSP. However remnant recurrence was observed only in CSP. In clinically, CSP can be safely used as one of the effectively techniques for the resection colorectal polyps, but It is important to make an accurate endoscopic diagnosis and exclude cancer before treatment.
183 Epidemiology of Diverticulitis and Prevalence of First-Ever Colorectal Cancer Post-Diverticulitis in Adults in the United States Between 2014 and 2019: A Population-Based National Study
Authors: Jin-Dominguez Fangyuan , Mansoor Emad , Saleh Mohannad Abou , Isenberg Gerard , Wong Richard C. , Cooper Gregory S.
Published: October 2019

INTRODUCTION:

Prior studies show the incidence of colorectal cancer (CRC) after an episode of diverticulitis ranges from 0 to 7.4%. We sought to describe the prevalence of first-ever diverticulitis in the US between 2014 and 2019 and evaluated the prevalence of first-ever CRC post diverticulitis in the US between January 2014 and 2019 utilizing a large population based database.

METHODS:

We queried a commercial database (Explorys Inc, OH), an aggregate of EHR data from 26 major integrated healthcare systems in the US from 1999 to 2019. We identified an aggregated patient cohort with a diagnosis of “diverticulitis of large intestine” from 2014 to 2019 followed by “first-ever primary malignant neoplasm of cecum, ascending colon, transverse colon, descending colon, sigmoid colon and/or rectum,” at least 1 day after and within 6 months of diverticulitis, aged >18 years, based on Systemized Nomenclature of Medicine—Clinical Terms. We excluded patients with IBD, family and personal history of CRC. We calculated the prevalence of diverticulitis and CRC post diverticulitis overall and among different patient groups.

RESULTS:

Of the 31,441,890 individuals active in the database from 2014–2019, we identified 785,740 individuals with first-ever diverticulitis with an overall prevalence of 2.5%. The prevalence in male was 2.6%, females 2.4%, adults (age 18–65 years) 1.5%, senior (>65 years) 5.5%, Caucasian 3.3%, African-American 2.3% and Asian 1.3% (Figure 1). Furthermore, 4,390 out of 785,740 individuals were diagnosed with CRC (first-ever) post diverticulitis with prevalence of 0.56% (Figure 2). In contrast, the prevalence of CRC without history of diverticulitis was 0.3%. Odds ratio (OR) of CRC post diverticulitis was 1.9 compared to individuals without diverticulitis (P < 0.0001). The risk of CRC post diverticulitis was higher in female (OR 2.04, P < 0.0001) vs male; African Americans (OR 2.16, P < 0.0001) vs Caucasians and Asians; adults (OR 2.36, P < 0.0001) than seniors (Figure 3).

CONCLUSION:

This is one of the largest population-based national studies that describes the epidemiology of diverticulitis and first-ever CRC post diverticulitis from 2014 to 2019. Prevalence of diverticulitis is higher in male, seniors, and Caucasians. Post diverticulitis, patients are twice as likely to be diagnosed with CRC. The risk of post diverticulitis CRC is higher in female, adults and African-Americans. Given the high burden of CRC, we advocate for screening for CRC after first occurrence of diverticulitis among adults.
199 Clinical and Molecular Characteristics of Early-Onset Colorectal Cancer Across Various Ethnicities
Authors: Dayah Rawan , Bilal Mohammad , Tun Nattpron , Abu-Shami Tewfeek , Booth Adam , Singh Shailendra , Parupudi Sreeram , Guturu Praveen
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) is the third most common cancer in the United States. Guidelines from the American Cancer Society recommend CRC screening at 45 years of age in average-risk patient populations. Previous studies have shown an increase in incidence of CRC in African Americans (AAs) less than 50 years of age. We aimed to examine the disease characteristics of patients with early-onset CRC (EOCRC) across different races.

METHODS:

A retrospective cross-sectional study was performed using our electronic pathology database. All patients diagnosed with CRC between January 2012 and September 2018 were included. Data regarding patient demographics, co-morbid conditions and patient presentation was noted. In addition to information regarding the location, staging and molecular features of CRC.

RESULTS:

A total of 627 patients with CRC were identified. Out of these, 117 (18.6%) were younger than 50 years of age (EOCRC). Table 1 compares the baseline characteristics of patients across different races. The mean age of onset of CRC was significantly lower in Hispanics compared to Caucasians [56.6 years vs 61.6 years, P value = 0.0002] and AAs [56.6 years vs 60.2 years, P value = 0.01]. The clinical and molecular features of CRC across different racial groups are summarized in Table 2. The proportion of patients with early-onset CRC was higher in Hispanics as compared to Caucasians (27.9% vs 16.0%, P value = 0.004) and AAs (27.9% vs 16.9%, P = 0.03). On a multivariate analysis after adjusting for confounders, the proportion of Hispanics with early-onset CRC was significantly higher as compared to Caucasians [OR: 2.2, (95% CI 1.3–3.7), P value = 0.003]. Hispanics were less likely to harbor BRAF mutation as compared to Caucasians (5.1% vs 13.1%, P-value: 0.05), while Hispanics were more likely to have mutations in MSH-6 (100% vs 91.3%, P-value: 0.01) and MSH-2 (100% vs 94.2%, P-value = 0.05) as compared to AAs.

CONCLUSION:

Our study shows that proportion of patients with early-onset CRC is higher in Hispanics as compared to Caucasians and AAs. In addition, there are unique molecular features specific to CRC across various racial groups. Our findings raise concerns that there might be knowledge gaps regarding early-onset CRC amongst minority populations. Further large multi-center studies are needed to better understand the unique clinical and molecular characteristics in early-onset CRC in minority populations.
213 Outcomes of Fecal Microbiota Transplants in High Risk Elderly Populations
Authors: Luo Yuying , Tixier Emily , Grinspan Ari
Published: October 2019

INTRODUCTION:

Recurrent Clostridioides difficile infection (CDI) in the elderly is associated with significant morbidity and mortality. Fecal microbiota transplant (FMT) is a safe and effective option for treating CDI; however, this is less clear for high risk elderly populations such as patients with severe or fulminant CDI, inflammatory bowel disease (IBD) and immunocompromised patients.

METHODS:

This is a retrospective study following patients 65 years of age or older who received at least one FMT between 2014 and 2019 at one high-volume academic center. Baseline patient characteristics were compared using Fisher's exact test or independent sample t-tests. Outcome measures included recurrence rates (early defined as <12 weeks, late defined as >12 weeks), adverse events, and subgroup analysis of high risk populations.

RESULTS:

75 patients (72% female) were included with a mean age of 76.4 ± 8.3 years and Charlson Comorbidity Index score of 5.4 ± 2.4. 20 out of 75 patients (26.7%) developed recurrent CDI with 18 patients (90%) recurring <12 weeks and 2 patients (10%) recurring >12 weeks from FMT. Use of antibiotics post-FMT was the only significant predictor associated with recurrence (P = 0.02) amongst analysis of pre- and post-FMT characteristics. Our cohort included 46 high risk patients: 15 immunocompromised, 8 IBD and 23 severe or fulminant. CDI recurrence occurred in 13 (28.3%) patients of this cohort including 4 out of 15 immunocompromised, 3 out of 8 IBD and 6 out of 23 severe or fulminant patients. The adjusted recurrence rate was 33.3% accounting for two patients with fulminant CDI who required colectomy and five patients who died from CDI-related complications. Serious adverse events were recorded in 16 patients (21.3%) across our entire cohort including 12 readmissions for recurrent CDI, three episodes of post-procedural hypotension, and one perforation during FMT.

CONCLUSION:

Overall, FMT is a safe and effective treatment modality for CDI in high-risk elderly populations including those with severe or fulminant CDI. Our cohort contained a significant portion of high-risk patients (61.3%) which likely accounts for our higher recurrence rate compared to that which is reported in literature. The majority of adverse events related to readmissions for CDI. Further studies of high risk populations is warranted.
214 12-Month Post Marketing Safety Surveillance Data of Chewable Inulin Fiber
Authors: Lacy Brian E. , Epstein Michael S. , Corsino Patrick
Published: October 2019

INTRODUCTION:

Most Americans consume only half of the daily fiber recommended by the National Academy of Medicine, which is 25 grams per day of fiber for women and 38 grams per day for men. Fiber has been shown to promote bowel regularity, lower cholesterol, control blood sugar, and maintain body weight. To fill the “fiber gap” many patients use fiber supplements. There is a perception that fiber supplementation can lead to bloating and excess gas production, among other adverse events. This study aimed to examine whether or not a pattern of adverse events was associated with chewable inulin fiber (CIF).

METHODS:

A call-in number for reporting adverse events (AEs) was provided on bottles of a specific brand of CIF. An independent call center with pharmacovigilance-trained health care personnel in accordance with the FDA and global regulatory guidelines on properly reporting AEs was retained to receive and record customer AEs. The AEs for this study were collected and processed from January 1, 2018 to December 31, 2018.

RESULTS:

An estimated 809,259 individual patients consumed CIF during the surveillance. An analysis of the data showed that there were no serious AEs reported. Additionally, the self-reporting rate of non-serious AEs was low, with only 23 non-serious events reported by 21 individuals; a rate of 2.8 per 100,000 users. The top reported, non-serious AEs were flatulence, diarrhea, and constipation; however, the rates for these were extremely low (4.9, 3.7, and 1.2 per million, respectively). Two events were reported that were classified as musculoskeletal and connective tissue disorders; however, these were considered to not be related, having no basis for biological plausibility.

CONCLUSION:

12 months of monitoring real-world use of CIF in a population of over 800,000 patients demonstrates an extremely low rate of self-reported AEs. Contrary to conventional thinking, the rate of flatulence was remarkably low (4.9 per million users), and can most likely be considered statistical background noise. These data, combined with previous RCTs, indicates that CIF is a safe and effective option for fiber supplementation.
216 Determinants of Hospital Admission in Patients With Community-Acquired Clostridium difficile Infection (CA-CDI)
Authors: Deshmukh Farah , Levy Victor , Merrell Nancy
Published: October 2019

INTRODUCTION:

Community-acquired Clostridium difficile infection (CA-CDI) is defined as Clostridium difficile infection (CDI) in patients who have not been in inpatient setting within 90 days of being tested positive for Clostridium difficile. The incidence of CA-CDI has been increasing in young individuals with no co-morbidities or recent antibiotic exposure. Recent research shows that up to 40% patients with CA-CDI need hospitalization, however, the risk factors associated with hospitalization of patients who test positive for CDI in outpatient setting has not been studied. The goal of this study is to look at patients diagnosed with CDI initially as outpatients and analyze the risk factors associated with hospitalization in these patients.

METHODS:

This study was approved by the Institutional Review Board. This is a retrospective chart review of 524 patients (189 males, 335 females, mean age 60 years) who were seen in the outpatient department from 2015 to 2018 and were tested for CDI. Inclusion criteria was patients over the age of 18 with positive C. difficile by nucleic acid amplification tests (NAATs). Exclusion criteria was prior diagnosis of C. difficile. For patients with positive C. difficile, the two outcomes selected were hospital admission within 2 weeks, and those remaining outpatients. The variables extracted from the electronic medical record included demographics, medications and co-morbidities. Utilizing a machine-learning algorithm, a Bayesian probabilistic predictive tool was constructed that evaluated a series of variables and their association with potential outcomes.

RESULTS:

Of the 524 patients that tested positive, 105 patients required admission within two weeks of diagnosis. The incidence of hospitalization among males and females was not significantly different. There was significant association between use of acid suppression medications (pantoprazole and famotidine) and risk of hospitalization for C. difficile (P-value <0.0001 and 0.002 for pantoprazole and famotidine, respectively). There was no association seen between co-morbidities such as coronary or carotid artery disease, peripheral vascular disease, diabetes mellitus and the risk of hospitalization.

CONCLUSION:

Although PPIs have been associated with increased risk of developing CDI, our study shows that acid suppression medications may also increase the risk of hospitalization for CDI. Providers should consider the risk versus benefit of continued use of acid suppression medications in patients with CDI.
217 Post Colonoscopy Diverticulitis: How Common Is It?
Authors: Shah Hardikkumar , Botros Youssef , Bhesania Siddharth , Baddoura Walid
Published: October 2019

INTRODUCTION:

Acute Diverticulitis (AD) is a common cause of hospitalization. Colonoscopy is a commonly performed outpatient procedure. There is limited data exist regarding post colonoscopy AD. There are few single center studies which discuss about post colonoscopy AD but larger studies are lacking. Our aim is to evaluate incidence, demographic factors, clinical factors and mortality associated with post colonoscopy AD in nationwide patient population.

METHODS:

We used Nationwide Readmissions Database (NRD) of year 2014 to find patients admitted with AD. From that sample, we found patients who had underwent colonoscopy between one and four days prior to admission. AD patients with and without prior colonoscopy were compared by univariate and multivariate analysis. Chi-square or fisher's exact test was done for categorical variables while t test was used for continuous outcome. Multivariate logistic regression was done to compare in hospital mortality between two groups.

RESULTS:

There are total 235847 weighted admissions in year 2014 with AD out of which 797 (0.3%) patients had underwent colonoscopy between one and four days prior to admission. Univariate analysis showed that patients who are male and with age above 65 were significantly more associated with post colonoscopy AD. It also showed that patients with post colonoscopy AD had significantly higher mortality and total hospitalization charges (Table 1). In Multivariate analysis, patients with liver disease (Odds Ratio 1.5, P 0.02), kidney disease or electrolytes abnormalities (Odds Ratio 3.9, P < 0.0001), age more than 65 (Odds Ratio 22, P < 0.0001), and those who had recent weight loss (Odds Ratio 3.8, P < 0.001) had higher in hospital mortality while obese patients (Odds Ratio 0.7, P 0.008) had significantly lower in hospital mortality.

CONCLUSION:

Incidence of AD between 1 to 4 days after colonoscopy is 0.3% (3/1000) which is more commonly seen in elderly patients. Although a rare complication, possibility of AD post procedure should be kept in mind mainly for patients who already had history of AD in the past as second episode of AD can increase their morbidity and mortality significantly. Also risk stratification becomes extremely important in high risk patients such as those who are more than 65 years of age, patients with liver and kidney diseases as they will have higher in hospital mortality and higher total hospitalization charges.