bluuebunny/crossref_metadata_2025 huggingface dataset:
220 Gender Differences of Acute Diverticulitis Hospitalizations in the United States
Authors: Persaud Alana , Panchal Dayna
Published: October 2019

INTRODUCTION:

The incidence of diverticulosis has been increasing and various factors including diet, race, and genetics may influence the severity of subsequent diverticulitis. However, it is recently seen that gut microbiota can also play a role in diverticular disease. Indeed, sex-specific microbiota have been documented in humans. Other works have demonstrated post-surgical complications and surgical outcomes that are greatly influenced by gender. This study sought to examine the different outcome measures of diverticulitis hospitalization, based on gender.

METHODS:

The National Inpatient Sample is an inpatient database consisting of approximately 20% of all admissions to non-federal hospitals in the United States. We collected data in all patients with a primary diagnosis of acute diverticulitis in 2014, which was then stratified by gender. Cases were identified using the International Classification of Diseases, Ninth Edition, Clinical Modification codes. Primary outcomes were mortality, cost of admission, and length of stay. Multivariate logistic regression was used to adjust for demographics, hospital characteristics, and co-morbidities.

RESULTS:

There were 220,390 patients included; 127,840 females (58%) and 92,550 males (42%). Caucasians comprised 77% of both cohorts and mean age was greater in women (64 years old vs. 56 years old, P < 0.00). The mortality was greater in women (590 deaths vs. 350 deaths), which mirrored the increased length of stay in females (4.77 days vs. 4.61 days, P < 0.00). Interestingly, there is an increased cost of hospitalization in males ($38,385 vs. $39, 445, P < 0.058). Logistic regression showed no association between women and increased mortality or length of stay. However, hospitalization was associated with greater economic burden in males.

CONCLUSION:

Diverticulitis hospitalization has been increasing over time and is a substantial source of morbidity and mortality in the United States. This analysis revealed that the female cohort develops diverticulitis to a greater extent. Despite this, mortality and length of stay are not significantly affected by gender. However, the financial impact of treatment is considerably more among males. A plausible explanation may reside in the treatment modality utilized (surgery versus prolonged antibiotic course). Furthermore, colon microbiota may also play a role in the outcome measures demonstrated above, but prospective studies are needed to further elucidate this relationship.
224 Is Completing Advance Endoscopy Fellowship Necessary to Perform Adequate Endoscopic Mucosal Resection to Remove Large Colon Polyps?
Authors: Mouchli Mohamad , Reddy Shravani , Walsh Christopher , Mir Adil , Kesar Varun , Shakhatreh Mohammad , Chitnavis Vikas , Yeaton Paul
Published: October 2019

INTRODUCTION:

Objective: The efficacy of Endoscopic mucosal resection (EMR) of large colon polyp could be addressed by assessing the recurrence rate, complication rates, and the number of procedures needed to eradicate the residual tissue. Aims: Assess risk factors for recurrence after EMR of large colon polyps and compare EMR efficacy between endoscopists who completed advanced endoscopy fellowship and skilled endoscopists who did not complete advance endoscopy fellowship.

METHODS:

We identified all patients with documented large colonic treated using EMR technique at Carilion Clinic, Roanoke between 01/01/2014–12/31/2017, with follow-up through 10–2018. Information on demographics, clinical and pathological features of high-risk polyps, number and timing of surveillance endoscopies, tools used during resection, and skills of performing endoscopist's were extracted. The cumulative risks of polyp recurrence after first resection using EMR technique were estimated using Kaplan-Meier curves. Risks associated with polyp recurrence were assessed using multivariate Cox proportional hazard analysis.

RESULTS:

One hundred and thirty patients (Mean age, 64.2 ± 10.7 yrs; 43.1% males) with large polyps removed using EMR (61 (46.9%) removed by advanced endoscopists (group 1) and 69 (53.1%) removed by non-advanced endoscopist (group 2)) were identified. Most of the polyp resected were located in the right colon (70.8%) and 60 (46.1%) removed in piecemeal fashion. At follow-up endoscopy, 37/130 (28.5%) developed polyp recurrence at the polypectomy site within a median of 5.5 months. The mean number of procedures needed to eradicate the residual tissue was 1.37 ± 0.64 and the resection was complicated by delayed bleeding in 6 cases (3 in each group). The median recurrence after polypectomy was not different between the two groups (1.76 yrs vs. 1.04 yrs, P = 0.26) (Figure 1). Using multivariate analysis, Prolonged withdrawal time (RR, 1.02; 95% CI, 1.003–1.027, P-value <0.01) and increased number of endoclips used to close the defect (RR, 1.2; 95% CI, 1.05–1.40, P-value <0.01) were found to be associated with high risk of polyp recurrence after resection.

CONCLUSION:

Polyp recurrence rates after EMR were not different between enodoscopists who completed advanced endoscopy training and the ones who did not. Prolonged withdrawal time and increased number of endoclips deployed to close the polypectomy defect were associated with increased risk for polyp recurrence.
235 Variable Classification of Sessile Serrated Colon Polyps Among Pathologists in an Academic Center
Authors: Abadir Alexander P. , Moosvi Zain , Karnes William
Published: October 2019

INTRODUCTION:

Sessile serrated polyps (SSPs) are candidate precursors of most interval colorectal cancers. These mostly right-sided lesions are easily missed, often incompletely removed, and may progress rapidly to malignancy. Accurate histologic distinction between precancerous and non-precancerous polyps is key to choosing appropriate intervals for colonoscopy. Among serrated polyps (SPs), precancerous SSPs are histologically similar to non-precancerous hyperplastic polyps, and disparity among expert pathologists is high with independent reviews of the same specimens. We assessed if this discrepancy would be reflected by significant variability in classification rates of HPs and SSPs among pathologists in a real-world academic clinical setting.

METHODS:

Using our Colonoscopy Quality Database (UCICQD) at a large academic medical center, we analyzed prospectively-collected data for all polyps removed and examined between 6/2012 and 12/2016. Polyp classification rates of each pathologist were calculated; association between pathologists and polyp classifications were assessed by unconditional logistic regression for multivariate analysis. The rate of classification of each pathologist was analyzed as polyp size increased.

RESULTS:

Of 8,274 in polyps classified by 9 pathologists, 62.5% were described as adenomas. For 3,103 SPs, a mean of 22.0% was classified as SSPs. SSP classification rate varied among pathologists; a statistically significant association was found between pathologists and type of SP (HP vs SSP) (P < 0.0001). The rate increased for all pathologists with increasing polyp size, although variability was high and pathologists maintained their relative positions when comparing SSPs/SPs between polyp sizes (1–3 mm vs >4 mm), R = 0.8, P = 0.01.

CONCLUSION:

The SP classification rates of pathologists in the right colons are highly variable. The fraction of SPs classified as SSPs increases with polyp size but variability among pathologists remains high. This suggests that each pathologist is influenced by polyp size but has a different histologic threshold for distinguishing HPs and SSPs in the right colon. This data supports the idea that serrated polyps (HPs or SSPs) proximal to the sigmoid colon should be considered "surveillance relevant". This strategy will likely reduce interval cancer rates at the expense of additional colonoscopies in those with true HPs. Novel methodologies are needed to distinguish these morphologically similar but biologically distinct lesions.
238 Prevalence of Advanced Polyps at Age 45–49 Is Similar to 50–54 Years
Authors: Butterly Lynn F. , Siegel Rebecca , Robinson Christina N. , Anderson Joseph C.
Published: October 2019

INTRODUCTION:

The American Cancer Society recommends that colorectal cancer (CRC) screening begin at 45 years. To further inform this issue, data on advanced adenoma (AA) and serrated polyp (SP) prevalence in this population are vital. We used the New Hampshire Colonoscopy Registry (NHCR) to examine age related prevalence of advanced findings in an average risk “screening” cohort <50.

METHODS:

Indications for colonoscopies in adults <50 are often diagnostic. We made the assumption that some indications (e.g., abdominal pain or constipation) might not be associated with increased risk of adenomas. To ensure an appropriate “average risk” population <50, we included only those indications expected to yield AA prevalence rates similar to screening exams, and also tested this assumption. We excluded higher-risk indications, such as GI bleeding, occult blood, Fe deficiency anemia and abnormal imaging. We also excluded surveillance exams, family history of CRC, incomplete exams and poor bowel preparation. AAs were adenomas >1 cm or with villous elements or high-grade dysplasia, or CRC. Clinically significant serrated polyps (CSSP) included large (>1 cm) SPs, any sessile SP or traditional serrated adenoma, and any proximal SP >5 mm. We present prevalence/adjusted risks for AA, adenomas and CSSP. Age was stratified into <40 (reference), 40–44, 45–49, 50–54, 55–59 and 60+ years. Covariates were sex, smoking and BMI. To test our hypothesis regarding indications, we examined the prevalence in screening versus the prevalence in included and excluded indications. We also added the presence of low-yield symptoms as a covariate.

RESULTS:

In our sample (n = 42,600), AA prevalence increased significantly at 40 yrs. The prevalence of AA and CSSP was similar for ages 45–49 and 50–54. In the model, older age was associated with significantly increased risk for AA and adenomas (Table 2). Older age effect was less pronounced in CSSPs. The prevalence of AA was 4.4% for screening, 3.2% for the included diagnoses and 5.8% for the excluded diagnoses (P < 0.001), supporting our assumption regarding indication. Low-risk symptoms were not associated with an increased risk (OR = 1.03: 0.84–1.13), further confirming our assumption.

CONCLUSION:

The prevalence of AA increased significantly in the 40–44 group as compared to those <40. The increased prevalence for both AA and CSSP at age 45–49 was similar to that for those 50–54 years. These data support the suggestion that to optimize prevention, screening should begin at 45 years.
240 Impact and Outcomes of a Weekend Screening Colonoscopy Program in a Large Health Network in Western Pennsylvania
Authors: Umar Shifa , Gladys-Oryhon Jordan , Cole Rita , Thakkar Payal , Syed Aslam , Aoun Elie , Abdul-Baki Heitham , Babich Michael , Bradley Bruce , Kulkarni Abhijit , Flannagan Renee , Goswami Raktima , El-Hachem Sandra , Lebovitz Paul J. , Dhawan Manish , Hadam Jennifer , Gomez Gustavo , Kandil Hussam , Mitre Marcia , Strahotin Cristina , Mlecko Michael L. , Gottfried Irving , Glick Kenneth , Midian Robin , Toney Rachel , Morrissey Suzanne , Gadani Akash , Chintamaneni Preethi , Appasamy Ragunath , Oliva Jose , Pfister Michelle , Deweese Dianna , Kochhar GurSimran , Manzi Susan , Parker Brian M. , Thakkar Shyam , Farah Katie
Published: October 2019

INTRODUCTION:

Colorectal cancer screening remains underutilized with 66–67% of adults 50–75 years old being up to date with screening. The National CRC Roundtable and the ACG aimed to increase screening rates to 80% by 2018. To achieve this goal, screening colonoscopy was provided on Saturdays to improve access and provide for patients who could not take a day off of work. We evaluated the impact of improved access to colonoscopy through Saturday screenings.

METHODS:

In March 2018, Fall 2018, March 2019, colonoscopies were scheduled with 28 different providers on 12 Saturdays at 8 different sites. Patients were asked to complete a brief survey to capture demographics and reasons for choosing a Saturday for their colonoscopy. Pathology results and adenoma detection rates were collected and analyzed 1 week after procedure.

RESULTS:

220 colonoscopies were scheduled and 214 procedures performed with 6 no-show/cancellations. 207 surveys were completed. Public awareness for Saturday colonoscopies was provided through our Network hospital and healthcare insurance provider websites as well as physician practices, and social media. The mean age of participants was 55 years with the majority being Caucasian and female. Post procedure results were analyzed for the number and size of polyps, polyp pathology, and resultant surveillance intervals. Of the 207 procedures, 37.7% (n = 78) of patient has at least one adenoma. Figure 1 shows breakdown of adenoma type by number of patients. Surveillance intervals changed to 5, 3 and 1 year for 37% (n = 76), 14% (n = 30), and 3% (n = 6) of patients, respectively (Figure 2). We also found that 86% of patients were more likely to complete their colonoscopy if scheduled on a Saturday. 42% indicated that the major reason for delay in scheduling was inability to take a day off of work (Table 1).

CONCLUSION:

The impact of Saturday colonoscopies within our large Network and surrounding community is evidenced by the overwhelming response that patients would be more likely to complete their screening colonoscopy on a Saturday, if offered. The convenience of non-traditional Saturday scheduling provides substantial positive impact in our mission to improve colorectal cancer screening rates in Western Pennsylvania and to provide high quality care as well as with improved patient experience.
249 Is Stool DNA Test More Specific for Proximal or Distal Neoplasia?
Authors: Inaganti Anupama , Fahed Julien , Fahed Gracia , Huq Nadia , Affi Aboud
Published: October 2019

INTRODUCTION:

A handful of studies evaluated stool DNA test as a screening method but there is little to no data on the location of the “positive findings” detected on subsequent colonoscopy. In our study, we performed a retrospective analysis on location of adenoma in patients with positive stool DNA test.

METHODS:

A retrospective chart review of 459 patients who had a positive stool DNA followed by “positive findings” on subsequent colonoscopy was performed. “Positive findings” was defined as finding of cancerous or advanced precancerous lesions. Only the location of the index lesion was recorded. If two positive findings were recorded, the larger of the two lesions was designated as the index lesion unless they share the exact characteristics. In that case, it was reported as “both proximal and distal.” Proximal colon lesion was defined as lesion noted in the splenic flexure and all the segments proximal to the splenic flexure. Distal colon lesions were defined as lesions distal to splenic flexure. Advanced adenoma was defined as an adenoma that is larger than 10 mm or had high risk features such as villous transformation or high grade dysplasia. Non-advanced adenoma was defined as an adenoma that is smaller than 10 mm and had no high-risk features.

RESULTS:

Out of the 459 patients, 24 patients had “adenocarcinoma,” 334 patients were noted to have an “advanced adenoma” and 101 patients who had “non-advanced adenoma.” Out of the 24 cancer patients, 70.83% had distal cancer, while 25% had proximal cancer. Interestingly, one patient had a proximal and distal cancer at the same time. The distribution of advanced adenomas was different and the location was shared equally between proximal and distal in 47.31% and 49.40% respectively, while the remaining 3.29% had advanced adenoma in the proximal and distal colon simultaneously. Among patients with non-advanced adenoma, 62.38% of the adenomas were proximal, 26.73% were distal while 10.89% of the patients had evidence of non-advanced adenoma in both proximal and distal colon.

CONCLUSION:

The location of the “positive findings” on colonoscopy following a positive DNA test varied significantly based on the final diagnosis. Among patients with positive fecal DNA test, more significant pathology such as an advanced adenoma or adenocarcinoma was noted to be in the distal colon.
251 Detection Rates by Anatomic Location in Caucasians, Hispanics, and Asians
Authors: Moosvi Zain , Abadir Alexander , Roccato Mary Kate , Karnes William
Published: October 2019

INTRODUCTION:

Ethnic and racial disparities in colorectal cancer (CRC) incidence and mortality rate have been well studied in the literature. However, no study to date has compared surrogates of precancerous polyp prevalence: adenoma detection rate (ADR), polyp detection rate (PDR), sessile serrated adenoma detection rate (SDR) amongst ethnic groups with respect to polyp location. This study serves to compare ethnicities with respect to ADR, PDR, and SDR in 3 ethnic groups as a function of anatomic location.

METHODS:

This retrospective nonrandomized nonblinded cohort study utilized prospectively collected data at our single tertiary referral center from the UCICQDRes database. A total of 19 attendings and 55 fellows performed 8,894 colonoscopies from June 2012 to October 2018. Three study subgroups (Asian n = 1505, Hispanic n = 951, and Caucasian n = 6438) were compared for age, gender, BMI, total procedure time (TT), bowel prep score (BPS), cecal intubation rate (CIR), ADR, PDR, and SDR stratified by anatomic location.

RESULTS:

Asians had the highest BPS and age, while Hispanics had the lowest TT. There were differences in PDR and ADR across the ethnicities in all areas of the colon. For instance, in the cecum, Caucasians had the highest PDR (0.18, P = 0.0007), ADR (0.11, P = 0.0142), and SDR (0.027, P = 0.0034). In the left colon, SDR was not significantly different between the ethnicities. With the exception of transverse colon ADR, Hispanics had the lowest PDR and ADR for all anatomic locations.

CONCLUSION:

Except for ADR in transverse colon and SDR in the descending colon, Hispanics had significantly lower ADR, PDR, and SDR compared to other ethnicities. That Hispanic patients, in general, had lower detection rates in all anatomic locations may be at least partially attributed to the lower BPS and higher BMI and TT in this group. Further analysis is required to ascertain the effect of these variables. In the cecum and ascending colon, differences in ADR, PDR and SDR were significant between all groups. This study suggests that variations in detection rates based on anatomic location may contribute to variations in CRC incidence rates across ethnicities. Additional studies may be of interest to confirm and further explore these differences, as they may have the potential to warrant ethnicity-dependent CRC screening guidelines.
253 Geographic Early-Onset Colorectal Cancer Incidence Rate Disparities Within White and African American Populations in the United States
Authors: Abualkhair Wesal , Zhou Meijiao , Wu Xiao-Cheng , Karlitz Jordan J.
Published: October 2019

INTRODUCTION:

Prior study by our group revealed marked geographic disparities in early-onset colorectal cancer (EOCRC) incidence rates (IR) (Abualkhair et al. abstract #984 DDW 2019). Although it is established CRC IRs in African Americans are higher than whites, there is paucity of data on geographic EOCRC disparities within both white and African American populations. Hence, we seek to explore the role race may play in IR differences between U.S. regions and individual registries.

METHODS:

2000–2015 SEER 18 CRC IR Analysis (170,434 cases) was performed in one-year age increments (ages 30–60) in four U.S. regions, individual registries and stratified by race.

RESULTS:

There are wide regional IR disparities at multiple ages within both white and African American populations. For example, at age 45, there is a 52% difference (P < 0.05) between the highest (south) and lowest (west) regional IRs in African Americans compared to a 32% difference (P < 0.05) in whites (Figures 1 and 2). At multiple age points <50, there is a trend for greater disparity between the highest and lowest regional IRs within the African American population compared to within the white population (shaded boxes in Figure 2) however these did not reach statistical significance at most ages.

CONCLUSION:

There are marked geographic EOCRC IR disparities within white and African American populations between U.S. regions. There appears to be a trend toward more pronounced geographic disparities within the African American population, however interpretation is limited by lack of statistical significance at multiple age points, likely due to lower case counts. Targeting all populations is critical for CRC prevention, however we must assure attention is paid to higher-risk populations. Potential interventions include targeted risk factor modifications, assuring concerning symptoms trigger prompt diagnostic evaluations and taking advantage of earlier age 45 screening options supported by some guidelines (USMSTF recommends screening African Americans at age 45 and ACS recommends average-risk screening of all patients at age 45). By identifying higher-risk populations, future targeted studies can also be performed which may allow better understanding of rising EOCRC rates.
257 White Women Are More Frequently Assessed for Hereditary Colon Cancer Risks Compared to Minority Women
Authors: Pascual Lauren , Kirelik Danielle , Cioffi Joseph , Borum Marie
Published: October 2019

INTRODUCTION:

It is estimated that 5% of individuals with colon cancer inherited a mutation which increased their risk for the malignancy. Multi-generational family histories are recommended to preliminarily determine genetic risks and initiate referrals for genetic counselling. While women may frequently be assessed for genetic risks associated with breast cancer, it is unclear if GI providers consistently obtain family history in women seeking colon cancer screening. This study evaluated the rates of family histories obtained in women referred for colon cancer screening at a university medical center.

METHODS:

A retrospective chart review evaluated all women seen by GI providers for colorectal cancer (CRC) screening in the gastroenterology clinic of a university medical center during a 3 month period. Patient age, race, documentation of family history (3 or more generations) was obtained. A confidential database was generated using Microsoft Excel. Statistical analysis using Fisher's Exact Test was performed with significance set at P < 0.05. The study was approved by the institutional IRB.

RESULTS:

500 medical records were reviewed. The mean age was 59.6 (range 33–89). Self-reported race/ethnicity included 276 African-American, 123 White, 32 Hispanic, 30 Asian, 20 other and 19 undocumented. 102 (20.4%) had a multi-generational family history. White women were significantly more likely to have a documented 3 generation history compared to all other women (30.08% vs 16.48%), P = 0.0016. African-American compared to white women were less likely to have detailed family histories obtained (17.03% vs 30.08%), P = 0.0050.

CONCLUSION:

This study demonstrated that multi-generational family histories were not adequately obtained in women by GI providers during colon cancer screening visits. White women compared to all other women more often had detailed family histories documented. Despite African-American women having the highest prevalence of colon cancer among all women in the United States, multi-generational family histories were less frequently obtained. While this study is limited by single institutional design, reliance upon provider documentation and short duration, it provides a foundation for additional research. Increased provider and patient education about the potential significance of family history in colon cancer risk assessment is critical to optimize outcomes.
262  The Effect of Deep Sedation on Adenoma Detection Rate in Screening Colonoscopies: A Meta-Analysis and Systematic Review
Authors: Alomari Mohammad , Al Momani Laith , Bratton Hunter , Aasen Tyler , Thota Prashanthi N. , Sanaka Madhusudhan R.
Published: October 2019

INTRODUCTION:

The cornerstone of colon cancer prevention is high-quality examination of the entire colonic mucosa at designated intervals. Deeper sedation has been correlated to greater patient satisfaction, shorter procedures, and faster recoveries. However, disagreement exists on whether deeper sedation correlates to an increase in adenoma detection rate (ADR); a surrogate marker of colonic visualization. The aim of this meta-analysis is to evaluate the previously published research on the difference in ADR in colon cancer screening colonoscopies between deep and moderate sedation (i.e., conscious sedation).

METHODS:

We performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through May 2019, to identify all human studies that evaluated the association between deep sedation with Propofol versus moderate sedation and the rate of adenoma detection. We included studies that presented an odds ratio (OR) with a 95% confidence interval (CI) or included data sufficient to calculate the OR with a 95% CI. Statistical analysis was performed using the Comprehensive Meta-Analysis (CMA), Version 3 software.

RESULTS:

Five studies with a total of 112,098 patients undergoing screening colonoscopies were included in this study, 6,476 of which received deep sedation with Propofol (5.8%). The pooled OR for ADR in patients who underwent deep sedation with Propofol compared to moderate sedation is 1.137 (95% confidence interval: 1.019–1.269, P = 0.022; I2 = 37.756%) (Figure 1). No publication bias was found using Egger's regression test (Figure 2).

CONCLUSION:

Our results indicate that patients receiving deep sedation with Propofol are 14 percent more likely to have adenoma detected during a screening colonoscopy than in those who are moderately sedated. To our knowledge, this study represents the first meta-analysis to assess this association. Future prospective randomized research is needed to confirm this association before making any changes in the standard practices of sedation during screening colonoscopies.
267 Family Comes First: GI Providers May Inconsistently Perform Multi-Generational Family History When Assessing Colon Cancer Risk
Authors: Cioffi Joseph , Kirelik Danielle , Pascual Lauren , Borum Marie
Published: October 2019

INTRODUCTION:

Approximately 5–10% of cancers are attributable to hereditary cancer syndromes. It is recommended that a preliminary risk assessment for colon cancer include a family history in first and second degree relatives, genetic testing when appropriate and tumor analysis when possible. GI providers can optimize clinical decisions regarding colon cancer screening by obtaining multi-generational family history. However it is uncertain if providers consistently document family history for possible referral for genetic testing. This study evaluated rates of multi-generational family history documentation by GI providers in patients referred for colon cancer screening at a university medical center.

METHODS:

A retrospective chart review of all patients referred for colon cancer screening to the gastroenterology clinic during a 3 month period was performed. Patient gender, age, race, indication for CRC screening, documentation of a family history (3+ generations) was obtained. A confidential database was generated using Microsoft Excel. Statistical analysis using Fisher's Exact Test was performed with significance set at P < 0.05. The study was approved by the institutional IRB.

RESULTS:

872 medical records (500 females, 372 males) with a mean age of 59.2 (range 29–89) were reviewed. Self-reported race/ethnicity included 452 Black/African-American, 363 White, 54 Hispanic, 42 Asian, 36 other and 34 undocumented. 144 (16.51%) had a multi-generational family history. Detailed family history was obtained significantly more often in females (102; 20.4%) compared to males (41; 11.02%) (P = 0.0023) and in whites (58; 22.05%) compared to non-whites (77; 13.39%) (P = 0.0023). Female providers were significantly more likely to obtained a detailed family history compared to male providers (26.9% vs 9.81%) (P = 0.0001).

CONCLUSION:

This study revealed that there was inconsistent documentation of multi-generational family history by GI providers in patients referred for colon cancer screening. Females and whites were more likely to have family risk assessment. Female providers more frequently obtained detailed family histories. While this study is limited due to duration and single institution design, it provides important information for subsequent studies and educational intervention. It is important that there is optimal assessment of colon cancer risk in effort to improve early detection and outcomes.
272  Artificial Intelligence Based Computer Aided Detection System Reliably Detects Polyps Earlier Than Physicians During Colonoscopy
Authors: Quan Susan Y. , Friedland Shai , Pirsiavash Hamed , Kompella Ravindra , Sachdev Vineet
Published: October 2019

INTRODUCTION:

Artificial intelligence (AI) is increasingly being used as an aid to physicians in multiple areas of medicine. Computer aided detection (CAD) has the potential to assist endoscopists in detection of colon polyps and flat lesions during colonoscopy. Real-time detection of polyps can potentially increase adenoma detection rates and decrease adenoma miss rates, as computerized algorithms are able to analyze the entire field of view more rapidly than humanly possible and do not suffer from fatigue or distraction.

METHODS:

We designed a deep learning based CAD system that is able to process 30 endoscopy video frames per second in real time and highlight one or more polyps that are detected anywhere in the field of view. Our deep learning algorithm was trained on 26000 images extracted from hundreds of procedure recordings. The detection performance of the CAD system was measured on 100 colonoscopies. To compare how early the CAD system detects relative to endoscopists, 25 different colonoscopy video clips of varying length (30–180 sec) that included a single polyp were reviewed by 5 experienced endoscopists. The endoscopist pressed a button on the computer keyboard as soon as the polyp was visualized, and the time was recorded. This was compared to the time at which the CAD system detected the polyp.

RESULTS:

In the 100 clinical colonoscopy cases, a total of 250 polyps were found and removed in 86 patients (14 patients had no polyps detected). There were 171 tubular adenomas, 54 hyperplastic polyps/mucosal excrescences, 11 inflammatory polyps, 6 villous adenomas, 6 sessile serrated polyps and 2 traditional serrated adenomas. The CAD system detected 247/250 polyps (98.8%). The 3 polyps that were not detected were: one 6 mm serrated polyp, one 4 mm tubular adenoma and one 3 mm tubular adenoma. Separately, as shown in Figure 1, the early detection experimental analysis revealed that more than 49% of the polyps were detected earlier by the CAD system by 2 seconds or more. CAD system typically detected much earlier when physicians initially missed brief transient visibility (<500 ms) of the polyps.

CONCLUSION:

Our deep learning based CAD system is capable of detecting 99% of polyps that are found during routine colonoscopy. The system detects polyps significantly faster than physicians. Future studies will address whether this translates into higher adenoma detection rates or reduced miss rates in clinical practice.
275 Annual Ultrasound Screening Value in Patients With Familial Adenomatous Polyposis
Authors: Yu Justin , Balasubramanian Adithya , Agarwal Suneal , Gallagher Kathleen
Published: October 2019

INTRODUCTION:

Patients with familial adenomatous polyposis (FAP) are at an increased risk for developing papillary thyroid cancer (PTC). The American College of Gastroenterology clinical guidelines have recommended annual thyroid ultrasound screening (TUS) for FAP patients. The goal of this study is to investigate the cost effectiveness of annual TUS screening in this patient population using a novel financial and epidemiologic model.

METHODS:

A cost analysis was performed to determine the financial viability of annual TUS compared to biennial (every 2 years) or triennial (every 3 years) screens. Population growth was modeled using a variable growth rate based on previous trends in the United States growth rate. Key modeling parameters including TUS sensitivity/specificity, prevalence of FAP, and risk of PTC in FAP patients were extracted from the literature. Treatment protocols based on early versus late detection were adopted from the American Thyroid Association and the National Comprehensive Cancer Network guidelines. Costs for each component were ascribed using either the Centers for Medicare & Medicaid Physician Fee Schedule or literature values. The cumulative cost savings was derived as a function of these parameters and time.

RESULTS:

The prevalence of FAP was estimated at 3 in 100,000 with a 6.8% risk of PTC. The cost for early detection was $10,582 compared to $37,277 for late detection. TUS sensitivity/specificity were found to be 0.83 and 0.90. Using these parameters, our model revealed that annual TUS screening is only financially viable for a short interval. A maximum cumulative cost savings of over $10.3 million is observed after 2 years of implementation. After this time, the cumulative cost savings decreases at a rate of $780,000 per year and becomes negative after 15 years. Biennial and triennial screening intervals extend the period of financial viability to 30 and 45 years, respectively. Triennial screening results in a maximum cost savings of $10.4 million after 4 years.

CONCLUSION:

FAP patients are at an increased risk of developing PTC. TUS screening is warranted for early detection and treatment, but annual TUS screening may not be financially viable in the long term. Guidelines for annual screening may need to be re-examined and extended to every 2 or 3 years.
280 Patients With Non-Colorectal Cancers May Be at Elevated Risk of Colorectal Neoplasia
Authors: Abu-Sbeih Hamzah , Ali Faisal , Lum Phillip , Qiao Wei , Shafi Mehnaz A. , Bresalier Robert , Hawk Ernest , Raju Gottumukkala , Wang Yinghong
Published: October 2019

INTRODUCTION:

Screening for colonic neoplasia has decreased the incidence of colorectal cancer in the United States in the past two decades. Whether personal history of noncolorectal cancer is a risk factor for colonic neoplasia has not been studied. We assessed the risk of colorectal neoplasia in noncolorectal cancer survivors.

METHODS:

We conducted a retrospective study of patients who had undergone colonoscopy for any indication between 2009 and 2018. Colonic adenoma detection rate and multivariate logistic regression were conducted to assess for the primary outcomes of the study.

RESULTS:

The study included 9408 cancer patients and 3295 control patients. Colonic adenomas were detected in 4503 cancer patients (48%) and 950 cancer-free patients (29%). Histologic examination of these adenomas revealed tubulovillous features in 620 patients (5%) and villous in 153 (1%). High-grade dysplasia was detected in 1611 patients (13%). Invasive colorectal adenocarcinoma was detected in 455 patients (12%); this rate was highest in patients with multiple myeloma (14%) (Table 1). Multivariate analysis revealed that a personal history of noncolorectal cancer was associated with increased risk of adenoma (Odd ratio, 2.04; 95% CI, 1.84–2.26; P < 0.001). The adenoma detection rate was 30% in patients younger than 40 years (n = 1211), 32% in patients between 41 and 50 years (n = 812), 47% in patients between 51 and 60 years (n = 2892), and 55% in patients older than 60 years (n = 4493) (Figure 1).

CONCLUSION:

The adenoma detection rate in patients with a personal history of noncolorectal cancer is higher than the reported rate of the general population and our control group.
283 Too Few or Too Many Endoclips to Close Polypectomy Defect After Endoscopic Mucosal Resection?
Authors: Mouchli Mohamad , Walsh Christopher , Reddy Shravani , Mir Adil , Kesar Varun , Shakhatreh Mohammad , Chitnavis Vikas , Yeaton Paul
Published: October 2019

INTRODUCTION:

Endoclips could be placed prophylactically at the polypectomy site after the removal of large polyps to prevent post-polypectomy bleeding. The effect of an increased number of endoclips deployed after endoscopic mucosal resection (EMR) on polyp recurrence is unknown.

AIMS:

Evaluate the risk of polyp recurrence in patients with large polyps undergoing EMR based on the number of endocips deployed.

METHODS:

We identified all patients with documented large colon polyps treated using EMR technique at Carilion Clinic, Roanoke between 01/01/2014–12/31/2017, with follow-up through 10-2018. Information on demographics, clinical and pathological features of high-risk polyps, additional treatments required, number of endoclips used, and number and timing of surveillance endoscopies were extracted. The cumulative risks of polyp recurrence after first resection using EMR technique were estimated using Kaplan-Meier curves.

RESULTS:

One-hundred and thirty patients (Mean age, 64.2 ± 10.7 yrs; 43.1% males) with polyps removed using EMR (60 (46.2%) removed in piecemeal fashion, 70 (53.8%) removed en bloc) were identified. The mean size of polyps resected was 2.12 ± 1.12. Argon plasma coagulation and/or the tip of the snare were used to cauterize remnant polyps in 42/130 (32%). Eighty-six patients (66.2%) required endoclips deployment to close the polypectomy defect (Table 1). At follow-up endoscopy, 14/53 (26.4%) in group 1 and 14/33 (42.4%) in group 2 developed polyp recurrence at the polypectomy site within a median of 5.9 months. The median time for recurrence after polypectomy was longer for pts in group 1 as compared to those in group 2 (P < 0.01) (Figure 1). After excluding patients receiving cauterization of the remaining polypoid tissue after EMR, median time for recurrence after polypectomy remained longer for pts in group 1 (P = 0.03) (Figure 2). Late post-polypectomy bleeding occurred despite endoclips deployment in 2/53 (3.8%) in group 1 and 4/33 (12.1%) in group 2.

CONCLUSION:

Large polyps EMR appear to be associated with higher recurrence rate in lesions requiring more than three endoclips. These findings need to be confirmed in prospective trials.
285 Adherence to Recommending 10-Year Intervals After Normal Screening Colonoscopy in Average-Risk Individuals: A Snapshot of 2017 for Phase 1 of the Michigan CRC Screening Quality Improvement Project
Authors: Schoenfeld Philip , Kathi Pradeep R. , George Khalid , Goyal Sachin , Kim Hyungjin M. , Tommolino Emily , Piper Marc
Published: October 2019

INTRODUCTION:

The Michigan CRC Screening Quality Improvement Project (CRC-QIP) is a multi-center, 4-phase project to improve adherence with recommending 10-year intervals after normal screening colonoscopies. Per guidelines, target is 90% adherence with recommended intervals.

METHODS:

Inclusion criteria: In order to minimize possible confounders, patients were limited to: (a) average-risk, 50–75 year olds; (b) colonoscopy performed in 2017; (c) sole indication-CRC screening; (d) no biopsy, polypectomy, or any abnormal findings on procedure report. Study Setting: In order to minimize confounders when stratifying for specialty and type of practice, only medical centers with (a) GI fellowship program; (b) Hospital-based “open” endoscopy unit (i.e., utilized by private practice gastroenterologists (GIs), colorectal surgeons, and general surgeons). Primary Outcome: Adherence to guideline-consistent intervals defined as repeat colonoscopy in 10 years or discontinue CRC screening due to patient's age when bowel preparation is adequate or <1 year if bowel preparation is inadequate. Primary analysis is frequency of adherence based on endoscopist specialty after adjusting for multiple confounders, including procedure-related factors (e.g., withdrawal time), and endoscopist-related factors (e.g., yrs in practice, solo vs group practice, colonoscopies performed per yr). Hierarchical logistic regression model was used with adherence as the dependent variable with random intercepts for endoscopist performing procedure to account for correlation between endoscopist and site as fixed effects.

RESULTS:

Among 1,694 eligible patients, mean age was 58.7 ± 6.5, 43% male, and 68% African-American. Adherence was better for academic gastroenterologists with or without GI fellows vs private practice GIs or academic general surgeons (P = 0.04). The latter two groups were adherent in <40% of patients (Table 1). Adherence was significantly better with good/excellent bowel preps compared to all other bowel prep categories (P < 0.05), and patients with poor, fair, or no documentation of prep were adherent <50% (Table 2).

CONCLUSION:

In this project, adherence did not meet guideline-specified target of 90% among private practice GIs and general surgeons. Phase 2 will include additional analysis to identify factors associated with non-adherence and a mixed methods qualitative study to identify appropriate interventions to improve performance.
287 The Effect of Smoking on Multitarget Stool DNA Testing
Authors: Huq Nadia , Fahed Gracia , Inaganti Anupama , Affi Aboud , Fahed Julien
Published: October 2019

INTRODUCTION:

There is a known association between smoking and the development of colorectal cancer. Newer screening tools for colorectal cancer including multitarget stool DNA testing may have differing results with regards to patients who smoke. To our knowledge, there have not been other studies looking at smokers who completed stool DNA testing. Our study was completed to evaluate the effect of smoking on stool DNA testing and subsequent colonoscopy.

METHODS:

A total of 19400 patients had multitarget stool DNA tests. There was 8448 who did not have the test, and 9008 tests completed had negative results. There were 1413 patients with positive stool DNA followed by documented colonoscopy. Patients with unknown smoking status or finding of other carcinoma aside from adenocarcinoma were excluded. Colonoscopy findings were recorded and were divided into smokers (former or current) and nonsmokers. Only the index lesion was recorded. Advanced adenoma was defined as an adenoma larger than 10 mm or had high risk features such as villous transformation or high grade dysplasia. Nonadvanced adenoma was defined as an adenoma smaller than 10 mm and had no high risk features. Advanced neoplasia was defined as adenocarcinoma or advanced adenoma. Statistical analysis with Chi-square was done to compare the proportions. A P-value < 0.05 was considered statistically significant.

RESULTS:

Among smokers, 5474 (54%) completed the stool study versus 5474 (59%) among nonsmokers (P < 0.01). The stool DNA test was positive in 1204 (22%) of the smokers versus 738 (13%) (P < 0.01). From the positive results, colonoscopy was completed in 896 (74%) of smokers versus 564 (77%) (P = 0.311). Follow-up colonoscopy yielded 16 (1.85%) adenocarcinomas in the smoking group versus 8 (1.47%) nonsmokers (P = 0.59), 285 (33%) advanced adenomas versus 149 (27%) (P = 0.025), 248 (29%) nonadvanced adenoma versus 168 (31%) (P = 0.395), and 315 (36%) with no adenoma versus 220 (40%) (P = 0.141). A total of 301 (35%) of smokers with a positive test had an advanced neoplasia versus 157 (29%) in nonsmokers (P = 0.02).

CONCLUSION:

From our study, there is an increased chance of a positive multitarget stool DNA test in smokers as well as a higher chance of finding advanced neoplasia. Further prospective studies are needed to validate patient characteristics for those being offered multitarget stool DNA testing. Smokers may benefit from more immediate colonoscopy given an increased risk of advanced neoplasia in lieu of other screening tools such as stool DNA testing.
291  Characteristics Associated With Young Colorectal Cancer in the United States
Authors: Ali Sajjadh M.J. , Catalano Marc F.
Published: October 2019

INTRODUCTION:

The incidence of young colorectal cancer (20–49 years) has been rising since the early 1990s and the American Cancer Society has recommended that we lower the age of screening colonoscopy to 45. There is much debate about whether the incidence is truly rising or whether it is impacted by earlier screening in predisposed individuals. We aimed to study the factors which predict presentation of colorectal cancer at a younger age as compared to older patients aged above 50 years.

METHODS:

The SEER 18 database was queried for colorectal cancer cases from 1990 to 2016. Cases were classified into young (20–49 years) and old (≥50 years), and multinomial logistic regression was used to predict the race/ethnicity, gender and tumor characteristics that were more likely with younger patients as compared to older patients.

RESULTS:

818,621 total cases were reported. Analyses demonstrated that females were more likely than males to have colorectal cancer at a younger age (OR 1.055, CI 1.039–1.071). Non-Hispanic blacks were more likely than non-Hispanic whites to have younger age cancer (1.637, 1.383–1.937). Spanish Hispanic Latinos were more likely to have young cancer than non-Spanish Hispanic Latinos (2.128, 2.08–2.177). Indians/Pakistanis were more likely (1.277, 1.085–1.503) whereas Chinese (0.546, 0.495–0.602) and Japanese (0.372, 0.334–0.414) were less likely to have young cancer when compared to whites. Stage IV and III (1.586, 1.523–1.651; 1.575, 1.515–1.637) were more likely with young cancer than Stage I. Tumor sites such as rectum (1.351, 1.323–1.381) were more likely whereas ascending colon (0.511, 0.495–0.527) and hepatic flexure (0.627, 0.597–0.658) were less likely to have young cancer than the sigmoid colon.

CONCLUSION:

Race/ethnicity, gender, tumor stage/site as well as grade/histology were found to predict colorectal cancer at a younger age as compared to older patients. Younger patients had higher chances of advanced cancer (Stage IV/III) at presentation compared to older patients possibly due to prophylactic screening of patients above 50 years. Colorectal cancer is common at the sigmoid colon; but rectum and rectosigmoid junction were associated more with young cancer while other sites like cecum, ascending colon, hepatic flexure and transverse colon were less likely to be young than old cancer. Studies based on stratifying these and other risk factors may provide clues to the rising incidence of young colorectal cancer, and further recommendations maybe made for screening colonoscopy at younger ages.