bluuebunny/crossref_metadata_2025 huggingface dataset:
506 Impact of Colonoscopy Timing on Rifaximin in Patients With Irritable Bowel Syndrome With Diarrhea (IBS-D)
Authors: Lacy Brian E. , Lembo Anthony , Pimental Mark , Heimanson Zeev , Cash Brooks D.
Published: October 2019

INTRODUCTION:

Bowel preps for colonoscopy can cause transient changes in gut microbiota. Rifaximin is indicated as IBS-D treatment in adults. This post hoc analysis evaluated effect of time since colonoscopy on rifaximin response for IBS-D.

METHODS:

Two phase 3 studies (TARGET 1/2) comprised adults who had documented history of colonoscopy <2 y prior to enrollment for IBS evaluation; otherwise they had 1 within 30 d of signed consent. Patients (pts) were randomized to rifaximin 550 mg TID or placebo for 2 wks. Responders, grouped by time from colonoscopy to treatment start (≤60 d or >60 d), were analyzed using LOCF. Composite responders (FDA endpoint) were pts meeting weekly response criteria for abdominal pain (≥30% decrease from baseline in mean weekly pain score [range, 0-6]) and stool consistency (≥50% decrease from baseline in d/wk with Bristol Stool Scale type 6/7 stool) during ≥2 of first 4 wks posttreatment; responders for individual components also were determined.

RESULTS:

Differences in responder rates between rifaximin and placebo were observed in colonoscopy-timing subgroups (≤60 d or >60 d), with largest differences seen in >60 d group (Figure 1). Among pts who had colonoscopy >60 d prior to starting treatment in TARGET 1, a greater percentage treated with rifaximin (n=109) vs placebo (n=106) were composite (47.7% vs 34.0%; P = 0.04), abdominal pain (53.2% vs 40.6%; P = 0.06), or stool consistency (81.7% vs 63.2%; P = 0.002) responders. For colonoscopy ≤60 d prior to starting treatment, a greater percentage of pts treated with rifaximin (n = 199) vs placebo (n = 208) were composite (45.7% vs 40.9%; P = 0.32), abdominal pain (50.3% vs 42.8%; P = 0.13), or stool consistency (77.4% vs 69.7%; P = 0.08) responders. In TARGET 2, a greater percentage of pts treated with rifaximin (n = 106) vs placebo (n = 97) in colonoscopy >60 d prior group were composite (45.3% vs 32.0%; P = 0.05), abdominal pain (53.8% vs 39.2%; P = 0.04), or stool consistency (71.7% vs 61.9%; P = 0.14) responders. A greater percentage of pts treated with rifaximin (n = 209) vs placebo (n = 223) in colonoscopy ≤60 d prior group were responders, although differences were smaller: composite (47.4% vs 38.1%; P = 0.05), abdominal pain (51.7% vs 44.8%; P = 0.16), and stool consistency (75.1% vs 65.5%; P = 0.03).

CONCLUSION:

Larger differences in responder rates with rifaximin vs placebo were observed in pts in whom colonoscopy was >60 d from start of IBS-D therapy. This may be related in part to reestablishment of IBS-related gut microbiota dysbiosis; further research is needed.
513 Recent Trends in Gastroenterology and Endoscopy Related Medical Professional Liability Claims in the United States of America
Authors: Jayaraj Mahendran , Makar Ranjit , Lankarani Daisy S. , Parikh Divya , Ohning Gordon
Published: October 2019

INTRODUCTION:

In the recent years medical malpractice claims have contributed significantly to the rising cost of medical practice in all specialties in the United States by increasing the malpractice insurance premiums and costs associated with the practice of defensive medicine. Being a procedure oriented specialty, the trends in gastroenterology diagnoses and endoscopy related claims need to be studied to educate the gastroenterologists towards risk management.

METHODS:

Retrospective analysis of Medical professional liability (MPL) claims data for the years 2006-2015 obtained from the MPL association [formerly the Physician Insurers Association of America (PIAA) Data Sharing Project (DSP)] was done. Among the gastroenterology claims the presenting medical condition, operative procedure, outcomes of the claims and the costs associated with the closed claims were compared between 2006-2010 and 2011-2015 time periods to analyze the trend over the years.

RESULTS:

From 2006-2015, 90,743 MPL claims were closed . Out of all the claims, 2.07% (1879/90,743) of closed claims and 1.5% (367/24,106) of all paid claims were against gastroenterologists. In the claims against gastroenterologists, 71.0% of were dropped, withdrawn, or dismissed. Within the GI, MPL claims involving diagnostic procedures of large intestine were the most common accounting for 26% of all closed claims leading to a payment of $18,392,668 in total and $301,519 as average indemnity. Average indemnity was highest for diagnostic procedures of gallbladder and biliary tract including ERCP procedures ($484,364).This was followed by procedures involving small intestine ($336,078), large intestine ($301,519) and esophagus ($267,577). In the time frame 2006-2015, the average indemnity increased by 8.2% from $341,563 in 2006-2010 to $369,508 in 2011-2015. Amount spent on legal defense also increased by 8.7% ($44,625 vs. $48,506) in gastroenterology related claims for the respective time periods.

CONCLUSION:

Gastroenterology specialty has an increasing trend in spending on average indemnity and defense. Diagnostic procedures of the biliary tract including ERCP have the highest average indemnity among the endoscopic procedures. Adequate endoscopic training, meticulous focus on procedural indication and well informed consent might help to reduce the costs associated with claims. Further studies are needed to investigate the variables associated with this trend in gastroenterology.
514 Optimal Bacterial Surveillance Protocol for Duodenoscopes and Linear Echoendoscopes: A Comparison of Two Approaches
Authors: Lui Jennifer , Chapman Christopher C. , Waxman Irving , Siddiqui Uzma D.
Published: October 2019

INTRODUCTION:

The complex design of the elevator mechanism in duodenoscopes has been recognized as a challenge for disinfection and previously implicated as a source of clinically significant bacterial transmission. Our group has also determined the potential for harboring bacteria in elevator-containing linear echoendoscopes (1). Despite increased awareness, there continues to be a lack of definitive guidelines for routine bacterial culturing protocols for these endoscopes. Our study aims to provide a bacterial culture protocol that is cost-effective, efficient, and accurate.

METHODS:

Consecutive duodenoscopes and linear echoendoscopes (Olympus; Center Valley, PA) used at a tertiary care center were reprocessed following hospital and manufacturer protocol and dried using an automatic machine. The following morning, these endoscopes were sequentially cultured for surveillance using two different protocols. The brush protocol consisted of suctioning and dispensing sterile water through the endoscope multiple times prior to brushing eight different components of the endoscope, costs $53.40 per culture, and takes an average of 15 minutes. The swab protocol consisted of using a flocked swab to sample above, below, and around the elevator mechanism while it was in mid-position, costs $32.04 per culture and takes 1 minute to perform.

RESULTS:

A total of 292 primary cultures were collected from 17 duodenoscopes and 8 linear echoendoscopes. Of these, 146 cultures were gathered using the brush method and 146 cultures using the swab method. No endoscopes tested positive using the brush method. Two cultures (1.4%) tested positive for Enterobacter cloacae bacteria using the swab method (one duodenoscope and one linear echoendoscope).

CONCLUSION:

In our pilot study data, the swab method appeared to be superior to the brush method when evaluating the presence of residual bacteria found on duodenoscopes and linear echoendoscopes. The swab method not only detected two positive cultures not found on the brush method. Furthermore, the brush method poses a risk for environmental contamination due to the increased duration of sampling. Based on our prior published data, the swab method could potentially save our center $26,529 and 290 nursing hours annually, supporting the use of the flocked swab methods. Further prospective studies in larger sample sizes are needed to validate optimal surveillance protocols for elevator containing endoscopes.
519 Differences in Quality of Life Between Patients With Functional Dyspepsia After Endoscopy With Empiric Treatment and Placebo
Authors: Mardjo Sumardjo , Bayupurnama Putut , Ratnasari Neneng
Published: October 2019

INTRODUCTION:

Functional dyspepsia is a common health problem found in society. Few of multifactorial aspects which become the underlying cause of functional dyspepsia are anxiety and psychosocial problem. Endoscopy examination can display exact information to patient with functional dyspepsia and expected to increase patient's quality of life. It is still necessary to evaluate the advantages of endoscopy examination in improving patient's quality of life.

METHODS:

Randomized double blind controlled trial is conducted to compare between group of patient who have been given an empiric treatment and other who have been given a placebo for 2 weeks after underwent endoscopy examination in patient with functional dyspepsia. The primary outcome of this study is decrease of NDI-SF score on both of groups at the end of study which has been tested with MannWhitney test.

RESULTS:

NDI-SF score decreased significantly in group who had been given empiric treatment (P = 0.001) and with placebo (P = 0.002) two weeks after performed endoscopy. Declined numbers which appear between two groups are not significantly different (P = 0.396). Endoscopy can lower NDI-SF score in psychosocial and anxiety aspects in groups with empiric treatment (P > 0.01) and placebo (P > 0.05). declined numbers are not significantly different in both groups (P = 0.74).

CONCLUSION:

There is compelling improvement in quality of life of patients whom diagnosed with functional dyspepsia after endoscopy in both groups. These improvements are not significantly different between these groups. This study show the placebo effect of endoscopy on functional dyspepsia patient. Unsedated endoscopy procedure give a real time experience for patient. This provides an improvement in the psychosocial and anxiety components of the NDI-score which simultaneously improves the overall NDI-score. In the future, endoscopic examination can be the first line in the diagnosis and treatment of functional dyspepsia. This can occur because of the increasing number of endoscopic centers to rural hospitals. Other benefits that can be obtained from early endoscopy in functional dyspepsia is to be abble to better capture cases of anatomical abnormalities of the upper gastrointestinal tract.
524 Nurse-Administered Propofol Continuous Infusion Sedation (NAPCIS) for Colonoscopy in Difficult to Sedate Patients
Authors: Lee Hyun Seok , Kozarek Richard , Ross Andrew , Lin Otto S.
Published: October 2019

INTRODUCTION:

Certain types of patients are considered difficult to sedate for colonoscopy using standard moderate sedation drugs such as midazolam and fentanyl. These include those with a history of alcohol abuse, those who regularly use marijuana, those taking high doses of opioids, and those suffering from post-traumatic stress disorder (PTSD). In the past, these types of potentially problematic patients were commonly referred for colonoscopy under general anesthesia. We recently demonstrated that Nurse-Administered Propofol Continuous Infusion Sedation (NAPCIS) is effective and safe for the sedation of healthy patients undergoing colonoscopy. NAPCIS confers the benefit of propofol-based sedation without the added expense for anesthesia professionals. Given the higher sedative potency of propofol compared to midazolam/fentanyl, NAPCIS may also be effective in difficult-to-sedate patients.

METHODS:

We retrospectively included patients from one of four difficult-to-sedate groups who had undergone NAPCIS colonoscopy: (1) Alcohol abusers; (2) Marijuana abusers; (3) Heavy opioid users and (4) PTSD sufferers, and compared against control patients who had undergone concurrent NAPCIS colonoscopy.

RESULTS:

Compared with the control group (n = 656), the marijuana group (n = 226) required higher mean doses (adjusted for subject weight) for both fentanyl (0.4 mcg/kg vs 0.6 mcg/kg; P < 0.001) and propofol (4.7 mg/kg vs 5.0 mg/kg; P = 0.025). The PTSD group (n = 67) required higher fentanyl dosages (0.4 mcg/kg vs 0.6 mcg/kg; P = 0.009). The alcohol (n = 22) and opioid groups (n = 133) showed no differences in sedative doses compared to controls. The procedural success rates for all 4 groups were uniformly high (98.6-100.0%) and similar to that seen in the controls (99.1%). Procedure times and recovery times were similar for all study and control groups. In the control group, there were 10 mild adverse events (mild desaturation, agitation due to undersedation or transient bradycardia). There was 1 case of mild desaturation each in the marijuana, PTSD and alcohol groups, 1 case of bradycardia in the opioid group and 1 case of hypotension in the marijuana group. Statistically, there were no differences in complication rates between the controls and the 4 study groups. There were no serious complications or deaths.

CONCLUSION:

NAPCIS is a safe and effective means of providing sedation for colonoscopy in difficult-to-sedate patients, most of whom would have been referred for general anesthesia if NAPCIS was unavailable.
530 Electrolyte Shifts of NER1006 Bowel Preparation for Colonoscopy in the Elderly Are Transient and Well-Tolerated
Authors: Epstein Michael S. , Lorenzen Sarah , Franklin Howard , Cash Brooks D.
Published: October 2019

INTRODUCTION:

Bowel preparation safety is important, especially in the elderly. The 1L PEG-based bowel preparation NER1006 is indicated for colon cleansing in preparation for colonoscopy in adults. An analysis of data from a phase 3 randomized study was conducted, subgrouping patients by age (≤65 and >65 y).

METHODS:

Adults undergoing colonoscopy were randomly assigned to receive NER1006 or oral sodium sulfate (OSS; evening/morning split-dosing) with total minimum volume requirements of 64 oz (NER1006) and 96 oz (OSS). Safety assessments included monitoring adverse events (AEs) and clinical laboratory testing. Plasma electrolyte levels were measured at baseline, Day 2 (day of colonoscopy), Day 4 ± 1, and Day 9 ± 1. The safety population included all patients who received ≥1 study dose. Upper limit of normal cut-off values were 145 mmol/L (sodium), 105 mmol/L (chloride), and 5 mmol/L (potassium).

RESULTS:

The safety population included 262 (NER1006) and 265 (OSS) patients. Most patients were aged ≤65 y (NER1006, n=214; OSS, n = 217). In patients >65 y, the most common AEs were nausea (10.4%) and vomiting (8.3%) with NER1006 and decreased glomerular filtration rate (6.3%) with OSS. Mean baseline sodium levels were similar for NER1006 and OSS in patients ≤65 y (141 mmol/L) and >65 y (140 mmol/L). A greater percentage of patients >65 y with normal baseline sodium levels had high sodium levels ( >145 mmol/L) on Day 2 with NER1006 (48.9%) vs OSS (6.5%); shifts were transient and 93.5% of NER1006-treated patients had normal sodium levels by Day 4 (mean, 141 mmol/L). In patients ≤65 y in NER1006 group, 37.6% had a shift in sodium levels from normal at baseline to high at Day 2 (mean, 144.5 mmol/L) vs 3.7% with OSS; 90.9% of NER1006-treated patients had normal sodium levels by Day 4 (mean, 141.3 mmol/L). Chloride levels transiently increased from baseline in 27.7% (>65 y) and 19.2% (≤65 y) of patients at Day 2 with NER1006; 84.8% and 83.8% had normal levels by Day 4. At least 95% of NER1006-treated patients in both age groups had normal potassium levels from baseline through Day 9. Hyperuricemia was not reported in either age or treatment group. No electrolyte shifts resulted in clinical sequelae.

CONCLUSION:

NER1006 was generally well tolerated regardless of age. Transient increases in sodium and chloride levels were observed on the day of colonoscopy, but changes were not clinically meaningful and levels returned to normal in most patients by Day 4. Funding: Norgine BV/Salix Pharmaceuticals.
536 Adenoma Detection Rate Is Higher in a.m. Colonoscopies Only When Performed in Full-Day Blocks: A Systematic Review and Meta-Analysis
Authors: Nehme Fredy , Al Momani Laith , Zafar Yousaf , Alomari Mohammad , Elkafrawy Ahmed A. , King Connor
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) is the fourth leading cause of malignancy in the US. Colonoscopy remains the most accurate tool for CRC screening. Adenoma detection rate (ADR) and polyp detection rate (PDR) are important quality indicators for colonoscopy and high rates are associated with decreased post-colonoscopy CRC. Colonoscopy performed in the afternoon has been reported to be associated with lower rates of ADR and PDR, however studies remain controversial. Our aim was to perform a systematic review and meta-analysis to evaluate the ADR and PDR between morning and afternoon colonoscopies.

METHODS:

We included trials comparing ADR or PDR between morning (AM) and afternoon (PM) colonoscopies. We searched Medline, Google Scholar, and Cochrane through May 2019. Eligible studies were searched for variables of interest. All statistical analyses were performed using the R Programming Language. Pooled rates of variables were reported as Odds ratio (OR) with 95% confidence interval and heterogeneity was reported as I2statistics.

RESULTS:

A total of 14 trials were eligible and included in the analysis. Colonoscopies were performed in full-day blocks in 3 studies and in half-day blocks in 5. There was a total of 18184 subjects in the AM group and 12326 in the PM group. ADR and PDR were significantly higher in the AM compared to the PM group only when performed in full-day blocks (OR = 1.25, 1.11-1.4; OR = 1.33, 1.13-1.58 respectively). Bowel prep adequacy was similar between the 2 groups (OR = 1.08, 0.8-1.45). There was substantial heterogeneity.

CONCLUSION:

Colonoscopy quality, as indicated by ADR and PDR is only affected when performing colonoscopies in full-day blocks with lower performance in the afternoon. Endoscopist fatigue, fellow participation and quality of bowel prep are important cofounders when comparing quality metrics in endoscopy. The difference between in ADR and PDR between studies is likely multifactorial, however scheduling colonoscopies in half-day shifts may prevent endoscopist fatigue and improve performance. Given the heterogeneity of the results, definite conclusions cannot be drawn and future randomized trials are needed.
542 Gastroenterologist Sentiment Toward Artificial Intelligence (AI) in Endoscopic Practice: A Nationwide Survey
Authors: Wadhwa Vaibhav , Alagappan Muthuraman , Gonzalez Adalberto , Chandnani Madhuri , Berzin Tyler M.
Published: October 2019

INTRODUCTION:

Application of artificial intelligence (AI) in gastroenterology has been shown to improve the performance of endoscopists in several tasks including colonic polyp detection. However, little is known about how gastroenterologists perceive AI, especially with respect to its costs, ease of use, and efficacy. This nationwide survey is amongst the first to describe how practicing gastroenterologists view this emerging technology

METHODS:

In this cross-sectional observational study, an online survey was sent to practicing gastroenterology physicians and fellows across the US. This included questions about physician background as well as questions about physician understanding and perception of AI. Descriptive statistics were utilized to summarize physician sentiment toward AI. Chi-square test or Fisher's exact test were utilized to assess whether background information about physicians was correlated to their sentiment towards AI. Finally, a multivariate regression model was created to determine which physician factors were most correlated to physician sentiment

RESULTS:

Online surveys were sent by email to 330 gastroenterologists nationwide representing a variety of practice settings and experience levels out of which 124 physicians completed the survey and were included in the analysis. 86% of physicians reported interest in AI-assisted colonoscopy and 84.7% agreed that computer assisted polyp detection (CAPD) would improve their endoscopic performance. Univariate analysis showed that physicians practicing in academic centers versus private practices (P = 0.025) and physicians with less than 15 years post-fellowship experience versus physicians with more than 15 years of post-fellowship experience (P = .006) had a greater expectation of AI improving endoscopic performance. Multivariate analysis showed that post-fellowship experience of less than 15 years was the most important factor in determining whether a physician was likely to believe that CAPD would improve endoscopic performance (OR = 4.03; P = .04). The most common concerns about implementation of AI in endoscopic procedures were cost (75.2%) and development of operator dependence (62.8%)

CONCLUSION:

Gastroenterologists nationwide have an interest in the application of artificial intelligence to endoscopic procedures in gastroenterology, and many believe that this technology would improve their clinical performance. Further studies are needed to determine if AI applications in gastroenterology are cost-saving and time neutral.
545 Converting Inpatient Consults to Directly Scheduled Outpatient Procedures
Authors: Brodsky Tamara , Rubin Moshe , Karaptis John , Hussain Syed , Kim Sang
Published: October 2019

INTRODUCTION:

Hospitalized patients undergo many tests which can reveal medical issues unrelated to their primary reason for hospitalization. This can lead to consultant evaluations which are necessary, although often not urgent. We evaluated one institution's practice of hospitalized patients requiring non-urgent gastroenterology (GI) procedures. The standard was for patients to either have an inpatient procedure or follow up in clinic after discharge to be scheduled for a procedure, often weeks to months after the initial hospitalization. We instituted a new protocol for scheduling hospitalized patients directly for outpatient procedures within two weeks of discharge.

METHODS:

A protocol was developed for GI fellows consulting on inpatients with incidentally discovered heme positive stool or non-life threatening anemia at New York-Presbyterian Queens Hospital to evaluate the urgency of a GI procedure. If non-urgent, the fellow notified the patient navigators who then reviewed the pre-procedure instructions with the patient and scheduled the procedure for within two weeks of discharge. Patients returned for their procedure and subsequently were seen in the clinic for follow up.

RESULTS:

17 patients were included with 6 procedures completed. Of the 11 patients whose procedures were not completed, 7 were “no shows”, 3 had medical contraindications and 1 insurance authorization was not obtained. On average, each inpatient procedure directly costs the hospital $1,200. Conversely, each outpatient procedure yields $800. In sum, this protocol resulted in approximately $25,200 in total savings/credit for the institution.

CONCLUSION:

Incidental medical problems discovered during a patient's hospitalization can have downstream effects including additional procedures. Without a system to timely complete these procedures outpatient, there is pressure to do so inpatient. This can decrease patient satisfaction, increase length of stay, strain the endoscopy unit, and cause financial loss. We instituted a protocol to ensure hospitalized patients requiring non-urgent GI procedures were directly scheduled for that procedure within two weeks of discharge without the delay of a clinic visit before scheduling. This lead to 17 procedures avoided in the hospital, a direct hospital savings of over $25,000. Hurdles included patients lost to follow up and delays with insurance pre-authorization. With continued refinement, we hope to improve this process to create a better system for patients, providers, and the hospital.
549 Efficacy and Safety of Non-Elevated Piecemeal Polypectomy Using Hot Snare
Authors: Sharma Sahil , Sharma Akhil , Khokhotva Vladislav
Published: October 2019

INTRODUCTION:

Piecemeal polypectomy refers to the removal of large sessile colonic polyps by means of multiple snarings and is commonly performed after submucosal injection of a liquid, typically normal saline. Some reports suggest submucosal injection may not be benign, due to concerns of needle tracking of neoplastic cells, and difficulty in removal of recurrences due to scarring after injection. There is a paucity of recent literature describing polypectomy without submucosal injection. Historically, non-elevated piecemeal polypectomy has been criticized for concerns regarding bleeding and perforation. The purpose of this study was to describe a retrospective review of colonic polyps removed using non-elevated piecemeal polypectomy and associated outcomes.

METHODS:

An outpatient endoscopy center database was searched for patients who had large (≥3.0) sessile polyps excised using non-elevated piecemeal polypectomy technique between December 2012 and December 2018. All polyps with invasive cancer were excluded (n = 3). Chart review was carried out to extract demographic data, outcomes and adverse events. Details of all subsequent colonoscopies, including recurrences, residual tissue, or need for surgery were recorded.

RESULTS:

During the study period, 73 patients underwent 78 non-elevated piecemeal polypectomies for polyps ≥3 cm. There were 27 (37%) female patients and 46 (63%) male patients. Most common polyp sizes were between 3.5 cm to 3.9 cm (48.7%) or ≥4 cm (52.6%). Tubulovillous adenoma was the most frequent histological subtype (48.7%). Most polypectomies occurred in the right colon (54.4%). There were zero events of perforation. Ten (12.6%) patients had intraprocedural bleeding controlled endoscopically. Four patients (5.1%) had post-procedural bleeding, 3 required colonoscopy and clip hemostasis. There were 10 recurrences (12.8%), nine were found at the first endoscopic follow up and controlled by means of non-elevated hot snare polypectomy. One patient had a persistent recurrence and required subsequent surgical management for an adenocarcinoma.

CONCLUSION:

Non-elevated piecemeal polypectomy with hot snare is a safe and effective technique for the removal of large sessile (≥3 cm) colonic polyps. Perforation and bleeding are uncommon. Recurrences are easily controlled by additional hot snare resection.
554 Continuous Intravenous Fluid versus On-Demand Fluid Therapy During Elective Endoscopy
Authors: Jilani Omar , Kim Pamela , Dhawan Annika , Brignone Emily , Shields Kelly , Dhawan Manish
Published: October 2019

INTRODUCTION:

Colonoscopy and esophagogastroduodenoscopy (EGD) are commonly performed under sedation with close hemodynamic monitoring. Given the risk of intra-procedural hypotension, it is common practice to start intravenous fluids (IVF) routinely during these procedures despite a lack of evidence for reduction in morbidity. This study aims to compare routine IVF administration versus on-demand IVF administration on patient outcomes after routine endoscopy in an ambulatory surgical center.

METHODS:

An IRB approved retrospective chart review of 100 patients was completed. Of the 100 patients, 50 patients received routine IVFs during endoscopy and the remaining 50 patients did not. Data collected included age, gender, body mass index, and American Society of Anesthesiologists (ASA) score, duration of the procedure, time spent in the recovery room post procedure, quantity of IVFs used and hemodynamics. Adverse patient effects such as dizziness, nausea, emesis, or shortness of breath were documented.

RESULTS:

The routine IVF group and the on-demand IVF group had similar demographics (Table 1). About 75% of the patients in both groups met criteria for ASA class 2. About one-third of the patients in both groups had a BMI over 30. There was no significant difference in the preoperative, intraoperative and postoperative hemodynamics between the two groups. The average preoperative and postoperative blood pressure in both groups was 137/83 and 116/66, respectively. The on-demand group received an average 15 milliliters of fluids, likely as KVO (Keep Vein Open) while the routine IVF group received an average of 423 milliliters of fluid (Table 2). Although 84% of patients in the routine IVF group received fluids postoperatively there was no reported change in hemodynamics to warrant this fluid. There was a significant difference in the post-procedure recovery time between the two groups, 49.9 minutes for the IVF group and 41.7 minutes for the on-demand IVF group (P < 0.002). Only one patient (from the IVF group) required vasopressor intraoperatively for hypotension.

CONCLUSION:

The lack of routine intravenous fluids did not result in adverse outcomes or any detrimental change in hemodynamics. Prospective studies can reveal more insight into the utility of routine IVF use during these procedures and any improvement in safety and quality to justify the increased cost.
558 Accuracy of Endoscopists in Predicting Colorectal Polyps
Authors: Fahim Peter , Ali Birmaji , Kindel Robert , Steinbrunner Jenni
Published: October 2019

INTRODUCTION:

Colonoscopy is the gold standard for the identification of colorectal cancer and polyps. The majority of colorectal polyps found at screening colonoscopy are diminutive (≤5 mm) and have a low prevalence for advanced histological features and rarely harbor cancer. Precise endoscopic determination of the histology of polyps at the time of colonoscopy could prevent unnecessary polypectomies. The ASGE PIVI statement on this topic proposes to leave a suspected recto-sigmoid hyperplastic polyp ≤5 mm, there should be ≤90% negative predictive value (when used with high confidence) for adenomatous histology. The study purpose is to assess the accuracy of experienced endoscopists in predicting histological types of polyps resected at standard screening colonoscopy using white light.

METHODS:

Patients undergoing screening colonoscopy were enrolled into this prospective study. The study was conducted at two sites – a tertiary community teaching hospital and an outpatient endoscopy unit. Screening colonoscopy was defined as the first colonoscopy performed in an adequately prepped asymptomatic patient between the age of 50-80 with no risk factors. Six endoscopists were asked to complete a form at the end of the procedure, which included their pathology prediction and level of confidence of each resected polyp. Classifications for prediction pathology were adenoma (tubular, villous, tubulovillous), serrated (hyperplastic, sessile serrated adenoma, traditional serrated adenoma), cancer and others. Analysis was conducted to determine the accuracy of predictions.

RESULTS:

Among the 158 patients eligible for the study, endoscopist predictions were made on 336 resected polyps. The majority of polyps (82%) were <5 mm. Predictive accuracy of all polyp types with high confidence was 84%. The accuracy in predicting adenomatous histology with high confidence was 89%. Negative predictive value of polyps <5 mm located in the recto-sigmoid predicted with high confidence was 90%. When comparing endoscopists, there was not significant variability for predicting polyp type or adenoma classification. Out of the 42 polyps predicted to be hyperplastic with high confidence, 30 (71%) were correctly predicted, 7 (17%), 3 (7%) and 2 (5%) were diagnosed as tubular adenoma, sessile serrated adenoma, and other respectively.

CONCLUSION:

Our study have met the negative predicative value threshold for adenomatous poly histology, supporting a “diagnose- and- leave” strategy for diminutive predicted polyps in the rectosigmoid.
563 High Rate of Discordant Pain Levels Reported by Patients and Physicians During Gastrointestinal Endoscopy
Authors: Yip Benjamin , Lewis Justin , Crain Tyler , Ho Nancy
Published: October 2019

INTRODUCTION:

Procedural sedation is given to reduce patient anxiety, discomfort, pain and to improve outcomes in endoscopy. Data are limited regarding patient satisfaction with endoscopy. Our goal was to evaluate physician perceptions of patient pain and anxiety before and after endoscopy and factors associated with their correlation.

METHODS:

We performed a prospective study of 233 consecutive patients who received procedural sedation during endoscopy from August to November 2018 at the Portland VA Medical Center. Patients were given a pre-endoscopy survey to assess expectations and a post-endoscopy survey to assess procedural satisfaction, and physician were given a post-endoscopy survey only. Outcomes included expected and actual pain, anxiety, and sedation level during endoscopy and was reported on a scale from 0 to 5.

RESULTS:

Upper endoscopy, colonoscopy, and bi-directional endoscopy were performed in 30%, 60%, and 10% of cases, with an average procedural time of 19.1 minutes. Midazolam and fentanyl were most commonly used for sedation with an average dose of 4.0 ±0.1 mg and 102.5 ± 2.7 mcg, respectively. A minority of patients reported alcohol, marijuana, non-opiate pain medication, and opiate use (39%, 15%, 19%, and 16%, respectively). Pre-procedural anxiety and expected level of pain significantly improved with patient's post-procedural assessment (Tables 1 and 2). The average difference of anxiety and pain levels pre-endoscopy and post-endoscopy was 0.48 and 0.41, respectively. There was poor concordance between the physician's perceived patient pain and patient reported pain level during endoscopy (61%) with an overall Cohen's kappa of 0.258. Several factors associated with reduced patient and physician pain correlation included the presence of mental health disorders and use of benzodiazepines, SSRI, or SNRI (Table 3). Despite the discordance, the majority of patients reported satisfaction in pain control and would return for a repeat procedure (85% and 95%, respectively).

CONCLUSION:

Patients reported higher levels of pre-procedure anxiety and expected pain than actual anxiety and pain post-procedure. Physicians have poor concordance with patients with respect to pain levels, especially with more severe pain scores and in the presence of mental health disorders. Patients at high risk for discordance may benefit from more thorough pre-procedural counseling and a lower threshold for escalating doses of sedation during endoscopy.
564 Prevalence, Risk Factors, and Global Impact of Musculoskeletal Injuries Among Endoscopists in Portugal
Authors: Morais Rui , Vilas-Boas Filipe , Lopes Pedro , Simões Carolina , Dantas Eduardo , Cunha Inês , Roseira Joana , Cortez-Pinto João , Silva João , Lage Jorge , Caine Mafalda , Rocha Manuel , Flor de Lima Margarida , Santos Maria Pia , Garrido Mónica , Sousa Paula , Marcos Pedro , Azevedo Richard , Castro Rui , Gonçalves Tiago Cúrdia , Leal Tiago , Magno-Ferreira Vítor , Ramalho Rosa , Rodrigues-Pinto Eduardo , Macedo Guilherme
Published: October 2019

INTRODUCTION:

The performance of endoscopy is characterized by frequent and repetitive activities. Endoscopists often report musculoskeletal injuries (MI). The widespread use of endoscopy and the execution of more technically challenging procedures may lead to higher rates of repetitive stress injuries. Despite previous American and Asian reports, little evidence has come from Europe. We aimed to determine the prevalence, risk factors and impact of MI among Portuguese endoscopists.

METHODS:

A 48-question electronic survey was developed by a multidisciplinary group. The electronic survey was sent to all members of Portuguese Society of Gastroenterology (SPG, n = 705) during May 2019. Study data were collected and managed using REDCap electronic data capture tools hosted at SPG–CEREGA.

RESULTS:

The survey was completed by 171 endoscopists (response rate of 24.3%), 55.0% female, with a median age of 36 years (31-50). The majority of the respondents were consultants (77.8%; trainees 22.2%), with 97.7% currently performing endoscopy. The median time of endoscopic practice was 9 years (5-22). Regarding practice setting, 52.0% worked in academic centers, 41.5% in community centers and 63.9% in private practice. The median weekly-working time was 50 hours (45-60), 50% (37.5-62.5%) performing endoscopy. The prevalence of reported MI was 69.6% (n = 119). The median time for MI development was 6 years (3-16). The most common sites of injury were neck (42.9%) and thumb (42.0%). In 45.4%, the pain was evident both in work and daily activities and 22.7% referred pain even at rest. In the respondents with MI, 34.5% changed practice and/or reduced working activity and 33.6% reduced work-unrelated physical activity. Missing work was reported by 10.1% [median 30 days (4-45)]. The most common treatments were NSAIDs (57.1%) and physiotherapy (30.3%) but surgery was required in 1.7%. In the multivariate logistic regression, endoscopic practice >15 years (OR 3.514, P = 0.004), female gender (OR 2.443, P = 0.018) and higher percentage of time performing upper endoscopy (OR 0.974, P = 0.026) were independently associated with MI.

CONCLUSION:

Musculoskeletal injuries were reported by over two thirds of the portuguese endoscopists that completed our survey. These injuries had a significant impact on regular and professional activities. Female endoscopists and those with a minimum of 15 years of practice are at higher risk. The identification of these risk factors may result in practice changes to reduce the burden of the injuries.
565 Prophylactic Antibiotics for PEG Tube Placement: An Updated Meta-Analysis of Randomized Controlled Trials
Authors: Mandal Amrendra , Kesar Varun , Gonzalez Zorisadday , Roy Neel P. , Kanth Rajan , Roy Praveen K.
Published: October 2019

INTRODUCTION:

Percutaneous endoscopic gastrostomy (PEG) tube placement is associated with a risk of infection. It is currently a standard of practice to administer prophylactic antibiotics with PEG tubeplacement. However, several recent studies have reported mixed results. We performed an updated meta-analysis to assess the efficacy of prophylactic antibiotics for PEG tube placement.

METHODS:

MEDLINE, Google scholar, Embase PubMed, Cochrane Database, and abstracts from gastroenterology scientific meetings were searched. Only randomized controlled trials (RCTs) of adult subjects comparing prophylactic antibiotics to no prophylactic antibiotics for PEG tube placement were included. Study quality was accessed by assigning a quality score. Two independent reviewers used standard forms to extract data and the differences were resolved by mutual agreement. Meta-analysis for the effects of prophylactic antibiotics was analyzed by calculating pooled risk or odds ratio for peristomal infections, systemic infections, and mortality using both fixed and random effects models. Heterogeneity among studies was assessed by calculating I2 measure of inconsistency. Publication bias was also assessed.

RESULTS:

Thirteen RCTs (636 controls/764 treatment arm) met the inclusion criteria. All trials were published between 1985 and 2016. Eight trials predominantly used cephalosporins and 5 trials used penicillins. Eleven trials reported the technique of PEG tube placement: 8 used pull technique, 1 push technique, 1 both and 1 used the introducer method. In the treatment arm 1.07% of the patients got peristomal infection and in the control arm it was 2.55%. Prophylactic antibiotics with PEG tube placement resulted in a significant reduction in the risk of peristomal infection (RR 0.49, 95% CI: 0.39–0.63, P < 0.001, NNT = 8) and systemic infection. On subgroup analysis, both cephaloporins and penicillin based prophylaxis resulted in statistically significant reduction in risk of infections. Both single dose and multiple doses of antibiotics resulted in a reduction in the risk of infection. No significant difference was noted for mortality. Heterogeneity among studies was not significant. Funnel plots revealed no significant publication bias. Majority of the studies received a high score for quality.

CONCLUSION:

Current evidence supports the administration of prophylactic antibiotics prior to PEG tube placement. Further studies need to explore different PEG tube placement techniques that might obviate the need for antibiotics.
569 Music During Colonoscopy: A Meta-Analysis of Randomized Controlled Trials
Authors: Heath Ryan , Parsa Nasim , Matteson-Kome Michelle , Samiullah Sami , Nguyen Douglas , Puli Srinivas , Bechtold Matthew
Published: October 2019

INTRODUCTION:

Music seems to be beneficial in multiple clinical areas. Colonoscopy is a stressful event for patients, especially with conscious sedation. Music during colonoscopy has been evaluated in multiple randomized controlled trials (RCTs) with varied results. Even meta-analyses on the subject over the years have yielded inconsistent conclusions. Therefore, we conducted an up-to-date meta-analysis on music during colonoscopy.

METHODS:

Multiple large databases were aggressively searched (November 2018). Only RCTs on adult subjects that compared music versus no music during colonoscopy were included. Standard forms were used to extract data by two independent reviewers. Meta-analysis for the effect of music on patients undergoing colonoscopy was analyzed by calculating pooled estimates of total procedure time, dose of sedative medications (midazolam and mepiridine), and patients' pain scores, experience, and willingness to repeat same procedure in the future using odds ratio (OR) and mean difference (MD) with random effects model. Heterogeneity and publication bias were assessed.

RESULTS:

11 studies (N=988) met the inclusion criteria. Music during colonoscopy demonstrated a statistically significant reduction in procedure times (MD -2.3 minutes; 95% CI: -4.13 to -0.47; P = 0.01) and patients' pain (MD -1.26; 95% CI: -2.28 to -0.24; P = 0.02) while improving patients' experience (MD -1.11; 95% CI: -1.7 to -0.53; P < 0.01) as compared to no music. No statistically significant differences were observed between music and no music during colonoscopy for midazolam (MD -0.4; 95% CI: -0.9-0.09; P =0.11), meperidine (MD -3.06; 95% CI: -10.79-4.67; P = 0.44), or patients' willingness to repeat the procedure (OR 3.89; 95% CI: 0.76-19.97; P = 0.1).

CONCLUSION:

Music appears to improve overall patient experience while reducing procedure times and patient pain. Therefore, music, being a non-invasive intervention, should be strongly considered during colonoscopy.
571 Diagnostic Accuracy of Narrow Band Imaging on Endoscopy in Detection of Duodenal Villous Atrophy Using Histopathology as a Gold Standard in Patients Presenting With Chronic Diarrhea
Authors: Kumar Sanjay Kirshan , Sham Sunder , Lail Ghulamullah , Mandhwani Rajesh , Hanif Farina , Luck Nasir Hassan , Samejo Khadim Hussain , Ul Haque Muhammad Manzoor , Devi Asha
Published: October 2019

INTRODUCTION:

Celiac disease and tropical sprue are common causes of chronic diarrhea & duodenal villous atrophy (DVA). Narrow band imaging (NBI) is chromoendoscopic technique which facilitates detailed visualization of the mucosal surface & allows targeted biopsy and thus increases the diagnostic yield of the biopsy specimen. Hence, we aimed to determine the diagnostic accuracy of NBI in detection of DVA using histopathology as a gold standard in chronic diarrhea patients.

METHODS:

All patients with diarrhea for >4weeks were enrolled. Endoscopy was performed in all the patients to take duodenal biopsy and simultaneously NBI villous pattern was noted. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and diagnostic accuracy of NBI were calculated comparing histopathology.

RESULTS:

Baseline characteristics are shown in Table 1. NBI findings of total patients were finger shaped (normal villi), gyriform (partial villi atrophy) and flat surface (complete villous atrophy) mucosa as 22.6%, 59.7% and 17.7% respectively. NBI has sensitivity, specificity; PPV, NPV, and diagnostic accuracy were 84.9%, 45.2%, 82.3%, 50.0%, and 75% respectively for the detection of DVA as depicted in Table 2.

CONCLUSION:

This study showed 93 (75%) of participants had DVA in contrast to another study from Pakistan which revealed DVA in 49.8% of patients. This disparity is likely due to difference in study population. Our patients had normal villi, partial and complete villous atrophy in 31 (25%), 72 (58.1%) & 21 (16.9%) respectively with P value 0.001. Dutta AK et al. found that NBI has sensitivity 81-87%, specificity 93%, NPV 96% and PPV 68-77% to detect DVA. We found sensitivity 85%, specificity 45%, NPV 50% & PPV 82.3%. In our study specificity & NPV were lower than in others as we included mild villous atrophy while most of the studies had a greater proportion of patients with moderate to severe villous atrophy. We found that duration of diarrhea is associated with presence of villous atrophy, as disease duration of >5 months had sensitivity 92.1% and specificity 60% while 5 months had sensitivity & specificity 80% & 31.3% respectively. This association was not observed in previous studies. So we conclude NBI is a promising technique for assessment of duodenal mucosal details in patients with longstanding chronic diarrhea.
581 Factors Associated With In-Hospital Mortality in Acute Variceal Bleeding
Authors: Alimirah Maryam , Sadiq Omar , Venkat Deepak
Published: October 2019

INTRODUCTION:

Risk stratification scoring systems for upper gastrointestinal bleeds, including the Glasgow Blatchford and Rockall scores, don't accurately predict outcomes in acute variceal bleeds (AVB). Similarly, the Child–Pugh score has poor prognostic value in AVB, likely due to its subjective parameters. The goal of this retrospective study was to identify factors that predict in-hospital mortality in patients presenting with AVB.

METHODS:

Data was obtained through the Medical Information Mart for Intensive Care III (MIMICIII), which is a large, freely available database comprised of patients admitted to Beth Israel Deaconess Medical Center. 236 patients were included in this study who were admitted to the ICU from 2001 to 2012 with an ICD code of cirrhosis and variceal bleed. After excluding 136 patients who did not undergo esophagogastroduodenoscopy (EGD) during admission, 100 patients remained and were analyzed. Factors such as transfusion requirements, number of EGDs, demographics, and laboratory values were collected using postgresql queries. Statistical analysis was done using R 3.5.1.

RESULTS:

19 of the 100 patients died during admission (mortality rate of 19%). There were no significant differences between the deceased and survival groups with regards to age, sex, race and insurance type. There were significant differences between both groups regarding hemoglobin nadir (P = .0001), MELD-Na score (P < .0001), MELD score (P < .0001), INR (P < .0001) and bilirubin (P = .005). Other factors analyzed included number of EGDs during admission, length of admission and blood product requirements. Compared with the survival group, the deceased group received a larger number of red blood cell transfusions (P = .02) and fresh frozen plasma (P = .007). The number of cryoprecipitate and platelet transfusions between both groups was not statistically significant (P = 0.14 and P = 0.07) respectively. The number of EGDs in the deceased group was higher, compared with the survival group (P = 0.008).

CONCLUSION:

We were able to identify several risk factors of mortality in variceal bleeders admitted to the intensive care unit. We found the MELD-Na score, INR as well as hemoglobin nadir to have the strongest association with mortality. Number of EGDs was also associated with increased mortality suggesting that in-hospital rebleeding is a strong predictor of outcome. The MELD score was as strongly associated with mortality as the MELD-Na score, contrary to previous studies of mortality in cirrhosis.