bluuebunny/crossref_metadata_2025 huggingface dataset:
290 Exploring Interventions to Improve the Efficacy of Fecal Immunochemical Testing in an Ambulatory Care Clinic for the Underserved Population
Authors: Oldfield Edward C. , Marcuard Maurice , Mendel David , Tahhan Sami G. , Johnson David A.
Published: October 2019

INTRODUCTION:

We previously conducted an initial analysis on the effectiveness of fecal immunochemical test (FIT) screening at our Ambulatory Care Clinic (ACC) for the underserved population during the first year of FIT implementation and first year of patient follow up. Although we met our initial goal of FIT completion of >60% (actual 81.8%), the follow up rate for repeat FIT testing was only 18% for patients with an initial negative FIT test (Figure 1). Recognizing these shortcomings, we implemented interventions to improve the follow-up FIT completion rate for those with initial negative testing.

METHODS:

All patients with initial negative FIT testing without a repeat FIT test after 1 year of follow-up were sent a letter notifying them of need for a repeat FIT test, which could be picked up from the front desk of the clinic (Figure 2). After two months, patient compliance was re-assessed and those who had still not completed the FIT test were given individualized phone calls with the same information. FIT completion rates were then assessed 1 month after these phone calls.

RESULTS:

A summary and patient flow diagram is shown (Figure 3). Among the 49 remaining active patients at the start of the intervention period, 9 patients (18%) completed a FIT test within 2 months of receiving the letter. No patients completed a FIT test within one month of receiving a phone call.

CONCLUSION:

1. Neither intervention significantly increased the rate of repeat FIT completion, although our 18% FIT completion at two months after the letter is near the published 23.5% completion rate.
1
2. Significant patient dropout occurred, adding up to 120 patients (71%) during a 6-month window immediately prior to our intervention period. This predominately occurred due to patients becoming inactive at the clinic over lack of follow-up or patients qualifying for insurance through the Virginia Medicaid expansion which started in January 2019. 3. There is clear need to refine our follow-up interventions and consider alternative tools, such as mailing FIT tests, automated text messaging, or incorporating FIT testing into well visits or existing clinic navigation tools. Additionally, the low rates of follow-up in this patient population will need to be monitored closely, as this may be a limiting factor for FIT testing which requires annual screening compared to other screening measures with longer interval screening periods.
293 Receptive Anal Sex in Women and Risk of Colorectal Cancer (2009–2014): A Retrospective Analysis of NHANES
Authors: Ramprasad Chethan , Major Vincent J. , Zhang Yian , LaBove Hannah , Haghighat Shida , Fass Ofer , El-Ashmawy Mariam
Published: October 2019

INTRODUCTION:

Risk factors for early presentation of colorectal cancer is a topic of particular current interest. Prevalence of receptive anal sex has not been well researched, although some studies suggest that it is increasingly popular. The objective of the current study is to examine if there is an increased risk for colorectal cancer in women who engage in receptive anal intercourse as compared to patients who have not engaged in receptive anal sex.

METHODS:

The National Health and Nutrition Examination Survey (NHANES) was considered for women who answered the sexual health questionnaire (SXQ) during the survey cycles that included a SXQ item referring to anal sex (2009–2014). The questionnaire assessed sexual health behaviors including history of receptive anal intercourse in women. Additional NHANES data was matched for demographics, including race, as well as medical diagnoses, such as colorectal cancer and HPV infection. Statistical analysis was conducted using the statistical software, R.

RESULTS:

A total of 7,781 women completed the NHANES SXQ between 2009 and 2014 but only 6,596 answered the question mentioning receptive anal intercourse. A total of 2,203 women (28.3%), stated that they had a history of receptive anal intercourse at least once. The rate of reported history of receptive anal intercourse did not significantly increase across the 3 cycles: 2009–2010 (789, 29.0%) to 2013–2014 (782, 29.6%). From 2009 to 2014, there were a total of 19 participants (0.29%) with a diagnosis of colorectal cancer, with 5 patients who had both a diagnosis of colorectal cancer and history of anal intercourse. The risk of a diagnosis of colorectal cancer with a history of receptive anal intercourse in women was 0.0023, whereas the risk of a diagnosis of colorectal cancer with no history of receptive anal intercourse was 0.0032. There was no significant evidence that receptive anal intercourse in women is associated with risk of colorectal cancer. There was insufficient data for concurrent HPV infection and CRC in those without a history of anal sex, thus we are unable to test for significant difference between risk of CRC for women with HPV as compared to women without HPV.

CONCLUSION:

Results from the questionnaire did not suggest an increasing trend of receptive anal intercourse from 2009 to 2014. No significant difference was found in relative risk of diagnosis of colorectal cancer in women who engaged in anal intercourse as compared to those who did not engage in anal intercourse.
296 Antibiotic Use and Risk of Colorectal Neoplasia: A Systematic Review and Meta-Analysis
Authors: Aneke-Nash Chino , Yoon Garrett , Du MengMeng , Liang Peter S.
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) is the third most prevalent cancer and the third leading cause of cancer death for women and men in the United States. There is emerging evidence that the gut microbiome plays a role in CRC development, and antibiotics are one of the most common exposures that can alter the gut microbiome. We performed a systematic review and meta-analysis to characterize the association between antibiotic use and colorectal neoplasia risk.

METHODS:

We searched Pubmed, EMBASE, and Web of Science for articles describing the relationship between antibiotic exposure and colorectal neoplasia (cancer or adenoma) through October 2018. A total of 5342 citations were identified, which were reviewed independently by two investigators. After screening, we evaluated 15 articles and included 5 in the final analysis. We assessed the association between any antibiotic use as well as intensity of antibiotic use (defined as number of courses or duration of therapy) and colorectal neoplasia risk. Random effects meta-analysis was performed.

RESULTS:

Four studies provided five estimates for the association between any antibiotic use and risk of colorectal neoplasia. There was a 4% increased risk of neoplasia among individuals exposed to antibiotics (RR 1.04, 95% CI 1.02–1.07, Figure 1), with no evidence of heterogeneity (P = 0.96, I2 = 0%). Five studies provided 13 estimates of the association between antibiotic intensity and colorectal neoplasia. Individuals with the highest intensity of antibiotic exposure had a 13% higher risk of colorectal neoplasia than those with lowest exposure (RR 1.13, 95% CI 1.06–1.21, Figure 2). However, significant heterogeneity was observed (P = 0.04, I2 = 45%). Given the small number of studies, sub-group analyses on antibiotic class could not be performed.

CONCLUSION:

Antibiotic exposure is associated with a subsequent increased risk of colorectal neoplasia. Furthermore, this relationship appears to be dose-dependent. Given the widespread use of antibiotics in childhood and early adulthood, additional research to further characterize this relationship is needed.
297 Increasing Colon Cancer Screening Rates at Myers Park Internal Medicine Clinic
Authors: Sang Jessica , Simmelink Andrew , Denmeade Travis , Ost Emily
Published: October 2019

INTRODUCTION:

Colon cancer is the third most common cause of cancer and cancer-related deaths. After regular colon screening was implemented, there was a 40% decline in incidence and mortality of colon cancer. The US Preventative Services Task Force gives grade A evidence recommendation for screening individuals age 50 through 75 that are of average risk. A US multi-society task force on colon cancer screening gave colonoscopy and Fecal Immunochemistry Test (FIT) a tier-1 recommendation. We sought to increase our internal medicine's clinic colon cancer screening rates.

METHODS:

We utilized the PDSA model for quality improvement. Baseline colon cancer screening rate was 53% in September 2018. The aim of our project was to increase colon cancer screening (CRCS) rates by 16.4% by April 2019 to a target goal of 69.4%, and to determine barriers to screening. A target goal of 69.4% was selected based on the clinic's metric goal. Our two main interventions included an informational video about CRCS reasoning and methods combined with a questionnaire that addressed barriers to care and recreation of FIT card instructions which were deemed inadequate. Educational materials and questionnaire were available in English and Spanish. We tracked improvement through clinic CRCS rate data available to physicians.

RESULTS:

Colon cancer screening rates at Myers Park Internal Medicine Clinic were increased by 15% (goal: 16.4%) to 68%. Ninety-two percent found the informational video “extremely informative,” with 38% choosing colonoscopy, 46% FIT testing, and 8% Cologuard®.

CONCLUSION:

Our clinic showed simple interventions can increase CRCS rates. The increase in CRCS rates we have shown can potentially lead to more early diagnoses of colon cancer and lower health care costs for the health system. The workflow used in our study could also be used in other clinics throughout Atrium Health to assess for increased colon cancer screening rates in other populations. The format of a simple informational video rather than documents may be beneficial in educating patients on different health care topics. Next steps will include reasons for not completing either FIT testing or having colonoscopy performed.
325 Novel Multi-Target Stool DNA Marker Panel Yields Highly Accurate Detection of Colorectal Cancer and Premalignant Neoplasia
Authors: Domanico MIchael , Kisiel John , Gagrat Zubin , Bourne Bridget , Allawi Hatim T. , Taylor William , Leduc Christine , Matter Michael B. , Mahoney Douglas W. , Ahlquist David , Lidgard Graham , Limburg Paul , Johnson Scott
Published: October 2019

INTRODUCTION:

Despite the demonstrated effectiveness of average-risk screening, colorectal cancer (CRC) remains the 2nd leading cause of cancer death in the US. For optimal prevention, CRC screening tools should be highly accurate, user-friendly, and broadly accessible. Patient and provider adoption of the FDA-approved, guideline-endorsed multi-target stool DNA (mt-sDNA) test has grown exponentially since its launch in 2014. Toward ongoing improvement in CRC screening effectiveness, we conducted a blinded case-control study to assess the detection accuracy of a mt-sDNA panel of novel, highly discriminant methylated DNA markers (MDMs).

METHODS:

We selected 12 candidate MDMs from prior whole methylome discovery and validation in tissue. Stool was obtained as part of previous large, multicenter studies and collected prior to or 7 days post-colonoscopy (prior to any clinically-indicated treatment). CRC, advanced adenoma (AA; size ≥1 cm, high-grade dysplasia, or ≥25% villous morphology), non-AA, or control (no neoplasia) status was defined by colonoscopy and histopathology. Samples were blinded to operators and randomized by characterization to balance the test sets prior to assessment. MDMs were quantified by target-specific DNA capture and Long-probe Quantitative Amplified Signal assay on bisulfite-converted DNA; fecal hemoglobin was quantified by immunoassay. Bootstrapping methods were used to select a panel of 3 MDMs, which was then 10-fold cross-validated; hemoglobin was also included, as was a colon epithelium-specific MDM to normalize stool MDM levels.

RESULTS:

Participant samples included 117 CRC, 120 AA, 161 non-AA, and 327 controls. Median age was 67 (IQR 61, 75) years; 51% were men. The AUC with best-fit was 0.97 for CRC and 0.84 for AA, and these high AUCs held up tightly on cross-validation (Figure 1). At 92% (95% CI 88-94%) specificity, sensitivity of the panel was 92% (95% CI 86-96%) for CRC. Neither CRC stage (Figure 2) nor CRC site significantly affected performance. At the same 92% specificity, sensitivity was 65% (95% CI 56-73%) for AAs overall, 67% (38-88%) for sessile serrated polyps ≥1 cm, and 71% (57-82%) for adenomas with villous features (Figure 3).

CONCLUSION:

These data support highly accurate performance of a novel panel of mt-sDNA markers for detecting both CRC (including early stage lesions) and AAs at greatest risk of progression. Prospective comparative studies are warranted to further establish the clinical potential of this novel screening tool.
332 Effect of Behavioral Interventions on the Uptake of Screening Colonoscopy: A Systematic Review and Meta-Analysis
Authors: Yakoubovitch Stephanie , Anand Sanya , Pecoriello Jillian M. , Zaki Timothy A. , Liang Peter S.
Published: October 2019

INTRODUCTION:

Screening decreases colorectal cancer (CRC) incidence and mortality, but uptake in the United States remains suboptimal at 62%. Prior studies have investigated the effect of various interventions on overall CRC screening and stool-based testing, but the effect on colonoscopy—the predominant screening test in the US—has not been fully examined. We performed a systematic review and meta-analysis to assess the effect of behavioral interventions on screening colonoscopy uptake.

METHODS:

We searched PubMed, EMBASE, and Cochrane databases through June 2018 for controlled trials that assessed the effect of behavioral interventions on screening colonoscopy rates. Our search yielded a total of 6,952 titles. All abstracts and articles were screened by at least two independent reviewers and 54 manuscripts were selected for review. Relative risk estimates were extracted from the original article or calculated from the raw data. The primary outcome was the relative increase in screening colonoscopy completion with any behavioral intervention. Subgroup analysis by type of intervention was also performed. Random effects meta-analysis was performed using Stata.

RESULTS:

A total of 21 studies with 24 behavioral interventions were analyzed. The most common interventions were patient navigation (n = 8), a combination of multiple interventions (n = 7), and educational interventions (n = 4). Overall, behavioral interventions increased colonoscopy completion by 58% compared to controls (OR 1.58, 95% CI 1.33-1.88, Figure). Patient navigation (OR 1.80, 95% CI 1.22-2.67) and multiple interventions (OR 1.70, 95% CI 1.15-2.50) had the strongest effect on colonoscopy completion. Significant heterogeneity was observed both overall and by intervention type, which may be attributed to differences in study setting and control group selection.

CONCLUSION:

Behavioral interventions increase screening colonoscopy completion and should be considered in clinical practice. In particular, patient navigation and multiple interventions are the best-studied and most effective interventions.
344 Multi-Modality Endotherapy of Esophagopleural Fistula (EPF) Using a Novel External Stent Anchoring Mechanism
Authors: Crain Rebecca , Abdulla Hamza , Guturu Praveen , Parupudi Sreeram
Published: October 2019

INTRODUCTION:

Esophagopleural fistula (EPF) is a condition associated with high morbidity and mortality. The management of patients with chronic, recurrent, nonmalignant EPF remains controversial and challenging.

CASE DESCRIPTION/METHODS:

A 61-year-old man with a history of esophagopleural fistula (EPF) in diagnosed in 2013 treated with covered esophageal stent and subsequent decortication with resolution of symptoms and esophageal leak who presented to the hospital with sepsis. Chest CT revealed a fistula between the distal esophagus and right pleural space with large right-sided hydro-pneumothorax with resulting near complete collapse of the right lower and middle lobes. Chest tube was placed with external wound suction by luminal vacuum sponge. GI were consulted for endoscopic management. Upper Endoscopy revealed a 20 mm fistula in the lower third of the esophagus. The decision was made to close the fistula with endoscopic suturing and placement of esophageal stent. Three days following the procedure the esophageal stent migrated distally. This was repositioned endoscopically and anchored with repeat Overstitch of endoscopic clips. This again was displaced after 4 days. Due to the patient poor conditional status and the absence of offers for nonsurgical options, an alternative method of anchoring of esophageal was explored in the form of an external anchoring. This was done by loading the stent and suturing the proximal end at 12 and 6 o’clock, the stent was loaded back and then deployed in the patient esophagus under flurouscopic guidance. Then, the previously placed anchoring suture material was located and brought out of the mouth using a forceps. The sutures then were rerouted into each nostril using a nasal gastric tube. Then these anchoring sutures were loosely tied at/around the nasal septum using a soft rubber tube to protect the nasal septum. The procedure was technically successful and the patients was discharged from the hospital three days later. After one month, the patient’s nutritional status improved, and he underwent definitive thoracic surgery at an outside facility.

DISCUSSION:

Self-expandable metal stents are increasingly used in the management of esophageal fistulas but their efficacy is limited by high migration rate. Previously described methods to prevent stent migration include the use of endoscopic clips and endoscopic suturing. We describe external anchoring technique to maintain the esophageal stent in position in a case when endoscopic suturing failed.

Watch the video: http://bit.ly/2YiObuS
349 A Natural Orifice Transluminal Endoscopic Surgical Approach to Cruroplasty for GERD Management: A Feasibility Study in an Acute Porcine Model
Authors: Manzo Carl , Mathew Abraham , Maranki Jennifer , Pauli Eric , Moyer Matthew , Izer Jennifer , Karaisz Fred
Published: October 2019

INTRODUCTION:

Gastroesophageal reflux disease is a common condition that often requires long term medical management or elective surgery in the form of fundoplication. Advanced endoscopic techniques can potentially be able to supply a safer alternative for patients with reflux disease. We propose a natural orifice transluminal endoscopic surgical technique that uses a self-approximating submucosal tunnel approach to the mediastinum to perform an anti-reflux procedure.

CASE DESCRIPTION/METHODS:

An acute porcine model was used for this acute animal feasibility study. Female Yorkshire pigs were kept on a liquid diet for forty eight hours and nothing by mouth eight hours prior to endoscopy. All animals were anesthetized and monitored. A four to five centimeter long submucosal tunnel is created in the posterior esophagus, beginning about ten centimeters above the gastroesophageal junction. From inside the tunnel, the muscles are incised to gain entry into the mediastinum. The esophagus is then followed down to the diaphragmatic hiatus and the right and left crura are located. The aorta, the vagal nerves, and other surrounding structures are identified. Using an overstitch device fitted on a double channel scope, we then suture the crura posteriorly, effecting a cruroplasty. Following the procedure, the animals were euthanized and immediate necropsy was performed to assess for any complications as well as determine the success of the cruroplasty. Esophageal pressure was assessed endoscopically in one animal.

DISCUSSION:

A submucosal tunnel was successfully achieved in all three animals with safe entry into the mediastinum. Mediastinal and then peri hiatal anatomy was demonstrated in each animal with excellent view of the thoracic aorta, esophagus, right and left vagus nerves, lungs, and the diaphragmatic crura. Endosuturing was successful with effective cruroplasty in all three animals without complications. Necropsy showed that sutures were in correct anatomical location without signs of procedural complication. We conclude that it is entirely possible to access the diaphragmatic hiatus and perform endoscopic cruroplasty for the potential treatment of reflux disease. A survival study aimed at developing a full-fledged anti reflux procedure is currently underway. We speculate that a trans-esophageal approach can provide an easy and safe treatment option for selected patients suffering from reflux disease.

Watch the video: http://bit.ly/2JQiEaF
422 Positive Association Between CDX2 and MUC2 Intestinal Factors and Dysplasia in Barrett’s Esophagus Utilizing WATS3D Tissue Sampling and Analysis
Authors: Odze Robert , Goldblum John , Sharma Prateek , Lightdale Charles J. , Smith Michael S. , Shaheen Nicholas J.
Published: October 2019

INTRODUCTION:

During the pathogenesis of Barrett’s esophagus (BE), the background columnar epithelium often shows evidence of intestinal differentiation, such as early expression of intestinal specific transcription factors (CDX2) and late expression of mucin proteins (MUC2), prior to the development of goblet cells. The clinical significance of these markers is unknown. The aim of this study was to evaluate the association between the expression of CDX2 and MUC2, and the presence and grade of dysplasia in a large cohort of patients with endoscopic evidence of esophageal columnar mucosa using wide area transepithelial samples (WATS3D, CDx Diagnostics, Suffern, NY).

METHODS:

Over a 2-year period, we collected data from 129,158 consecutive patients with endoscopic evidence of esophageal salmon colored mucosa who were evaluated with WATS: 125,749 no dysplasia (ND), 2,012 crypt dysplasia (CD), 745 low grade dysplasia (LGD), and 652 high grade dysplasia/adenocarcinoma (HGD/EAC). CDX2 and MUC2 immunostaining was performed, and then their extent was graded semi-quantitatively (on a 4-point scale) in the background non-dysplastic, non-goblet epithelium, from all patients. The CDX2 and MUC2 results were then correlated statistically with the presence and grade of dysplasia.

RESULTS:

Table 1 summarizes the data according to dysplasia grade. Overall, 33.3% of cases were CDx2- MUC2-, 30.6% were CDx2+ MUC2-, and 36.1% were CDX2+ MUC2+. A significant (P < 0.0001) increase in CDX2+ MUC2+ staining occurred in dysplasia cases (97.0%) compared to non- dysplasia cases (34.5%). Upon regression analysis, there was a highly significant (P < 0.0001) association between both the presence and grade of CDX2 and MUC2 staining and dysplasia, that increased progressively from CD to LGD to HGD/EAC. CDX2+ MUC2+ was present, uniformly, in more than 94% of all dysplasia categories. In a sub-analysis of either CDX2 or MUC2 staining in ND vs. HGD/EAC cases only, there was a significant increase (P < 0.0001) in the grade of CDX2, and in the grade of MUC2, staining, such that 3+ or 4+ CDX2 or MUC2 staining was noted in 8.8% and 9.1% of ND cases, respectively, compared to 54% and 41%, respectively, in HGD/EAC.

CONCLUSION:

CDX2 and/or MUC2 positivity is a highly significant risk factor for dysplasia/EAC in patients with endoscopic evidence of esophageal columnar mucosa. CDX2/MUC2 immunostaining may represent a more effective method of confirming Barrett’s esophagus, and the risk for dysplasia/cancer, than the identification of goblet cells.
435 Trends and Correlation Between Eckardt Scores and Timed Barium Esophagram Parameters After Per-Oral Endoscopic Myotomy in Achalasia
Authors: Sanaka Madhusudhan R. , Parikh Malav P. , Tang Andrew , Chadalavada Pravallika , Khoudari George , Gupta Niyati M. , Thota Prashanthi N. , Gabbard Scott , Murthy Sudish , Raja Siva
Published: October 2019

INTRODUCTION:

Symptomatic relief by Eckardt scores is used to assess treatment success after per-oral endoscopic myotomy (POEM). However, it is unclear if symptomatic improvement correlates with objective esophageal emptying on timed barium esophagram (TBE). Hence, our study aims were to identify the trends and correlation between Eckardt scores and TBE parameters after POEM.

METHODS:

Medical records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients who underwent timed barium esophagram (TBE) and high-resolution esophageal manometry (HREM) prior to POEM along with two-month post-POEM, TBE and HREM were included. Demographics and procedural details, TBE, HREM and Eckardt scores were reviewed. Post-POEM Eckhardt score of ≤3 was considered as successful palliation of symptoms. Trends in Eckardt scores and TBE parameters were identified and their association was analyzed. Statistical tests were performed using linear mixed effects and longitudinal modeling.

RESULTS:

A total of 219 patients underwent POEM with a median follow up duration of 2.6 months [Q1-3: 2.2 to 13.7 months]. Baseline patient characteristics and outcomes are described in Table 1. Improvement in Eckardt scores was stable over 24 months, however symptoms were lowest at 3-6 months after POEM (Figure 1a). TBE width at 1 and 5 minutes were lowest at 6-9 months after POEM, however TBE width gradually returns to baseline around 18-21 months even becoming worse than baseline levels (Figure 1b,c). Lower esophageal sphincter-Integrated relaxation pressure (LES-IRP) improvement was stable over 15 months, however this parameter was limited by number of patients undergoing follow up testing (n = 62). BMI increases slightly but remains around baseline for 24 months (Figure 1d). Among the 4 TBE parameters assessed, Eckardt scores correlates the most with barium column width at 5 minutes and the degree of correlation is moderate (Figure 2).

CONCLUSION:

Although patients continue to have symptomatic relief after POEM, objective parameters of esophageal emptying on TBE return to pre-operative levels or even worsen around two years after POEM. Eckardt scores correlate the most with barium column width at 5-minutes on TBE. Our findings suggest that barium column width at 5 minutes on TBE might be a useful objective marker for treatment response in the mid to long-term follow up after POEM.
479 Length of Time Spent in the Outpatient Setting With Patients With Irritable Bowel Syndrome: Analysis of the National Ambulatory Medical Care Survey
Authors: Mossad David , Ellis Matthew , Agrawal Sangeeta
Published: October 2019

INTRODUCTION:

Irritable bowel syndrome (IBS) is a chronic and debilitating functional gastrointestinal disorder that affects 9%-23% of the population across the world. Based on IBS association with psychological symptoms such as anxiety and depression, it is assumed that patients with this condition require more time during outpatient visits than the average patient. The purpose of this study was to evaluate differences in time spent by physicians in the outpatient setting with patients with IBS versus patients with other conditions.

METHODS:

The National Ambulatory Medical Care Survey was searched using International Classification of Diseases - Ninth Revision (ICD-9) diagnosis codes for patients seen in the outpatient setting for IBS for the years 2011-2015. Time spent during the outpatient visits was also gathered. Patients were separated into two groups, those with IBS and those with other conditions. Data was analyzed with regards to patient age, sex, and duration of outpatient visit. Statistical comparisons were made using Statistical Package for the Social Sciences (SPSS) with chi-square and student T tests with a significance level of 0.05.

RESULTS:

175,863 outpatient visits were identified, with 381 patients with IBS and 175,483 patients with other conditions. Patients with IBS were significantly older (mean age of 49.3 vs 46.1, P = 0.0129) and had a longer duration of visit with the physician (24.7 minutes vs 22.5 minutes, P = 0.0007). The IBS group had a significantly larger proportion of females compared to the other conditions group (80.05% vs 57.16%, P < 0.0001)

CONCLUSION:

In this study, it was found that IBS patients take a significantly longer clinic time compared to patients with other conditions. These patients were more likely to be older and female. Various comorbid factors such as fatigue, lack of sleep, anxiety, and depression are potential contributors to the extended amount of time needed for these patients. Physicians should expect to potentially spend more time with these patients during their clinic visits and adjust their schedules accordingly to provide the best quality of care for patients with IBS.
499 Plecanatide for Patients With Chronic Idiopathic Constipation and Irritable Bowel Syndrome-Constipation: Analysis of Abdominal Bloating From Four Randomized Phase 3 Clinical Trials
Authors: Franklin Howard , Sayuk Gregory S.
Published: October 2019

INTRODUCTION:

Patients with chronic idiopathic constipation (CIC) or with irritable bowel syndrome with constipation (IBS-C) often report bloating. Plecanatide is an analogue of human uroguanylin, an intestinal peptide that induces fluid and ion secretion. Data from 4 large randomized, placebo-controlled trials in CIC (2 studies) or in IBS-C (2 studies) were analyzed to determine whether plecanatide improved bloating in patients with CIC or IBS-C.

METHODS:

Patients (N = 2683) who met modified Rome III criteria for CIC or patients (N = 2189) who met Rome III criteria for IBS-C were included in separate combined phase III intention-to-treat populations in CIC and IBS-C, respectively. Patients were randomized to placebo, plecanatide 3 mg QD, or plecanatide 6mg QD for 12 weeks. Baseline characteristics were comparable between groups within the CIC studies and within the IBS-C studies. The primary endpoint for the CIC trials was the percentage of durable overall complete spontaneous bowel movement (CSBM) responders (≥3 CSBMs plus increase of ≥1 CSBM over baseline in the same week) for ≥9 of the 12 treatment weeks, including ≥3 of the last 4 weeks. The IBS-C primary endpoint was the percentage of Overall Responders, defined as a patient who was a weekly responder (CSBM + ≥30% improvement in abdominal pain) for ≥6 of the 12 treatment weeks. Electronic diaries recorded daily symptoms of bloating (0 = none to 4 = very severe) and bowel movements.

RESULTS:

In patients with CIC, pooled efficacy demonstrated a significantly greater percentage of CSBM responders in each of the plecanatide groups when compared to the placebo group. Both plecanatide 3mg and 6mg resulted in a significantly greater percentage of Overall Responders than did placebo in the IBS-C studies (Table 1). In CIC or IBS-C, over the 12-week treatment period, both plecanatide treatment groups experienced a significantly greater reduction in weekly mean abdominal bloating scores compared with the placebo group (Table 2). The most common adverse event (AE) was diarrhea across all studies; discontinuation rates due to AEs including diarrhea were similar across studies (Table 3).

CONCLUSION:

Patients with CIC or IBS-C who received plecanatide 3 mg and 6 mg demonstrated a significantly greater percentage of responders compared to patients who received placebo. Bloating was significantly improved both in patients with CIC and IBS-C. Plecanatide treatment was associated with a low incidence of diarrhea and other AEs.
518 Optimizing Inpatient Colonoscopy Preparation: A QI Project
Authors: Buaisha Haitam M. , Rao Sirish , Koppala Jahnavi , Vellanki Meghana , Abdussalam Abdullah , Machain Jose , Rangray Rajani
Published: October 2019

INTRODUCTION:

Hospitalization is an independent risk factor of poor bowel preparation and it has a lower procedure completion rate as compared to outpatients. Ineffective inpatient colonoscopy preparation may lead to delayed or canceled procedures which subject the patient to additional bowel preparation and sedation. Subsequently it results in patient inconvenience, increased cardio-pulmonary complications, longer hospital stays, and increased hospital cost.

METHODS:

Defining the problem: Chart review of the inpatient colonoscopies performed between May and July 2017 revealed that 4 liters-single dose polyethylene glycol–electrolyte lavage solution [PEG-ELS] was used in more than 90% of the inpatient colonoscopies. The percentage of colonoscopies with a rating of fair or poor was 36%. On average, 15% of patients failed inpatient bowel preparation. Aim of the project: To reduce the percentage of failed inpatient colonoscopies to less than 10% by May 2018 and to reduce the percentage of inpatients colonoscopies with an inadequate bowel preparation by 5% by May 2019. Interventions: 1) Fellows education on the evidence based split-dose regimen. 2) Bowel prep quality deemed adequate if cecal intubation was successful and prep was satisfactory to identify the targeted lesions. 3) Nothing by mouth orders to be started at 4 am or later instead of traditional after midnight orders. 4) Notify MD orders if the patient has any problem with the bowel prep to enhance communication with nurses. 5) As needed orders for nasogastric tube placement for administration of the prep. 6) An order set was implemented in Epic to facilitate the process and make it uniform.

RESULTS:

After the first PDSA cycle (Sep 2017-May 2018), we were able to reduce the percentage of failed inpatient colonoscopies from an average of 15% to less than 5% and we reduced the percentage of inadequate bowel prep by 4% (Goal of 5%). In the second PDSA cycle (May 2018-May 2019), we maintained the percentage of failed inpatient bowel preparation under 10% (4.2-7.5%) and reduced the percentage of inadequate bowel prep 17% from the baseline.

CONCLUSION:

Implementing a split-dose regimen of 4 liter PEG-ELS for all inpatient colonoscopies, improving communication between nurses and ordering physicians, and executing a standard order set for bowel prep orders and instructions are successful strategies in optimizing inpatient bowel preparation. The reliability of the bowel preparation quality scales needs to be validated for use in inpatient colonoscopies.
606 Aggressive Approach Save Life in People Admitted for Both Upper GI Bleeding and Acute Coronary Syndrome
Authors: Al-Aboodi Yasir , Al-Chalabi Ahmed , Kobeissy Abdallah , Sodeman Thomas , Nawras Ali
Published: October 2019

INTRODUCTION:

We occasionally encounter patients with upper gastrointestinal bleed (UGIB) who also happen to have coronary syndrome (ACS) during the same admission. In this study we tried to give a better insight about this target population demography and what's the best approach in terms of treatment options and its relationship with the inpatient mortality.

METHODS:

We did retrospective analysis using the National Inpatient Data base (NIS) for 2014. Its the largest available public all payer and it includes more than 7 millions inpatients admission. we examine the mortality difference among people who were admitted for UGIB and ACS and received different interventions approach including no interventions, endoscopy (Colonscopy/Endoscopy), Left heart Cath, or combination of left heart Cath and endoscopy. All diagnosis and procedures were captured using the the international code for disease version nine (ICD9).

RESULTS:

2830 ACS and UGIB related admission were extracted from the data. Mean age is 68 yr. 62% (1750) male and 38% (1075) female. 73% (2070) white; 14% (400) black; 7.1% (200) Hispanic; 65 (2.3%) Asian; 25 (0.9%) Native; % Others 2.5%. 195 out of the 2830 died. Of the 195 dead, 130 (66.7%) received no interventions, 50 (25.6%) received scopes only, 10 (5.1%) received left hearth catheterization only and 5 (2.6%) received both scopes and left hearth catheter. Considering no intervention as a reference, the likelihood of surviving are 3.3, 3.1, and 1.5 among combined therapy, Left heart Cath only and scopes only respectively (P < 0.005, CI 95% 1.3-2.5).

CONCLUSION:

Combined approach of endoscopy (colonoscopy/EGD) and left hearth catheterization for people with (UGIB and ACS) related admission have 3 times more likelihood to survive compared to patients who received no intervention.
610 The Comparative Effectiveness of Endoscopy versus Angiography in Patients With Recurrent Non-Variceal Upper Gastrointestinal Bleeding
Authors: Sanghi Vedha , Garber Ari , Lopez Rocio , Rizk Maged , Vargo John , Jang Sunguk
Published: October 2019

INTRODUCTION:

Patients with recurrent non-variceal upper gastrointestinal bleed (NVUGIB) undergo repeat EGD, and for any further bleeding episode, consideration of angiography or interventional radiology (IR) with arterial embolization is employed. However, there is minimal evidence to support these recommendations promulgated by the national societies (refer to guideline). We sought to compare the effectiveness of repeat EGD with IR in achieving hemostasis in patients with recurrent NVUGIB after initial endoscopy.

METHODS:

This is a single-center retrospective cohort study. Between 2008-2018 consecutive ICU patients who underwent an EGD for diagnosis of NVUGIB (melena, hematochezia, hematemesis, coffee-ground emesis) were included. Continuous bleeding was defined by no hemostasis achieved, while recurrent bleeding was defined as re-bleeding within 30 days of hemostasis after index EGD. When hemostasis was not achieved, patients were stratified into treatment modalities of repeat EGD, IR without embolization, empiric embolization or lesion embolization. Generalized linear mixed models were used to evaluate if treatment effects re-bleeding when all bleeding episodes were analyzed.

RESULTS:

A total of 1067 patients were eligible for analysis. Mean age was 63 years and 44% were female. Following initial EGD, 90% (n = 960) of patients achieved hemostasis, 16% (n = 157) had recurrent bleeding and 10% (n = 107) had continuous bleeding without initial hemostasis. When compared to patients who underwent EGD and IR, patients with repeat EGD only had significantly higher Charlson Comorbidity Index (4.8 ± 3.2 vs. 3.4 ± 2.4; P < 0.001) and fewer re-bleeding episodes (P < 0.001). When all episodes of recurrent and continuous bleeding were analyzed, EGD had a three times higher likelihood of hemostasis when compared to IR without embolization (OR 2.9, 95%CI 1.05-7.7; P = 0.039). There is no significant difference between EGD and IR with empiric or lesion embolization or when all forms of IR were combined.

CONCLUSION:

Repeat EGD is three times more likely than IR without embolization in achieving hemostasis for all episodes of recurrent or continued NVUGIB after an initial endoscopy. However, EGD and IR with embolization appear equally effective modalities in achieving hemostasis after recurrent or continuous NVUGIB. The study is the first to directly compare EGD with IR and validates consensus recommendations of repeating upper endoscopy when hemostasis is not initially achieved as well as utilizing IR when necessary.
611 Finding the Ideal BUN to Creatinine Ratio in an Upper GI Bleed
Authors: Patel Sneha , Peraza Jellyana , Hasani Aliaskar , Luther Sanjana , Chugh Rishika , Tokayer Aaron
Published: October 2019

INTRODUCTION:

The ratio of blood urea nitrogen (BUN) to creatinine can be used as a surrogate for identifying sources of upper gastrointestinal bleed (UGIB). The proposed mechanism of this “accelerated azotemia” is brisk bleeding above the ligament of Treitz, followed by blood protein breakdown and absorption in the upper GI tract in the setting of hypovolemia and subsequent kidney hypoperfusion. Several ratios have been described in the literature, with variable sensitivities and specificities, but there is no consensus on the ideal ratio for recognizing an UGIB. Our study seeks to expand upon a prior research study done at our institution to determine the sensitivity, specificity, and positive predictive value (PPV) of gradated BUN/creatinine ratios (20:1 to 100:1) in identifying an UGIB.

METHODS:

1,194 patients were identified between 2008 and 2016 using “Looking Glass Clinical Analytics”TM. Inclusion criteria were patients admitted with hematochezia, melena, or hematemesis, with a decrease in hemoglobin (Hb) of >1 g/dL from baseline. Patients with chronic kidney disease stage 3 or greater were excluded. Demographic data and source of bleeding were collected. Hb, BUN, and creatinine values were collected at baseline, day 1, and day 2 of admission. Sensitivity, specificity, and PPV were calculated for each ratio. A receiver operating characteristic (ROC) curve was created for day 1 and 2 of admission.

RESULTS:

604 patients had GI bleeding confirmed by endoscopy. Average age was 67 years, 50% (n = 302) were female, and 76% (n = 459) were Black or Hispanic. 62% (n = 375) had a confirmed UGIB source. Median change in Hb from baseline was 3.0 g/dL. For a BUN/creatinine ratio of ≥20:1 on day 1, specificity was 66.67%, sensitivity was 73.32%, and PPV was 78.16%. Values for day 1 and 2 of hospital admission are listed in Tables 1 and 2. ROC curve on day 1 (Figure 1) had an area of under the curve of 0.68 (CI = 0.64-0.73).

CONCLUSION:

A BUN/creatinine ratio of ≥30:1 has a PPV of 84% and may be ideal for identifying an UGIB. Interestingly, as the ratio increases above 30:1, the PPV plateaus and the likelihood of UGIB does not increase further. The specificity of UGIB at 30:1 is high at 85%. The ROC curve shows that the BUN/creatinine ratio is an accurate test for predicting an UGIB. This indicates that in clinical practice, a patient presenting with GI bleeding and a drop in hemoglobin ≥1 g/dL associated with an “accelerated azotemia” of ≥30:1 should first undergo upper endoscopy to localize a bleeding source.
629 Point-of-Care Ultrasound Improves Aspiration Risk Assessment for Anesthesia in Upper GI Bleeding: A Prospective Study
Authors: Jen Henry , Beg Tazeen , Ahmad Sahar , Buscaglia Jonathan M. , Bucobo Juan Carlos
Published: October 2019

INTRODUCTION:

Gastric contents can be identified using point-of-care ultrasound prior to administration of anesthesia as part of a risk assessment tool to prevent aspiration however its clinical use is still being explored. We investigated the utility of US immediately prior to EGD in patients with suspected upper GI bleeding and its effect on anesthesia management.

METHODS:

We performed a prospective observational study of 30 patients undergoing EGD for upper GI bleeding at a large tertiary care center. All patients underwent a 2-5 minute US assessing antral contents in the endoscopy suite. EGD was then performed and actual gastric contents was assessed. A decision to proactively intubate was made prior to US findings and adjusted accordingly at the discretion of the anesthesiologist depending on US results. Outcomes included the confirmation of US results with EGD findings, aspiration events, intubation decisions, need for escalation of care, successful EGD intervention, and mortality.

RESULTS:

All 30 patients had US results that correlated directly with EGD findings. A total of 26 of the 30 patients (86.7%) were found to have negative US findings and all were found to have empty stomachs on EGD. 7 of these 26 (26.9%) presented initially with hematemesis. A total of 4 of the 30 patients (13.3%) had positive US findings and all were confirmed to have old or fresh blood seen immediately upon entering the stomach on EGD. Additionally, 5 of the 30 patients had US findings that altered anesthesia management preprocedure. Of these, 4 patients had empty stomach findings on US and thus were not intubated. All 4 had successful endoscopic interventions without aspiration events. The other 1 patient was unexpectedly found to have a full stomach on US and thus was electively intubated. The patient was found to have significant blood and clot in the stomach due to an underlying ulcer which was treated successfully. The patient was extubated post procedure without any aspiration event.

CONCLUSION:

In a prospective observational study, point-of-care US use prior to EGD was found to be accurate and effective in determining gastric contents and aided in preprocedural decision-making to help prevent aspiration events. To our knowledge, this is the first prospective study assessing this question and is a proof of concept that US is a viable risk assessment tool for patients with upper GI bleeding undergoing EGD.
662 Inflammatory Bowel Disease Patients With Type 2 Diabetes and Obesity Have a Higher Annual Burden and Costs of Hospitalizations: A Call for Action
Authors: Butnariu Madalina , Porter Kyle , Husain Syed , Afzali Anita
Published: October 2019

INTRODUCTION:

Morbid obesity (MO) is increasingly more common among patients with inflammatory bowel disease (IBD). Prior studies describe a complex interplay between the proinflammatory state associated with obesity and IBD. Type 2 diabetes (T2D) patients are also at risk for poorer outcomes and additional healthcare costs. The clinical implications of obese, diabetic IBD patients are not well described. We conducted a nationally representative cohort study to estimate and compare the burden, costs and causes for hospitalizations and readmissions among IBD patients with or without diabetes and obesity.

METHODS:

Using the Nationwide Readmissions Database (NRD) 2010-2014, IBD patients were categorized into 4 groups: T2D and MO; MO alone; T2D alone; no-T2D and no-MO. A 1:1 propensity score was performed for each group matching to patients with both T2D and MO. Linear regression was used to compare rates of hospital days, total costs, and number of hospital admissions among the 4 groups. Outcomes were log-transformed for analysis to better meet normality assumptions, as each was right-skewed. Calendar year mortality were compared between groups by logistic regression.

RESULTS:

There were 8,526 IBD patients with T2D and MO; MO alone (n = 12,512); T2D alone (75,269); and no-MO and no-T2D (466,508). After propensity score matching, the mean number of hospital days per year (13.9 days, 95% CI 13.2-14.7) and mean cost per year ($32,709, 95% CI 30,937-34,582) were higher in the T2D and MO group compared to other groups (P < .001). Mean number of admissions per year was higher in the T2D and MO group (2.88, 95% CI 2.77-2.99) compared to MO only group (2.70, 2.58-2.82) (P < .05). T2D and MO were more likely than other groups to have infection- and respiratory-related readmissions (P < .001); and more likely than no-T2D/no-MO to have IBD-specific (P = 0.01) or cerebrovascular readmissions (P = .004). T2D patients were more likely than MO only or no-T2D/no-MO for cardiac-related readmissions (P < .001). There were no differences in mortality among the four groups.

CONCLUSION:

Our NRD analysis demonstrates that diabetic, obese IBD patients have higher burden and costs of hospitalizations. Improved strategies and preventative care efforts for tighter glycemic control and weight loss are needed to target this high-risk group of patients with IBD.