bluuebunny/crossref_metadata_2025 huggingface dataset:
1123 Utility of Non-Invasive Screening Tools for Assessing Liver Fibrosis in Individuals With Medically Complicated Obesity
Authors: Nath Anand , Lameda Ivanesa Pardo , Shope Timothy R. , Koch Timothy
Published: October 2019

INTRODUCTION:

Individuals with medically-complicated obesity are at risk for cirrhosis as the result of chronic nonalcoholic steatohepatitis (NASH). Several cases of acquired ornithine transcarbamylase (OTC) deficiency have been reported after bariatric surgery, and underlying liver disease is hypothesized as a risk factor. Liver biopsy has been the gold standard for diagnosis and staging of fibrosis, but it is not favored as a screening test due to cost, invasive nature of the test. Commercial blood testing for ALT may be useful for screening for NASH, while the NAFLD Fibrosis Score (NFS) has gained popularity to assess fibrosis. We hypothesize that non-invasive screening can identify both at risk individuals in whom bariatric surgery will potentially halt and reverse fibrosis as well as at risk individuals who should be monitored for signs and symptoms of postoperative OTC deficiency

METHODS:

This is a retrospective study of 593 consecutive individuals evaluated for bariatric surgery at our urban, community teaching hospital. Each individual is assessed for risk of liver fibrosis with NFS evaluated at their initial visit. ALT levels are also recorded using ACG guidelines for elevation (women > 25 U/L; men > 33 U/L). Intraoperative liver biopsies were suggested in individuals with elevated ALT levels or NFS which was > - 0.70. Steatohepatitis on liver biopsies is staged based on the NAFLD Activity Score (NAS), which in previous studies is reported to have a sensitivity of 43% to 77%. The potential correlation between NFS and NAS is assessed with simple linear regression (Statview, SAS Institute Inc.).

RESULTS:

Among the 593 subjects, 102 (17.2%) had elevated ALT. Forty-nine individuals underwent liver biopsy (6 for elevated ALT and 43 for NFS > -0.70). Table 1 shows the demographics of these patients. The mean NFS was 0.580 (SD: 1.01) and the mean NAS was 2.9 (SD 1.2). Correlation Coefficient (R: 0.025, P = .86) between NFS calculated at the initial visit and NAS on liver biopsies is not significant.

CONCLUSION:

Elevated ALT levels may be useful for assessment of risk in individuals with medically-complicated obesity. Our retrospective study has not identified a significant correlation between NFS (from routine parameters) and NAS (from liver biopsies). This finding suggests that NFS is not a sensitive non-invasive screening tool in individuals with medically-complicated obesity. Future studies can be designed to utilize ALT levels and NAS to look at the risk of developing postoperative OTC deficiency.
1127 Hepatic Blood Flow and Oxygen Delivery in Metabolic Syndrome
Authors: Zakaria Ali , Wider Michael , Selis James , Williams Michael , Marshall Michael
Published: October 2019

INTRODUCTION:

Metabolic syndrome MS is defined as the co-occurrence of metabolic risk factors for both DMII and cardiovascular disease. There is no consensus on the diagnostic criteria of the MS due to unclear pathogenesis uniting its components. We propose that compromised hepatic arterial blood supply and oxygen delivery as a response to a nutrient load in patients with MS will lead to hepatorenal activation of sympathetic overdrive, which can be the single common factor in MS pathogenesis

METHODS:

This prospective case-control study included patients 18-65 y/o diagnosed with MS and control healthy individuals with BMI 30-50 kg/m2. Subjects underwent an initial pre-prandial US, followed by drinking 8 oz of TwoCal high calorie drink immediately and in 15 mins. A second post-prandial US was performed 15mins after completing the second drink. US using the standard procedure for mesenteric artery examination for intestinal ischemia was performed to evaluate the diameter, velocity and flow of the superior mesenteric artery, hepatic artery, and portal vein. Both US images were interpreted by experienced diagnostic US radiologist. The results were analyzed using t-test

RESULTS:

Ten MS patients (age 55 ± 8) and ten control subjects (age 38 ± 11) with BMI 30-50 kg/m2 (37.6 ± 6.1) were compared. The relative change in blood flow in response to the nutrient load was reflected by the ratio of post- to pre-prandial readings. Total hepatic blood flow was calculated as the sum of HA and PV blood flow. The mean difference between post to pre-prandial ratio of total hepatic blood flow and total blood flow in all three vessels in MS group vs control group were 1.66 ± 0.57 vs 1.37 ± 0.40 (P = 0.162), 1.80 ± 0.42 vs 1.42 ± 0.27 (P = 0.025); respectively. The increase in postprandial total hepatic blood was 17.65% less in MS group.

CONCLUSION:

Why some obese patients develop MS while others don't raises the question of what is different between these cohorts. Excessive eating can produce obesity by causing chronic relative hypoxia in the liver. This produces sympathetic overdrive which causes insulin resistance, hypertension and dyslipidemia. Bariatric surgeries limit contact of nutrient with the GI mucosa resulting in increased splanchnic O2 delivery to the liver and preventing the hepatorenal reflex. The relative increase in total hepatic blood flow in response to a nutrient load was less in patients with MS compared to healthy obese controls. The difference was not statistically significant. Further studies with larger sample size needed.
1129 Increased Risk of Sessile Serrated Adenomas on Initial Screening Colonoscopy in Post-Bariatric Surgery Patients
Authors: Fakhreddine Ali Y. , Lee Joy A. , Gupta Nealansh , Magavi Pooja R. , Takata Mark , Konijeti Gauree G.
Published: October 2019

INTRODUCTION:

An increased standardized incidence ratio of colorectal cancer (CRC) with longer follow-up intervals after bariatric surgery has been suggested in a large retrospective Swedish cohort study. By impacting epigenetic modifications versus de novo chromosomal mutations, the complex physiologic changes following bariatric surgery may preferentially modulate CRC risk via the sessile serrated adenomas (SSAs) pathway or conventional adenoma-carcinoma sequence, respectively. Our aim was to examine the risk of CRC precursors in post-bariatric surgery patients as compared to the general population.

METHODS:

We conducted a single center retrospective case-control study of patients age 40 to 50 at time of bariatric surgery between 2007-2019 with subsequent documented initial screening colonoscopy and pathology. Diagnostic colonoscopy or patients with a family history of CRC (1st-degree relative age< 60 years, or two 1st-degree relatives) were excluded. 88 patients met both inclusion and exclusion criteria. Cases were matched 1:1 by age ± 2 years and gender to controls with BMI ≥ 25 undergoing average-risk screening colonoscopy during the same time period.

RESULTS:

Among cases, bariatric procedures consisted of Roux-en-Y (51%), laparoscopic gastric band placement (28%), and vertical sleeve gastrectomy (20%). Mean BMI pre-surgery was 42 kg/m2 compared to 33 kg/m2 at their initial screening colonoscopy (Table 1). Average time from surgery to colonoscopy was 4.5 years (SD 2.5 years), with 45% undergoing colonoscopy ≥ 5 years post-surgery. There was no significant difference in adenoma detection rate or BMI at time of colonoscopy between surgical and control groups. SSA detection rate was significantly higher in post-surgery patients (9.1%) compared to controls (3.9%, P < 0.01). Of all detected adenomas, SSA proportion was significantly higher in surgical (15%) vs. control patients (8.2%, P = 0.03). Rectal adenomas were more common in the surgical vs. control groups (12.3% vs 3.0%, P < 0.01), but otherwise we observed no difference in the proportion of adenomas by anatomic location or advanced adenomas. Neither group had high-grade dysplasia or CRC.

CONCLUSION:

SSAs are more common among average-risk post-bariatric surgery patients compared to average-risk non-surgical controls. By anatomic location, adenomas are more common in the rectum compared to non-surgical controls, but the overall distribution of adenomas was similar. Further studies are needed to understand the risk of CRC following bariatric surgery.
1131 A Multifaceted Weight Loss Program for Management of Obesity Related Gastrointestinal Disorders in a Community Based Gastroenterology Practice
Authors: Hawa Fadi , Gladshteyn Mark , Zolotarevsky Mitchelle , Berger Stephen H. , Corsello Paul M. , Fine Michael R. , Peters Stevany L. , Walsh John W. , Velarde Mark J. , Duda Jill E. , Gunaratnam Naresh T.
Published: October 2019

INTRODUCTION:

Obesity related gastrointestinal disorders including Non-Alcoholic Fatty Liver Disease (NAFLD) and Gastroesophageal Reflux Disease (GERD) are more frequent and usually present earlier than diabetes mellitus type 2 and cardiovascular disorders. This provides an opportunity for the gastroenterologist to intervene early with an effective weight loss therapy. We evaluated the outcomes of a gastroenterologist supervised weight loss program aimed at achieving a 10% total body weight (TBW) loss at 3 months, a known correlation with NAFLD and GERD regression.

METHODS:

Patients with NAFLD and GERD seen at the clinic between May, 2017 to January, 2019 were offered participation in a medically supervised weight loss program comprised of a calorie restricted (800 Kcal/day) meal replacement diet, supervised medical fitness program, and weekly behavioral support groups for 3 months. This was followed by monthly follow up visits with slow reintroduction of whole food plant-based or Mediterranean diet. Two-sample t-Test assuming equal variances was used for statistical analysis.

RESULTS:

One hundred and fifty-three patients presented for their baseline office visit, 56 patients dropped out within 12 weeks of enrollment, and 97 patients with NAFLD (64 patients had both NAFLD and GERD) continue to participate in the program to date. At baseline, the 97 participants (68 Females), had a mean age of 56 years, and a mean BMI of 38 kg/m2. Average percentage weight loss was (4.1% ± 3.5%), (10.5% ± 4.7%), and (13.3% ± 6.5%) at 1 month, 3 months, and 6 months follow up respectively. At 3 months, 63% of patients had lost at least 10% of TBW. Furthermore, patients who attended > 50% of the offered behavioral support groups lost 11.9% TBW at 3 months compared to 10.9% and 9.5% TBW loss for those who attended 10 - 50% and < 10% respectively. Attending > 50% of behavioral support groups was associated with a statistically significant higher TBW loss at 3 months when compared to no attendance (11.9% versus 10%, P-value = 0.042).

CONCLUSION:

Over 60% of patients who completed a 3 month follow up in a multifaceted, community based, gastroenterologist supervised, weight loss program have achieved a clinically significant TBW loss of at least 10%. Our results also suggest that incorporating weekly behavioral support groups into the program might be a useful adjunct to achieving a clinically significant weight loss in this patient population. Studies are ongoing to determine the sustainability of this weight loss over 1 year.
1138 Intragastric Balloon on Blood Pressure Reduction in a Gastroenterology Practice in Eastern Northern Carolina: A Retrospective Review
Authors: Samuel Gbeminiyi O. , Lambert Karissa , Asagbra Oghale O. , Ibegbu Eric
Published: October 2019

INTRODUCTION:

Obesity is a global pandemic and a major health concern contributing to cardiovascular disease (CVD). Cardiovascular disease (CVD) causes nearly 18 million deaths yearly. Amongst the CVD risk factors, hypertension remains the leading cause of excessive premature mortality and morbidity. The consequences of hypertension are of momentous impact on public health. It is estimated that nearly 1.5 billion adults in the world will have hypertension in the decade ahead. If this trend is not reversed, the ramifications do not bode well for the pandemic of CVD. The highest CVD hospitalization rates are clustered primarily in rural Eastern North Carolina (ENC), a pattern similar to that of all CVD death rates. Also, the prevalence of obesity and HTN in ENC are comparable. Bariatric surgery is the most effective weight (wt.) reduction intervention with short- and long-term health improvements. However, little is known about endoscopic bariatric therapy, such as intragastric balloon therapy (IGBT) on HTN improvement.

METHODS:

Retrospective chart review between January 1, 2016, and January 31, 2019, of adults who received IGBT in a GI practice in ENC. Data collection comprised patient demographics. The primary outcome was wt. reduction, expressed as kilograms lost, and % wt. loss at 3 and 6 months after IGB. The secondary outcome was the impact of weight reduction on hypertension (cut off SBP/DBP: 140/90) post-implantation at 6 months. Logistic regression analyses were performed to determine the association between weight and hypertension at 6- months post-implantation. Statistical analysis was done using STATA 14.

RESULTS:

See Table 1 for baseline demographics. Wt. was found to be a significant factor in determining SBP given the JNC 8 guidelines (β = 0.0140, P < 0.000). These results indicate that for every increase in wt., the log odds of SBP will increase by 1.4%. These results indicate that for every increase in wt, the log odds of hypertension will increase by 1.2%. No association was shown between wt. and DBP. 11 patients requested early removal (IGB removal in the first two weeks to one-month post-implantation). Of the 11, 10 patients reported intolerable side effects, such as intractable nausea, vomiting, diarrhea, and abdominal pain; and one patient reported a sensation of a foreign body.

CONCLUSION:

There was a statistically significant wt reduction post-implantation. Statistically significant correlation was found between wt reduction and changes in SBP at 6 months post-implantation.
1139 High Prevalence of Non-Alcoholic Steatohepatitis in Veterans With Non Alcoholic Fatty Liver Disease Undergoing Sleeve Gastrectomy
Authors: Rabiee Atoosa , Pavle Alexis , Paal Edina , Brody Fredrick , Papademetriou Marianna
Published: October 2019

INTRODUCTION:

Sleeve gastrectomy leads to significant weight loss and improves features of metabolic syndrome. The prevalence of non-alcoholic fatty liver disease (NAFLD) in the general population undergoing bariatric surgery is reported at 84% -95%. Prevalence of Non Alcoholic Steatohepatitis (NASH) in this population is 25%- 50%. Around 10% of these patients have advanced fibrosis at the time of surgery. The prevalence of NAFLD/NASH or advanced fibrosis in the veteran population undergoing sleeve gastrectomy has not been previously reported. NASH may be underrecognized prior to time of surgery, particularly if there are no associated laboratory abnormalities. This study aims to assess the prevalence of NASH and advanced fibrosis in veterans undergoing sleeve gastrectomy.

METHODS:

This is a retrospective study of 39 patients who underwent sleeve gastrectomy between January 1, 2018- April 30, 2019 at a Veterans Affairs Hospital. Patients with known alcohol use, cirrhosis or without liver biopsy at the time of surgery were excluded. A single pathologist reviewed the liver biopsies and provided a NASH Activity Score (NAS) for each sample. A Fib 4 score and NAFLD fibrosis score were calculated. Summary statistics was used to determine the prevalence of NAFLD at time of surgery.

RESULTS:

Patients baseline characteristics are outlined in Table 1. Only 13% of patients had an abnormal ALT at the time of surgery. There was no evidence of liver synthetic dysfunction with normal INR, bilirubin and albumin. Median NAFLD fibrosis score was -0.8 and median FIB-4 was 0.9 which rules out advance fibrosis. 59% of patients had NAFLD and 61% of these patients had evidence of NASH on pathologic exam. Advanced fibrosis was seen in 8% of patients. 70% of patients had NAS score of 4 or below. Percentage of steatosis, inflammation, ballooning and fibrosis score have been summarized in Table 2.

CONCLUSION:

More than half of our NAFLD patients had characteristics features of NASH on biopsy. This is higher than reported in the general population and close to what has been reported in diabetic patients. However, prevalence of diabetes in the NAFLD patients was only 26%, which would not explain the high number of NASH patients. Advanced fibrosis was only seen in 8% of patients at the time of surgery, which is similar to previous studies. This is the first study to our knowledge to report high prevalence of NASH in a VA population undergoing surgery in the absence of high rate of concomitant diabetes.
1144 A Prospective Study on PPI Response in Children With Eosinophilic Esophagitis
Authors: Bose Paroma , Albright Eric , Idrees Muhammad T. , Sawyers Cindy L. , Perkins Anthony , Gupta Sandeep , Hon Emily
Published: October 2019

INTRODUCTION:

Proton pump inhibitors (PPIs) are now considered a treatment option for eosinophilic esophagitis (EoE). High-dose PPI (HDPPI) response rates are 23-63% in pediatric studies. Our primary aim was to determine PPI response rate in children with EoE. Secondary aim was to determine clinical, endoscopic, or histologic characteristics that impact this PPI response.

METHODS:

A prospective cohort study of children was conducted. Demographics, clinical history, child and parent-proxy Pediatric EoE Symptom Scores version 2 (PEESSv2.0), EoE endoscopic reference scores (EREFS), and histology scores were collected at endoscopies before and after at least 8 weeks of HDPPI. EoE was defined as ≥ 15 eosinophils/high powered field (eos/hpf) on biopsy from any level of the esophagus on initial endoscopy with symptoms of esophageal dysfunction. Children with < 15 eos/hpf on repeat endoscopy were classified as PPI-responsive (PPI-R) EoE, and ≥ 15 eos/hpf were classified as PPI-nonresponsive (PPI-NR) EoE.

RESULTS:

72 children were enrolled from 2015 to 2018 (58% male; mean 9.4 years). 40 children (56%) met criteria for EoE, and 25 had endoscopies before and after HDPPI. 11 refused HDPPI, and 4 were lost to follow-up. 32% (8/25) of children had PPI-R EoE. Baseline demographics, clinical history, child and parent-proxy PEESSv2.0 scores, parent-proxy dysphagia subdomain scores, EREFS, and histology scores were similar in PPI-R and PPI-NR EoE patients. Baseline child dysphagia scores were worse in PPI-NR EoE patients than in PPI-R EoE patients (17.8 v 11.0, P = 0.012). Parent-proxy PEESSv2.0 scores improved in PPI-R and PPI-NR EoE groups after HDPPI (P = 0.046, P = 0.005). Child PEESSv2.0 scores, and parent-proxy and child dysphagia scores improved significantly in the PPI-NR group after HDPPI (33.2 to 19.1, P = 0.006; 18.9 to 8.9, P = 0.004; 17.8 to 9.2, P < 0.001). EREFS improved in PPI-R and PPI-NR EoE groups (P < 0.001, P = 0.030), but had more improvement in the PPI-R group (P = 0.017). Children in the PPI-R group had improvement in degranulation and basal cell hyperplasia compared to the PPI-NR group (P = 0.016, P = 0.008).

CONCLUSION:

32% of children with EoE responded to HDPPI therapy. No characteristics predicted PPI response. As anticipated, endoscopic and histologic features of EoE improved more in the PPI-R group. We did not expect to find that child and parent-proxy symptom scores would improve significantly in the PPI-NR group. The value of these symptom scores and their role in EoE management should be further studied.
1145 Are There Predictors of Eosinophilic Esophagitis in Children Undergoing Initial Endoscopy for Esophageal Dysfunction?
Authors: Bose Paroma , Albright Eric , Idrees Muhammad T. , Sawyers Cindy L. , Perkins Anthony , Gupta Sandeep , Hon Emily
Published: October 2019

INTRODUCTION:

Eosinophilic esophagitis (EoE) is a clinicopathologic disease that requires endoscopy for evaluation. At this time, we do not have non-invasive methods to differentiate between EoE and non-EoE causes of esophageal dysfunction. The Pediatric Eosinophilic Esophagitis Symptom Score version 2 (PEESSv2.0) is an EoE-specific validated outcome metric for use by children and parents/caregivers, but its use has not been explored outside of EoE. Our primary aim was to determine if demographics, clinical history, or PEESSv2.0 scores can differentiate between EoE and non-EoE patients in children undergoing initial esophagogastroduodenoscopy (EGD) for esophageal dysfunction.

METHODS:

A prospective cohort study of pediatric patients was conducted at our center after IRB approval. Children ages 1-18 undergoing initial EGD for esophageal dysfunction were enrolled. Demographics, clinical history, and child self-report and parent-proxy report PEESSv2.0 symptom scores were collected at the time of endoscopy. Esophageal biopsies were reviewed by two blinded pathologists. EoE was defined as ≥ 15 eos/hpf seen in any level of the esophagus on biopsy with symptoms of esophageal dysfunction. Non-EoE was defined as < 15 eos/hpf.

RESULTS:

72 children were enrolled in the study from 2015 to 2018 [58% (42/72) males; mean age 9.4 years; age range 1-17 years]. 56% (40/72) had ≥15 eos/hpf on esophageal biopsy and met criteria for EoE. 43% (31/72) had <15 eos/hpf and were labeled non-EoE. Children with EoE trended towards being older than non-EoE patients (mean age 10.4 vs 8.3 years, P = 0.070). Children with EoE were more likely to be male than non-EoE patients (70% vs 45.2%; P = 0.051). Presence of personal or family history of atopy did not differ between these groups. Non-EoE children and their parents had higher (worse) mean PEESSv2.0 total scores than those with EoE (P = 0.001 for child-report and P = 0.049 for parent-proxy). PEESSv2.0 dysphagia subdomain scores (child and parent-proxy) did not differ between EoE and non-EoE groups.

CONCLUSION:

Children with EoE tended to be older and of male gender than non-EoE patients. Personal or family history of atopy did not increase likelihood of diagnosing EoE. Interestingly, the total PEESSv2.0 scores were worse in non-EoE group compared to EoE group. We plan to explore this unexpected finding by analyzing PEESSv2.0 subdomains and compare PEESSv2.0 with other EoE outcome metrics. These data may help stratify likelihood of EoE prior to subjecting a child to initial endoscopy.
1148 Radiation Exposure in Pediatric Population During Endoscopic Retrograde Cholangiopancreaticography (ERCP)
Authors: Ramireddy Srinivas , Subramanian Sruthi K. , Patil Prithvi , Davee Tomas , Badillo Ricardo , Thosani Nirav
Published: October 2019

INTRODUCTION:

Radiation exposure during ERCP has been well studied in adult population but not specifically in the pediatric population. Use of fluoroscopy during ERCP exposes patients to ionizing radiation with potential for deleterious health consequences including risk of malignancy in future. Based on recent studies, fluoroscopy time (FT) is considered as an imperfect measure of radiation exposure. There are other factors like DAP (dose area product), effective dose (ED), Radiation dosage (RD), which need to be considered in assessing the radiation exposure to patients. The primary aim of this study is to assess the overall radiation exposure to pediatric population during ERCP and to determine if there is a difference between the dose received between adult population and pediatric population.

METHODS:

All procedures performed at our center between 2015 and 2017 were included in this study. Most of the ERCP’s were performed by one high volume endoscopist performing >200 ERCP’s per year in adult population. All ERCPs were performed in the same fluoroscopy unit equipped with an undercouch x- ray tube, collimator, an overcouch image intensifier and image receiver, and a digital image system allowing automatic brightness/exposure control and last image hold. ERCP-associated radiation data are automatically recorded in preinstalled manufacturer-provided software in an operator console unit. This unit automatically records FT (minutes), total radiation dose (TRD) (mGy), and DAP (Gy-cm2). DAP provides an easily measurable estimate of the total radiation delivered to patients undergoing ERCP. Fluoroscopy equipment was entirely operated by the endoscopist.

RESULTS:

Total of 143 pediatric patients were included in the study (n = 143). Mean age was 15.2. The overall median FT was 1.4 minutes. The overall median TRD was 25.375 mGy. The overall median DAP was 6.077 Gy-cm2. The overall ED received by patients during ERCPs was 1.58002 mSv. Age group < =10 appeared to have received less ED and TRD compared to age group 11-18. When compared to adult population, pediatric age population are exposed to more ED and DAP.

CONCLUSION:

Radiation exposure during ERCP should be kept to minimum and there is a strong need to create more awareness among endoscopists about how to use to different settings (by selecting a low frame rate and magnification setting, by using collimation, etc) with newer fluoroscopy machines which can decrease the overall radiation exposure.
1150 Safety, Feasibility, and Cost-Effectiveness of Pediatric Gastrointestinal Procedures at an Outpatient Endoscopy Center
Authors: Kunde Sachin , Chopra Sana , Arora Monica , Hutzenbuhler Megan , Saini Angelie , Sachdeva Neeraj K.
Published: October 2019

INTRODUCTION:

Pediatric endoscopic procedures are traditionally performed in hospital-based endoscopy centers or operating rooms due to safety concerns. However, the healthcare costs of these pediatric procedures are significantly higher in the hospital setting. Current healthcare environment necessitates safe, effective, and a cost-effective approach for pediatric endoscopic procedures. We implemented specific patient selection criteria for pediatric gastrointestinal procedures at our ambulatory endoscopy center. We report 15-month data on the safety and feasibility of performing pediatric gastrointestinal procedures at an outpatient endoscopy center. We also evaluated the cost of these procedures at our center compared to the hospital-based endoscopy centers.

METHODS:

We conducted a retrospective chart analysis of pediatric endoscopic procedures performed at our ambulatory center over the last 15 months (February 2018 to May 2019). Sedation was provided by certified registered nurse anesthetists using propofol. We used inclusion and exclusion criteria as defined by our QA committee. In addition to standard adult criteria for endoscopy, pediatric-specific criteria included: age >6 years, weight > 22kg, avoidance of documented anaphylactic reaction to soy or egg, and inclusion of ASA I or II only. Adverse events were defined as cardio-respiratory distress indicated by use of the bag and mask ventilation, airway intubation or transfer to a hospital due to respiratory distress. Cost analysis data were obtained from the NC Blue Cross Blue Shield treatment cost estimator tool which is based on historical BCBSNC claims data.

RESULTS:

Overall 316 pediatric patients underwent procedures at our endoscopy center, of which 271 underwent upper endoscopy and 90 underwent colonoscopy. The average patient age was 13 years (range 6-20 years) and 44% were males. 38% of patients met ASA I criteria. None of the patients experienced any adverse events. The average cost of upper endoscopy with biopsy at our center was $750 (+/-100) compared to $4000 (+/-500V) at the hospital. The average cost of colonoscopy with biopsy at our center was $1250 (+/-50) compared to $5000 (+/-500) at the hospital-based endoscopy center.

CONCLUSION:

Performing pediatric gastrointestinal endoscopic procedures at an ambulatory center is feasible and safe, as long as appropriate patient selection criteria are used. Performing pediatric procedures at an ambulatory center is highly cost-effective compared to performing procedures at a hospital.
1152 Financial Relationships of Gastroenterology Guideline Authors: Analysis of Sunshine Act CMS Open Payments Database
Authors: Shah Raj , Numan Laith , Chandar Apoorva K. , Maruggi Chiara , Alabdulwahhab Motib , Chauhan Mahak , Davitkov Perica , Falck-Ytter Yngve
Published: October 2019

INTRODUCTION:

There is a lack of data in regards to industry financial relationship in gastroenterology. The Sunshine Act CMS Open Payment Database is a national program that increases the transparency of financial relationships between physicians and industry. Per the 2011 Institute of Medicine standards for guidelines, an increased effort is being placed on minimizing conflicts of guideline authors. We aimed to delineate the financial relationships between industry and guideline authors in gastroenterology using the Sunshine database.

METHODS:

Guidelines and guideline authors using GRADE methodology from American Association for the Study of Liver Disease, American College of Gastroenterology, American Gastroenterology Association, and American Society of Gastrointestinal Endoscopy societies from 2013 to October 15, 2018, were abstracted. We searched the Sunshine database for each author the year the guideline was published and the year before the guideline publication date, when available. Only general payments were examined. Authors who published many guidelines in the same year were only counted once when calculating general payments.

RESULTS:

562 authors were included. Of those, a total of 249 guideline authors were found on the open payment website with available data. 238 (95.5%) received general payments during the time of their publication, and 176 (73.9%) of them got more than $500. 238/562 (44.3%) of total authors received general payments. Payments made for consulting amounted to $2,279,469 (39.5%). A total of 5,883 payments were made. The total amount of general payments for all authors is $5,775,403. The average payment per author was $24,266.

CONCLUSION:

Collectively, guideline authors received at least $5,775,403 from industry relationships between 2013-2018 and three quarters received over the amount $500. The largest amount of money was spent on consulting fees. Less than half of Gastroenterology guideline authors receive payments from industry during the time they are working on guidelines, but as a scientific community, we can improve in minimizing external influences in the guideline development process.
1153 Conflict of Interest in Gastroenterology Guidelines: A Lack of Transparency
Authors: Shah Raj , Numan Laith , Chandar Apoorva K. , Maruggi Chiara , Alabdulwahhab Motib , Chauhan Mahak , Davitkov Perica , Falck-Ytter Yngve , Sultan Shahnaz
Published: October 2019

INTRODUCTION:

In 2011, the Institute of Medicine (IOM), now the National Academy of Medicine (NAM) published standards for developing clinical practice guidelines, highlighting the necessity of transparency and the importance of minimizing conflict of interest (COI) in guideline authors. We aimed to assess the prevalence of COI and transparency of reporting COI in gastroenterology guidelines.

METHODS:

Guidelines using GRADE methodology from American Association for the Study of Liver Disease, American College of Gastroenterology, American Gastroenterology Association, and American Society of Gastrointestinal Endoscopy societies from 2013 to October 15, 2018, were abstracted. We reviewed each guideline to determine if COI information was provided and the prevalence of COI among guideline authors. We further categorized conflicts as “research/academic funding” (not directly paid to the individual) or “other.” This other category included disclosures such as speaker's bureau, stocks, consulting, advisory board, honoraria, non-research funding, and industry-sponsored continuing medical education activities. Funding from government or nonprofit organizations were excluded.

RESULTS:

A total of 78 guidelines were reviewed. Of these, only 11 (14.1%) provided no or vague information on COI; ten guidelines (12.8%) provided only general statements about COI without details informing the reader if they were present or not and one guideline did not report COI. Across the 78 guidelines, 823 authors were identified. When COI was examined at the individual guideline author level, 222/823 authors (27%) had reported COI. The total number of conflicts for all guidelines across all authors was 816 and the majority (79.5%) of them were reported as “other” conflicts such as speaker’s bureau, consulting, advisory boards and honoraria.

CONCLUSION:

During 2013-2018, approximately 14% of Gastroenterology guidelines did not fully inform their readers about COI and about 1 in 4 gastroenterology guideline authors self-reported as having potential conflicts. As this is based on self-report, underreporting could possibly inflate this issue. We suggest that societies producing guidelines consider a more rigorous COI management process to mitigate the perceived risk of biased guidelines and be more transparent about reporting COI.
1156 Trends in Matching in GI Fellowship: Data From NRMP
Authors: Kesar Varun , Lakhani Komal , Taylor Savannah , Kanth Rajan , Mouchli Mohammad , Kesar Vivek
Published: October 2019

INTRODUCTION:

Gastroenterology (GI) fellowships continue to be highly sought after by internal medicine residents interested in pursuing subspecialty training. A recent study reported that GI fellowships had the highest number of applicants per available position among the major subspecialties. The National Resident Matching Program (NRMP) Specialties Matching Service® (SMS®) conducts Matches for fellowship positions. NRMP identified ten applicant characteristics that contribute to Match success: number of contiguous ranks, number of specialties ranked, USMLE scores, number of research, work, and volunteer experiences, number of publications, and Alpha Omega Alpha Honor Medical Society membership. We aim to compare the temporal trends in these characteristics by comparing data in 2011 and 2018.

METHODS:

Data was collected from the NRMP booklet: charting outcomes in the match in 2011 and 2018. Four applicant groups are included in the report: U.S. allopathic medical school graduates (USMG), U.S. citizen international medical school graduates (US-IMG), Non-U.S. citizen international medical school graduates (Non-US-IMG), and U.S. osteopathic medical school graduates (DO) We compared various variables from 2011 and 2018 including the number of applicants and positions offered, type of applicants, USMLE mean scores, research experiences.

RESULTS:

The total number of positions offered in 2011 was 383 and the number of applicants were 648; making 1.7 application per position, the most per any other IM subspecialties. In comparison, the total number of positions offered in 2018 was 496 and the number of applicants were 758; making 1.5 applicants per position. Percentage of matched USMG, US-IMG, Non-US-IMG and DOs in 2011 and 2018 were as follows: 65 vs 61%, 7 vs 9%, 18 vs 23%, 4 vs 5 %. The mean step 1, step 2, step 3 for USMG has increased as follows 223 to 235, 230 to 248, 221 to 235. A similar trend is observed in other groups. The mean number of scholarly activity have increased significantly in USMG (3 to 11), US-IMG (6 to 13) Non-US-MG (9 to 21) and in DOs 5 to 10.9.

CONCLUSION:

The total number of fellowship positions has increased, however positions per candidate have been relatively stable. There has been a slight increase in the proportion of Non-US-IMG (∼5%), US-IMG (2%), and DOs (1%) in GI fellowship match in the year 2018 as compared to 2011. However, a slight decrease in USMG (4%) was noted. There has been increase in USMLE step scores and scholarly activity in all groups.
1157 Given the Offer of GI EConsultation, PCPs Decline: A Prospective Study
Authors: Moore Danielle , Hays R. Ann , Dowdell Kimberly
Published: October 2019

INTRODUCTION:

eConsult is an asynchronous communication using an electronic chart by primary care physicians (PCP) to specialists that involves sharing of patient-specific information and for clarification or guidance regarding clinical care. It can provide the PCP with timely access to specialist consultation for evaluation, treatment and management of the PCPs patients. It could benefit patients by saving time and costs of travel to and copays of unnecessary clinic visits. Subspecialities at our institution provide eConsults whereby the PCP asks specific questions of the specialist through Epic; only the PCP has a face to face (F2F) visit with the patient but the chart is available to the specialist. We aimed to determine whether eConsultation would improve the satisfaction and outcomes for PCPs and their patients if the PCP was offered an eConsult immediately after their patient was scheduled with a F2F visit with gastroenterology (GE).

METHODS:

Prospective study offering eConsults for all referrals made to GE at a single U.S. based tertiary care academic medical center from Nov 1,2018 to May 1,2019 evaluating 4 segments of eConsultation (query, response, action, resolution) for 6 high frequency topics (abdominal pain, GERD, chronic constipation, diarrhea, iron deficiency anemia and Barretts esophagus). Scheduling notified us when an appointment was made for these indications; the PCP was then offered an eConsult by Epic staff message and email.

RESULTS:

43 consults met study criteria. The mean time after a F2F referral was scheduled to eConsult offer was 42 hours. PCPs placed eConsult order following 6.9% of eConsult offer. The average response time for eConsult completion was 56 hours as compared to 109.1 days wait for a F2F consultation in digestive health clinic.

CONCLUSION:

We found that when offered the opportunity for eConsultation, PCPs did not place an eConsult order 93% of the time. The literature and studies at our institution indicate eConsult has the potential to improve timely access to specialty care, save costs for the patient and optimize appropriate testing prior to F2F consultations. The poor response to our offer for eConsult could be attributed to lack of marketing, high PCP patient volumes, excess email and/or epic staff messages; or lack of PCP familiarity with the eConsult model. Additionally, patients may prefer F2F visits. With rising demand for GI consultation anticipated in the next decade, further research and/or modification of the eConsult model is needed.
1159 Tweeting the Meeting: Analysis of Twitter Use During the Digestive Disease Week DDW 2019
Authors: Azawi Muaataz , Vijayasekar Kavitha , Homsi Maher , Alwan Manar , Syed Umer , Walfish Aaron
Published: October 2019

INTRODUCTION:

The DDW is an international gathering of physicians around the globe in the fields of GI. Collectively sponsored by few of the largest GI societies. Nowadays, social media is widely used to deliver information and business marketing. Twitter is a social network site that rapidly gained worldwide popularity. With over 300 million users, and over 500 million Tweets sent daily, there is a great opportunity to spread ideas to a global audience. In this study, we are aiming to analyze the use of Twitter during DDW.

METHODS:

The Symplur Signals, a specialized healthcare social media analytics platform was used to analyse the hashtag #DDW19, the official hashtag of the DDW 2019 meeting. The analysis was conducted on tweets during the meeting days between May 18-21, 2019. The number of tweets, participants, impressions, average tweets per hour and average tweets per participant was determined. Advanced search on Twitter was also conducted using the hashtag #DDW19 with time frame between May 18-21. The resulted tweets were sorted by category “top tweets”. The top 50 tweets were categorized by content to scientific, social, administrative, industry promotion, or irrelevant.

RESULTS:

DDW 2019 had over 14,000 attendees from around the world. The number of people who participated in the hashtag #DDW was 3,924 (28% of the attendees) sending 15,350 tweets during the meeting days, with an average of 4 tweets per participant and 160 tweets/hour, leaving 71.594 million impression. The hashtag activity reached a peak of 4,815 tweets on the 2nd day of the meeting, May 19th. 60% of the top tweets were from physicians, 10% by medical journalist, and 30% by medical society/organizations. 42% of the top 50 tweets had social content such as group photos or appreciation of other presenters. Whereas 40% were scientific content. However administrative tweets were 10%. Only 8% of content was industrial promotions. There were no irrelevant tweets.

CONCLUSION:

Social Media has become the most effective medium to reach an enormous audience. With over 71 Million impressions produced during the recent DDW. Twitter has successfully promoted the event worldwide and disseminated medical information in a quick and cost-effective method. It has communicated to millions of individuals, including non-medical professionals, in a way that is difficult for traditional media sources to achieve. In order to create a more informative and influential post, it is encouraged that users tweet more on scientific and medical contents.
1167 Internal Medicine Residents’ Perspective on Gastroenterology Rotation: An Insight From a Survey
Authors: Gboluaje Temitayo , Pantangi Pramod
Published: October 2019

INTRODUCTION:

Studies evaluating the Internal Medicine (IM) residents’ perspective on the attributes of Gastroenterology (GI) rotation are lacking. Inadequate knowledge of residents’ perspective can create a disconnect between residents’ expectations and experience during the rotation, leaving some residents on GI rotation disenchanted. We surveyed IM residents in our residency program and present our findings.

METHODS:

A paper questionnaire was distributed to IM residents at Morehouse School of Medicine Internal Medicine Residency program. The questions included in the survey gauged residents’ years in training, prior experience in GI rotation, the best and least desired aspects of the GI rotation and additional opinions as mentioned in the survey. The survey responses were analyzed for significant findings.

RESULTS:

We distributed the survey to 63 residents and received 51 responses. Of those that responded, 41% are in 1st, 31% in 2nd and 28% in 3rd year of training. 51% already completed GI rotation. Of those that already completed GI rotation: the statistical mode showed favorability rating of their experience was 9 on a scale of 1-10 with 10 being the most favorable; 62% rated case based learning as the best aspect of their experience; 42% rated didactics as the least desired aspect; 85% considered a length of 1 month to be about right for the rotation; 65% believed they had enough subspecialty training during their GI rotation; 35% and 39% considered 1-2 hours daily adequate for watching endoscopy and didactics respectively; 42% preferred 2-3 hours daily for case based learning; 31% believed the rotation increased their interest in GI but only 19% were considering a career in GI; 85% would like to rotate again. Of those that have not rotated through GI: using statistical mode, 72% would like the opportunity to rotate; 44% anticipate experiencing GI case-based learning the most and 44% anticipate watching endoscopy; 44% and 28% consider 1-2 hours daily adequate for didactics and case-based learning respectively; 16% are considering a career in GI.

CONCLUSION:

Gastroenterology rotation continues to be well coveted amongst IM residents. According to our findings, residents rotating through GI most favored case-based learning with didactics being least favored. We recommend that more emphasis be placed on case-based learning during GI rotation with an approximate daily time limit of 2-3 hours and allot an approximate 1-2 hours for other aspects of daily learning like didactics and watching endoscopy.
1168 Time Spent on Ambulatory Electronic Health Records Outside of Scheduled Work Hours by Gastroenterology Physicians
Authors: Ramrakhiani Nathan S. , Shetler Katerina
Published: October 2019

INTRODUCTION:

The introduction of electronic health records (EHR) has been linked to physician burnout. This study aims to quantify the time gastroenterology physicians spend on ambulatory EHR outside of scheduled work hours.

METHODS:

Data was collected for time spent in ambulatory EHR for the eight-week period 02/03/2019 - 03/30/2019. Cumulative scheduled time was calculated for each physician. Hospital-based clinical encounters and time spent in hospital-based EHR were excluded from analysis. Ratios of ambulatory EHR time to scheduled time were calculated. We also analyzed data on physician FTE status, post-fellowship experience, new patient visit time interval, and correlated these data with the aforementioned ratio. P-values < 0.05 were considered significant. This study was reviewed by our Institutional Review Board, and a waiver was obtained.

RESULTS:

Data was available for 41 providers; 18 providers were excluded (5 non-physicians, 3 with FTE status < 0.2, 2 pediatric gastroenterologists, 8 without available scheduled time data). Data were analyzed for 23 gastroenterology physicians with 7,373 ambulatory encounters (3465 office visits, 310 office-based procedures, and 3598 ASC) across 4 sites. The average weekly time spent in EHR was 41.30 ± 11.73 hours, and the average weekly scheduled time was 24.48 ± 7.64 hours. Correspondingly, the average ratio of EHR time to scheduled time was determined to be 1.78 ± 0.70. Part-time and full-time physicians were also compared. There was a greater proportion of males in the full-time group rather than the part-time group (90.91% vs. 58.33%, P = 0.076). In addition, there was a trend towards a higher ratio of EHR time to scheduled time for part-time physicians (1.99 ± 0.88 vs. 1.56 ± 0.36), although this was not statistically significant (P = 0.15). The only statistically significant predictor of ratio was FTE status, treated as a continuous variable; the slope of the linear regression model was -3.06 ± 0.83 (P = 0.001) and the corresponding R2 was 0.39. Neither experience, in years after fellowship, nor new patient visit interval, were correlated with ratio.

CONCLUSION:

Our data show that gastroenterology physicians spend significant time outside of their scheduled time on EHR-related tasks. More studies are needed to better understand the distribution of time across different tasks; targeted countermeasures, such automation and utilization of non-physician staff, may help reduce the burden of EHR time and, correspondingly, the risk for physician burnout.