bluuebunny/crossref_metadata_2025 huggingface dataset:
124 Investigating the Impact of Ambient Lighting on Adenoma Detection Rate and Eye Fatigue During Screening Colonoscopy
Authors: Hoff Ryan T. , Mazulis Andrew , Doniparthi Meghana , Munis Assad , Rivelli Anne , Lakha Asif , Ehrenpreis Eli
Published: October 2019

INTRODUCTION:

Previous studies indicate that adenoma detection rate (ADR) decreases as the number of consecutive hours performing procedures increases. Differences in adaptation between a bright screen and a dimly lit room may contribute to eye strain and eye strain related symptoms occur in most video display users. Increasing ambient light may improve symptoms of eye strain, but ambient light effects have yet to be explored in the field of gastroenterology. We aim to determine if the use of ambient lighting, between 75–150 lux, during screening colonoscopy will maintain ADRs and decrease symptoms of eye strain.

METHODS:

A single center study comparing screening colonoscopies in a dimly lit room to use of ambient lighting by 9 gastroenterologists was performed. Retrospective data was collected over a 6-month period performed in procedure rooms with no lighting. Prospective data was then collected on colonoscopies with ambient lighting during the same 6 calendar months the following year. A survey on eye fatigue was completed by all gastroenterologists before and after the use of ambient lighting. Satisfaction surveys were completed by gastroenterologists, anesthesiologists, nurses and technicians.

RESULTS:

There were 498 low light and 611 ambient light cases. 172 adenomas (ADR = 34.5%) were detected with low light and 220 adenomas were detected with ambient light (ADR = 36.0%) (P = 0.611). For low light cases, ADR was 37.5% for 1st cases of the day and 31.9% for last cases of the day (P = 0.545) (Table 1). For ambient light cases, the ADR was 34.1% for 1st cases of the day and 36.9% for last cases of the day (P = 0.266). Overall difference in ADR between 1st and last cases using ambient lighting (+2.80%) versus no lighting (−5.60%), was statistically significant (P = 0.010) (Table 2). 41% of respondents agreed or strongly agreed fewer symptoms of eyes strain occurred with ambient light and 54% of respondents felt that ambient light improved detection of changes in patient status.

CONCLUSION:

Our data suggests that performing screening colonoscopies with ambient light may improve the differential change in ADR that occurs from the beginning to the end of the day, as compared with lights off. This improvement in ADR may be related to improved symptoms of eye strain, and further investigation is warranted.
126 Association Between Sessile Serrated Adenoma and Extra-colonic Malignancies
Authors: Fathallah Jihan , Al-Jumayli Mohammed , Jahandar Donya R. , Hejazi Reza , Young Chase
Published: October 2019

INTRODUCTION:

Sessile serrated adenomas (SSAs) are precursors for 20% of microsatellite unstable colon cancers with the CpG island methylator phenotype. They are the result of a BRAF mutation and promoter hypermethylation of tumor suppressor genes or mismatch repair genes. Eighty percent of SSA harbor BRAF V600E mutation with some having KRAS mutation. BRAF V600E mutation can lead to different kinds of malignancies. Therefore, we conducted a retrospective study to assess the association between SSAs and extra-colonic malignancies.

METHODS:

We performed a retrospective study of patients diagnosed with SSA on colonoscopies done in Kansas University Medical Center from 2016 to 2018. The diagnosis of SSA was confirmed by histologic exam interpreted by pathologists. The group of SSA patients was compared to patients diagnosed with non-SSA polyp (control group). The electronic records were reviewed for data extraction regarding demographics and extracolonic malignancies.

RESULTS:

400 patients were diagnosed with SSA from 2016 to 2018 compared to 372 patients with tubular/villous adenomas. The majority of patients in SSA and non-SSA groups were Caucasians (92% and 84.5% respectively). Mean age in group of SSA was higher than control group (age 65 ± 11 vs 55 age ± 10). Underlying morbidity i.e., obese/overweight (43.75% vs 24.5%), and HTN (51.25% vs 21%) were more common in SSA group. The two groups demographics are shown in Table 1. 60% of patients with SSA, including 6.25% of patients with skin cancer and 5.5% of those with breast cancer, had family history of cancer in first degree relative. Only 2.75% of patients with SSA had history of different organ transplant. Thirteen extra-colonic malignancies were identified (Table 2). Patients with SSA had significantly higher rates of skin cancers including, non melanoma skin cancer (12%) and breast cancer (8.25%) compared to non-SSA patients (6.2%, and 3%, P-values < 0.05 respectively).

CONCLUSION:

To our knowledge this is the largest study of the association between SSA and extra-colonic malignancies. We found a significant association between breast and skin cancer with SSA. This could be potentially explained by presence of BRAF V600E mutation in SSA which is a precursor for different types of tumors especially melanomas. We suggest prospective studies are needed to determine whether patients with SSA should have more expanded and different cancer screening tests. Until then we emphasize the importance of skin exams and screening mammograms for patients with SSA.
129 Association Between Colitis and Immune Checkpoint Inhibitor Use: Analysis of the FDA Adverse Event Reporting System (FAERS)
Authors: Tunio Nahel A. , Cooper Gregory S.
Published: October 2019

INTRODUCTION:

Immune checkpoint inhibitors (ICI) are increasingly being used for management of malignancies, but they are associated with serious immune-related adverse events (irAE) due to overactivation of the immune system. Gastrointestinal tract is commonly affected by the ICI and have been frequently reported in literature. The purpose of this study is to evaluate the epidemiology of colitis associated with ICI use reported to the FDA.

METHODS:

We used the Food and Drug Administration Adverse Event Reporting System (FAERS), a database that contains adverse events reports, medication error reports and product quality complains reported to the FDA. It is a voluntary post-marketing pharmacosurveillance database maintained by the FDA. We identified all adverse events (AEs) associated with 5 FDA-approved ICIs (Nivolumab, Ipilimumab, Pembrolizumab, Atezolizumb, Durvalumab) between April 2011 and December 2018. We investigated the number of colitis cases associated with these ICI reported to the FDA.

RESULTS:

We identified 53,899 adverse events related to ICI that were reported to FDA, out of which 1908 (3.54%) were reported as colitis. The highest number of colitis was reported to be associated with Ipilimumab 1278 (53.9%), followed by Nivolumab 784 (33.1%). Given that these ICI were approved during different years ranging from 2011–2017, we identified total number of colitis cases in the year 2018 and determined that 12.01% of colitis-deaths were associated with Nivolumab, followed by Ipilimumab (7.48%). The number of colitis cases reported increased from 236 in 2011–2013, to 665 in 2014–2016, and 1007 in 2017–2018 (Figure 2). Moreover, of the total 1908 colitis cases, 1849 cases were noted to be serious cases out of which 336 (17.6%) died due to colitis.

CONCLUSION:

In the FAERS database we described the prevalence of colitis as an immune related adverse event associated with the use of immune checkpoint inhibitors. Colitis accounted for 3.5% of the total adverse events reported with ICI between 2011 and 2018. Moreover, our study showed high mortality rate (17.6% of the cases) associated with ICI-Colitis.
135 Fecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection in Patients Above 75 Years of Age: A Tertiary Center Experience
Authors: Abdallah Mohamed , Abdalla Abdelmohaymin , Wiedel Noah , Baloun Brett , Gilbert Jorge
Published: October 2019

INTRODUCTION:

Fecal microbiota transplantation (FMT) is established as an effective treatment for recurrent Clostridioides (formerly Clostridium) difficile infection (CDI). Incidence and mortality from CDI are significantly higher in the elderly population (CDI is 10 times more common and 92% of CDI-related deaths occur in the elderly). Risk of cardiopulmonary complications from sedation prior to colonoscopy is increased in the elderly. Efficacy and safety of FMT via colonoscopy in the elderly are unknown.

METHODS:

A retrospective study comparing patients ≥75 years, and patients < 75 years who had FMT at Sanford Medical Center, Sioux Falls, SD, between 2013–2018. All patients underwent FMT via colonoscopy. Antibiotics prior to FMT, donor screening, preparation and delivery of FMT, and post-procedural follow up were based on a standardized protocol in our institution. Data on baseline characteristics, co-morbidities, antibiotics-associated with CDI, safety, and success rate of treatment (defined by resolution of symptoms and absence of CDI recurrence at 8 and 52 weeks) were collected.

RESULTS:

Of 59 patients, 17 (28.8%) were ≥75 years with a mean age of 84.4 years, and 42 (71.2%) were <75 years and a mean age of 46.4 years. Baseline characteristics of both groups are described in Table 1. Number of CDI before FMT, history of severe CDI, nosocomial CDI were similar. No fulminant CDI was reported in our study. In ≥75 years vs. <75 years, serum albumin was lower (3.4 vs 4 g/dl, P < 0.002) and hypertension was more common (52.9 vs 23.8%, P = 0.03). 80% of our study population had a history of antibiotics exposure prior to CDI, but there was no statistically significant difference between groups. Of antibiotics-associated with CDI, penicillins were more likely to be reported in ≥75 vs. <75 years (38.1 vs 5.9%, P = 0.014). Cephalosporins, macrolides, fluoroquinolones, and clindamycin were similar in both groups. Prior to FMT, both groups were treated similarly with vancomycin with or without taper, oral or intravenous metronidazole, or fidaxomicin. No major complications related to anesthesia or FMT via colonoscopy or deaths attributed to FMT were reported in our study. The success rates at 8 and 52 weeks in both groups were similar (76.5 vs. 83.3%, and 76.5 vs. 71.4%, respectively).

CONCLUSION:

Despite the increased risk of CDI and colonoscopy in the elderly population, success rate and safety of FMT appears to be equivalent between elderly and non-elderly. Prospective studies with larger sample size are needed.
141 Changes in Antibiotic Usage Patterns for Treatment of Colon Ischemia Since ACG Guideline Recommendations
Authors: Noorian Shaya J. , Aroniadis Olga , Feuerstadt Paul , Kwah Joann
Published: October 2019

INTRODUCTION:

In 2015, the ACG introduced a clinical guideline defining colon ischemia (CI) severity (mild, moderate, or severe) and recommending administration of antibiotics in those with moderate and severe CI. The goal of our study was to assess for differences in guideline-adherent antimicrobial use pre- and post- guideline publication.

METHODS:

A database of consecutive patients diagnosed with biopsy-proven CI at Montefiore Medical Center and Yale-New Haven Hospital was utilized. Patients admitted from 2012–2014 (CI 12–14) and 2015–2017 (CI 15–17) composed the pre- and post- guideline cohorts, respectively. Our primary outcome was the frequency of guideline-recommended antibiotic use, defined as: (i) metronidazole+ (ciprofloxacin or cephalosporin) or (ii) piperacillin-tazobactam in patients with moderate or severe CI. Secondary outcomes included overall antibiotic use for CI, individual antibiotic type and clinical outcomes (ICU requirement, length of stay, readmission, recurrence, mortality, and colectomy rates).

RESULTS:

The CI 12–14 (n = 169) and CI 15–17 (n = 84) cohorts were similar in background characteristics: mean age (68.2 vs. 69.5 yrs; P = 0.47), female sex (65.1% vs. 76.2%; P = 0.07), and Charlson comborbidity score (5.3 vs. 5.1; P = 0.65). CI severity was similar between cohorts: mild (1.2% vs. 0.0%; P = 0.55), moderate (41.4% vs. 47.6%; P = 0.35) and severe (57.4% vs. 52.4%; P = 0.65). A trend for increased guideline-recommended antibiotic use was observed from CI 12–14 to CI 15–17 (50.3% vs. 58.3%; P = 0.23) (Figure 1). A non-significant increase was observed in overall antibiotic use (69.8% vs. 77.4%; P = 0.21). Ciprofloxacin use decreased from CI 12–14 to CI 15–17 (61.0% vs. 44.6%; P = 0.03), but no significant differences were observed for other antibiotic types (Figure 2). The 30-day mortality (1.3% vs. 8.0%; P = 0.01) and 30-day mortality and/or colectomy rates (6.0% vs. 16.0%; P = 0.01) increased from CI 12–14 to CI 15–17. Non-significant differences were observed for other clinical outcomes (Figure 3).

CONCLUSION:

The trend of increased antibiotic use post-guideline publication may have been a result of the new recommendations or the treatment of acutely sicker patients experiencing worse clinical outcomes. The decrease in ciprofloxacin use follows a nationwide trend and may be due to antimicrobial stewardship efforts to minimize the risk of C. difficile infection. Further research is needed to better understand the indications for antimicrobial use in the post-guideline era and worsened outcomes.
145 Effectiveness and Tolerability of Very Low-Volume Preparation for Colonoscopy: A Prospective, Multicenter Observational Study
Authors: Maida Marcello , Morreale Gaetano , Sinagra Emanuele , Sferrazza Sandro , Manganaro Michele , Scalisi Giuseppe , Schillaci Dario , Vettori Giovanni , Conoscenti Giuseppe , Di Bartolo Concetta , Garufi Serena , Virgilio Clara Maria , Camilleri Salvatore
Published: October 2019

INTRODUCTION:

The effectiveness of bowel cleansing is essential for a quality colonoscopy since it affects diagnostic accuracy and adenoma detection rate. This study aimed to assess the effectiveness and tolerability of NER1006, a novel 1L PEG preparation, compared to 4 and 2 L PEG solutions in a real-life setting.

METHODS:

All in- and out-patients scheduled for a screening, surveillance or diagnostic colonoscopy, after an afternoon only or afternoon/morning 1, 2 or 4L PEG-based preparation were consecutively enrolled from September 2018 to February 2019 in 5 Italian centres. Bowel cleansing was assessed through the Boston Bowel Preparation Scale (BBPS), a bowel cleansing success was defined as a total BBPS ≥6 with a partial BBPS ≥2 in each segment and a high-quality cleansing of the right colon as a partial BBPS = 3. Tolerability was evaluated through a semi-quantitative scale with a score ranging from 1 to 10.

RESULTS:

1289 patients meeting inclusion criteria were enrolled in the study. Of these, 490 performed a 4L PEG preparation, 566 a 2L PEG cleansing and 233 a 1L PEG preparation. Overall, bowel cleansing by BBPS was 6.3 ± 1.5, 6.2 ± 1.5 and 7.3 ± 1.5 (P < 0.001) for 4L, 2L and 1L PEG preparation respectively. Cleansing success was achieved in 72.4%, 74.5% and 90.1% (P < 0.001), while high-quality cleansing of the right colon in 15.5%, 11.7% and 39.5% (P < 0.001) for 4L, 2L and 1L PEG preparation groups, respectively. The 1L preparation was the most tolerated compared to the 2 and 4L PEG solutions, with an average score of 7.8 ± 1.7 vs 7.1 ± 2.0 and 7.3 ± 2.0 (P < 0.001) respectively, in the absence of serious adverse events. At multivariate analysis, age (OR = 0.98, 95% CI = 0.97–0.99; P = 0.02), absence of diabetes (OR = 1.51, 95% CI = 1.01–2.25; P = 0.04), adequate cleansing at previous colonoscopy (OR = 2.37, 95% CI = 1.37–4.09; P = 0.002), afternoon-morning split regimen (OR = 2.52, 95% CI = 1.65–3.83; P < 0.001), low-fiber diet for at least 3 days preceding colonoscopy (OR = 2.31, 95% CI = 1.61–3.31; P < 0.001), colonoscopy within 5 hours after the end of preparation (OR = 2.16, 95% CI = 1.30–3.60; P = 0.003) and tolerability score (OR = 1.22, 95% CI = 1.14–1.31; P < 0.001) were independently associated with bowel cleansing success.

CONCLUSION:

The novel 1L PEG-ASC solution (NER1006) presents greater effectiveness compared to higher-volume PEG preparation in terms of overall bowel cleansing and high-quality cleansing of the right colon with the advantage of better tolerability respect to comparators.
146 Safety of NER1006 in the Elderly: A Post-Hoc Analysis of a Prospective, Multicenter Cohort
Authors: Maida Marcello , Sferrazza Sandro , Sinagra Emanuele , Morreale Gaetano , Manganaro Michele , Scalisi Giuseppe , Schillaci Dario , Vettori Giovanni , Conoscenti Giuseppe , Di Bartolo Concetta , Garufi Serena , Virgilio Clara Maria , Camilleri Salvatore
Published: October 2019

INTRODUCTION:

The effectiveness of bowel cleansing is a key element for a quality colonoscopy since it affects diagnostic accuracy and adenoma detection rate. A very-low-volume 1L PEG solution (NER1006) has been recently introduced after the publication of three phase 3 randomized controlled trials showing non-inferiority respect to comparators. Despite its proven effectiveness, the safety of NER1006 in the elderly has never been assessed in a real-life setting.

METHODS:

This study aimed to assess the safety profile of NER1006 in the elderly compared to younger patients in a real-life setting. We performed a post-hoc analysis of data from a cohort of 1289 patients undergoing a colonoscopy after a afternoon-only or a afternoon-morning preparation with a 1, 2 or 4L PEG-based solution consecutively enrolled from September 2018 to February 2019 in 5 Italian centers. The elderly population was defined by an age ≥65 years. Safety was monitored through adverse events reporting.

RESULTS:

Among 1289 patients, 233 subjects undergoing a bowel preparation with NER1006 were included in the analysis. The mean age was 59.5 ± 15.9 years, 52.4% of patients were male, and 43.5% were older than 65 years old. Mean age was 48.6 ± 11.9 years (range 18–64) in the group of patients aged <65 years, and 73.7 ± 6.3 years (range 65–91) in the group of patients aged ≥65 years, while prevalence of hypertension, diabetes, and obesity was 13.7 vs. 32.7% (P = 0.03), 3.1 vs. 9.9% (P = 0.001) and 12.2 vs. 13.9% (P = 0.7) in the two groups, respectively. Overall incidence of adverse events was 19.8% and 10.9% (P = 0.06) in the group of patients aged < 65 and ≥65 years. Incidence of nausea, vomit, abdominal pain, dehydration and headache was 3.1 vs. 3.0% (P = 0.9), 9.9 vs. 5.9% (P = 0.2), 0.8 vs. 0.0% (P = 0.3) 2.3 vs. 0.0% (P = 0.1) and 2.3 vs. 0.0% (P = 0.1), in the group of patients aged <65 and ≥65 years, respectively. No serious adverse events or deaths occurred in any of the two groups.

CONCLUSION:

In this post-hoc analysis, we did not find any substantial difference in the safety profile of NER1006 in the elderly compared to younger patients. Given the observational nature of our study, an assessment of blood electrolyte or creatinine was not feasible. Nevertheless, no clinical event attributable to electrolyte imbalance or dehydration was observed in any patient. These results confirm the safety of this product even in the elderly and in a real-life setting.
151 Teaching Hospitals Have Lower Adjusted Rates of Hospital-Onset C. difficile Infection Compared to Non-Teaching Hospitals
Authors: Dalal Rahul S. , Lichtenstein Gary R.
Published: October 2019

INTRODUCTION:

Hospital-onset Clostridioides difficile infection (HoCDI) is a preventable but significant cause of morbidity among patients hospitalized at teaching hospitals (THs; Consumer Reports 2016). Prior research that did not adjust for patients' disease severity demonstrated higher HoCDI rates in THs compared to non-THs (Open Forum Inf Dis 2016, 3(suppl_1):2062). We therefore attempted to determine the impact of hospital teaching status (HTS) on HoCDI rates while adjusting for underlying disease severity using the Vizient clinical database.

METHODS:

In this cross-sectional study, we used the Vizient database to analyze all adult hospitalizations from 10/1/2014 to 3/31/2018. Vizient includes >90% of academic centers and their affiliated community hospitals in the US. Vizient hospitals (n = 369) were grouped into major THs (members of Council of THs), minor THs (medical school affiliation only), and non-THs (all other hospitals), as defined by the 2016 American Hospital Association (AHA) Survey. We excluded hospitals missing from the AHA survey and discharges to another hospital or against medical advice. We used multivariable linear regression (MVLR) of aggregated data to assess the impact of HTS on HoCDI rates while adjusting for demographics, comorbidities, severity of illness indices, case mix, and hospital factors. MVLR was also performed using hospital resident-to-bed ratios (RTBR) to reflect teaching intensity. Final models were generated using step-wise backward elimination of covariates using P < 0.05.

RESULTS:

We identified 18,247,643 hospitalizations among 337 hospitals (132 major THs, 110 minor THs, 95 non-THs) from 10/1/2014 to 3/31/2018. Hospitalization characteristics are presented in Table 1. Unadjusted rates of HoCDI were higher in major THs compared to non-THs (median 0.4% vs. 0.2%, P < 0.01). After MVLR to adjust for confounders, major and minor HTS (Table 2) and RTBR (Table 3) were negatively correlated with HoCDI. Because mean length of stay and ICU stay reflect not only disease severity but also effects of HoCDI, they were added separately to the final models and the negative correlations between HTS and HoCDI persisted.

CONCLUSION:

After adjusting for metrics of disease severity and complexity, THs may have lower rates of HoCDI compared to non-THs. Additional research is needed to determine how inpatient practices that may contribute to HoCDI differ in THs vs. non-THs.
155 Therapeutic Oxygen for Gastrointestinal Atomy (TOGA) Pilot Trial: Management of Acute Colonic Pseudo-Obstruction and Ileus With Oxygen Supplementation
Authors: Zhang Wei , Baumann Alexandra J. , Brar Tony , Banerjee Debdeep , Khan Walid , Westerveld Donevan , Sutchu Selina , Jacobson Max E. , Grajo Joseph R. , Forsmark Christopher , Weiner Brian
Published: October 2019

INTRODUCTION:

Acute intestinal dysmotility can lead to bowel distension, which promotes hypoperfusion and further negates contractility in acute colonic pseudo-obstruction (ACPO) and ileus. Current medical treatment is supportive. When bowel distension worsens, endoscopic decompression or surgical intervention may be necessary to avoid mortality; Interventions are time-consuming and not without risk. New effective and safe management approaches are needed. Manipulation of partial pressures of oxygen trapped within the bowel has been shown in patients with ACPO and ileus to improve clinical and radiographic outcomes. Therapeutic oxygen for gastrointestinal atomy (TOGA) is a pilot study aimed to demonstrate the benefit of a six hour course of 100% oxygen by non-rebreather mask as an adjunctive treatment for patients with ACPO and ileus who have failed to respond to alternative medical therapy after 24 hours.

METHODS:

Eight patients with ACPO or ileus were enrolled in this pilot study (ClinicalTrials.gov Identifier: NCT03386136) between May 1, 2018 and March 1, 2019 and administered 100% oxygen by non-rebreather mask for 6 hours in conjunction with traditional medical management. Abdominal radiographs were examined before and after treatment. Patient demographics, maximum diameter of bowel lumen distension on radiography, and clinical symptoms were recorded.

RESULTS:

Of the 8 patients (mean age 53.6 ± 17.4 years; 37.5% female), 87.5% demonstrated clinical improvement of symptoms after 6 hours of 100% oxygen (Table 1). For 7 patients, maximum luminal diameter improved on average by 1.14 ± 0.87 cm, the percentage decrease in luminal diameter on average was 13.8 ± 7.1%. One patient failed to improve but was later determined to have malignant small bowel obstruction. Only one patient suffered a potential adverse event to the oxygen therapy (transient tachycardia). No patients developed complications from their underlying disease, such as ischemia or perforation. Responding patients also reported improvements in abdominal pain, distension, and bowel movements.

CONCLUSION:

TOGA demonstrates that high concentrations of supplemental oxygen is a feasible and tolerable intervention to improve the clinical status of patients with ACPO and ileus, which may shorten hospitalization and overall morbidity. Further prospective enrollment is needed to extrapolate these promising findings and ensure confidence of its incorporation into common clinical practice.
156 Predictive Factors for Inadequate Inpatient Bowel Preparation
Authors: Poola Shiva , Jampala Nannaya , Tumin Dmitry , Ali Eslam
Published: October 2019

INTRODUCTION:

Colonoscopy is highly sensitive for the detection of precancerous polyps and for the visualization of the entire colon during colorectal screening. Inpatient colonoscopies pose a special risk of poor preparation. We reviewed bowel preparation methods and patient factors to identify predictors of inadequate bowel preparation for inpatient colonoscopy at our institution.

METHODS:

All patients ages older than 18 years of age undergoing inpatient colonoscopy in 2017–2018 were reviewed. The primary outcome was inadequate bowel preparation and secondary outcomes were successful cecal intubation, duration of colonoscopy, and hospital LOS. Outcomes were compared according to demographic characteristics, comorbidities, abdominal surgery, and medications using multivariable regression with stepwise covariate selection. Statistical significance was set at P < 0.05.

RESULTS:

The analysis included 315 patients (median age = 67 years; 45% female, Table 1). The majority of colonoscopies were performed for anemia (78%). Visualization was deemed adequate in 56%, fair in 27%, and poor in 17% of cases. Cecal intubation was successful in 84% of cases. The median duration of colonoscopy was 25 min and LOS was 2 days. Unsuccessful cecal intubation was most likely with poor visualization (36% vs 11%, P = 0.014). There was no increased colonoscopy duration with poor visualization (P = 0.075). There was no significant LOS with worse visualization quality (P = 0.185). Factors predicting worse visualization quality included older age, history of CHF, cirrhosis, and motility disorders (Table 2). Older age, COPD, and colonoscopy performed for other indications were associated with unsuccessful cecal intubation. Factors predicting prolonged LOS included several comorbidities and usage of iron or neuromodulators (Table 3).

CONCLUSION:

At our institution, patients who were older or had significant co-morbid conditions (CAD, CHF, COPD, motility disorders, or cirrhosis) were more likely to have inadequate inpatient bowel preparation. Other studies found similar findings in patients with diabetes, cirrhosis, history of stroke or TCA use. Bowel preparation type did not affect the duration, quality of visualization, or the success of cecal intubation. Further work is needed to optimize inpatient bowel preparation protocols in older patients with multiple co-morbidities. Future studies should evaluate the success of bowel preparation in inpatient setting with a standardized bowel preparation score like the Boston Bowel Prep score.
162 Development of a New Bowel Preparation Prediction Model Based on Patient's Questionnaire: To Proceed or Not to Proceed With Colonoscopy? A Study From Veterans Affairs Hospital to Stratify High Risk Population
Authors: Dhaliwal Amaninder , Buddam Avanija , Chandan Saurabh , Bhat Ishfaq , Singh Shailender , Sayles Harlan , Antoniak Derrick , Hewlett Alexander , Rochling Fedja A.
Published: October 2019

INTRODUCTION:

Bowel preparation (BP) is one of the intra-procedural quality indicators. The percentage of poor BP leading to repeat colonoscopy in = or < 1 year should not exceed more than 15%. The challenge remains that before doing the colonoscopy, we cannot reliably predict, whether a BP will be adequate for a good quality examination? The aim of our study is to propose a model based on patient's questionnaire that can identify patients with poor BP in pre-operative (pre-op) area prior to their colonoscopy.

METHODS:

From November 2018 to May 2019, 461 consecutive patients of 18 years of age or older who presented to Veterans Affairs (VA) Nebraska-Western Iowa Health Care System for colonoscopy each completed a voluntary questionnaire in the pre-op prior to their colonoscopies. This study was approved by VA institutional review board (IRB#00163). Information was collected regarding gender, age, ethnicity, education level, first colonoscopy, days of BP, BP instructions, amount of BP completed, last solid meal, timing of last bowel movement (BM), travel time to VA, nausea/vomiting and abdominal pain/bloating while taking BP, Bristol stool scale and last BM stool character (A-clear liquid stool, B-turbid, C-soft stools). Information regarding the Boston bowel preparation scale (BBPS) was calculated during the colonoscopy. Accuracy of the model was measured by the area under ROC curve. Statistical analysis was performed using STATA version 14.2.

RESULTS:

461 patients were included (94% males, 92% Caucasians). BBPS score of 5 or greater was noted in 95% of the patients. We used a multivariable logistic regression model using most of the variables depicted in Table 1 to predict the outcome of a patient having a BBPS score of 5 or greater. Area under the ROC curve was 0.7675 (Figure 1). With a cut point for the predicted probability of having a Boston Prep Score of 5 or greater of ≥0.8935, we achieved a sensitivity of 87.4% and a specificity of 50%. The coefficients included in the predicted model are depicted in Table 2.

CONCLUSION:

Our new bowel preparation prediction model to predict probability of having a BBPS of 5 or greater in pre-op area achieved sensitivity of 87.4% and specificity of 50% with area under ROC = 0.7675. Only 5% of our patient population had BBPS < 5 which could explain the low specificity of our predicted model. Multi-center studies are needed to further validate our model.
164 Innovative Practice Strategies for Preventing Clostridioides difficile (CDI) in a Community-Based Hospital
Authors: McSharry Doreen , Raskin Jeffrey M. , Stein Aaron A. , Lee Rose , Yalamanchi Vinay , Lopez Frank , Chandy Joel
Published: October 2019

INTRODUCTION:

The prevalence of hospital-acquired Clostridioides difficile infection (CDI) in a healthcare facility is directly correlated with the efficacy of infection prevention practices. Although associations are well documented between CDI incidence and the exposure to antibiotics and acid-reducing medications, to effectively prevent CDI, all risk factors for transmission must be investigated. This study will demonstrate how innovative practice strategies, created by a multidisciplinary CDI Prevention Team, that were introduced and sustained over a 20 month period of time, resulted in dramatic improvements in CDI rates.

METHODS:

A cohort of 52 patients with a diagnosis of CDI were chosen for the purpose of determining the efficacy of an innovative, multi-disciplinary intervention. The subject lists were obtained from the NHSN reported cases. The study was comprised of three phases: Pre-intervention Period, Transitional Period, and Intervention Period. During the Transitional Period, the innovative, multidisciplinary intervention was introduced, consisting of a series of preventive strategies aimed at eradicating CDI in the patient population and the hospital's physical environment.

RESULTS:

Of the 52 patients studied with CDI, 23 patients were Community-Onset while 29 patients were Hospital-Acquired. With each study period, CDI HAI's were shown to decrease as the innovative practice strategies were incorporated into practice. In fact, during the Pre-intervention Period, there were 17 HAI's with 9461 patient days resulting in a 1.79 infection rate; the Transitional Period, 6 HAI'S/14,697 patient days resulting in a 0.40 infection rate; and the Intervention Period, 6 HAI's/33,603 patient days resulting in a 0.17 infection rate. In summary, the annual CDI rate decreased by 62% over one year after implementation of multidisciplinary interventions, demonstrating a statistically significant trend of reducing the infection rates (P value < 0.0001).

CONCLUSION:

The data analysis identified well-known CDI risk factors that included residing in long-term care institutions, acid suppressive therapy, prior antibiotic use and the management of the patient's environment. The incorporating of a variety of strategies such as: hand washing, isolation precautions, electronic medical record features, diagnostic testing parameters, UV technology, disposable meal trays, cutlery and plates, and managing the patient's environment, could serve as a paradigm for reducing CDI in a Community-based hospital.
165 Effect of Bowel Preparation Volume Size in Inpatient Colonoscopy. Results of a Prospective, Randomized, Comparative Pilot Study
Authors: Hernandez Patricia V. , Horsley-Silva Jennifer L. , Snyder Diana L. , Baffy Noemi , Atia Mary , Koepke Laura , Buras Matthew , Lim Elisabeth , Ruff Kevin , Umar Sarah , Islam Sameer , Ramirez Francisco C.
Published: October 2019

INTRODUCTION:

Inpatient status has been shown to be a predictor of poor bowel preparation for colonoscopy since these patients are usually older, less mobile, have more medical comorbidities, and often require emergent evaluation. Our aim was to compare the efficacy of bowel preparation volume size in hospitalized patients undergoing inpatient colonoscopy.

METHODS:

This prospective, single blinded (endoscopist), randomized controlled trial was IRB approved and conducted as a pilot study at a Tertiary Referral Medical Center between September 2013 and March 2019. Hospitalized patients aged 18 years or older undergoing inpatient colonoscopy were assigned randomly to receive a high-volume solution (GoLYTELY®, medium-volume solution (MoviPrep®) or a low-volume Prepopik® solution. Adverse effects including unpleasant taste, nausea, and vomiting were scored through a questionnaire using a five-point scale ranging from 0 (no symptoms) to 4 (severe symptoms). Boston Bowel Prep Score (BBPS) was used to evaluate colon cleanliness. Descriptive statistics are presented as mean values ± standard deviation (SD), and P-values were calculated using Chi-Square and Kruskal-Wallis tests.

RESULTS:

Twenty-five colonoscopies were performed in 25 subjects. Mean age was 66.6 years (16.34) and 68% were male (Table 1). Indications for colonoscopy varied and are shown in Table 1. Total BBPS scores were higher in patients who received Prepopik®, 7.4 (1.62), than GoLYTELY® 6.6 (2.19) or MoviPrep® 6.9 (1.55), P = 0.66 (Figure 1). There was no difference in BBPS in right, transverse, or left colon scores. Regarding tolerance to preparation, 100% of the Prepopik® group reported completing the bowel preparation compared to 77.8% of the GoLYTELY® group and 66.4% of the MoviPrep® group (P = 0.24). The Prepopik® group reported fewer side effects than GoLYTELY®/MoviPrep® groups (Table 2).

CONCLUSION:

In this pilot study, a low-volume colon preparation demonstrated at least equivalent quality of bowel preparation measured by BBPS in comparison with traditional higher volume regimens, with less adverse effects, and better compliance for cleansing completion. This study suggests small volume purgative may lead to better patient compliance and therefore, better bowel preparation in the inpatient setting. The lack of statistical significance is likely due to a type II error. Further more robust studies are required to confirm these findings.
167 PDGF-BB and Receptor Augment Epithelial-Mesenchymal Transition in Colorectal Cancers
Authors: Cho Byungha , Son Seung-Myoung , Kim Ki Bae , Lee Eun Jeoung , Lee Sang-Jeon , Park Seon Mee , Choi Jongwook , Kwon Hyeonwoo , Kim Seongmin , Lee Jun Su
Published: October 2019

INTRODUCTION:

Platelet-derived growth factor (PDGF) and its receptor (PDGFR) signaling are key regulators of the tumor microenvironment and they contribute to tumor progression. We evaluated the correlation of PDGF-BB and PDGFR expression with the activation of epithelial-mesenchymal transition (EMT) and cancer-associated fibroblasts (CAFs) in colorectal cancer (CRC) tissues.

METHODS:

We evaluated PDGF-BB and PDGFR expression, EMT activity (E-cadherin loss and S100A4 gain in tumor cells), and CAFs (aSMA and S100A4 in stromal cells) via immunohistochemistry analysis of 270 CRC tissues. The expression levels of PDGF-BB/PDGFR, EMT, and CAFs were analyzed in the relation to pathological parameters and disease-free and overall survival times.

RESULTS:

PDGF-BB in tumor cells and PDGFR in both tumor and stromal cells were expressed. Spindle-shaped stromal cells exhibited expression of both PDGFR and aSMA. PDGFR expression was related to lymphovascular invasion, lymph node metastasis, AJCC stages, and high number of tumor buds. PDGF-BB was weakly related to lymph node metastasis and perineural invasion. PDGFR expression was related with E-cadherin loss and stromal expression of S100A4 and aSMA. PDGF-BB or PDGFR expression was not associated with the disease-free or overall survival time of CRC patients.

CONCLUSION:

PDGFR expression was related to the activity of CAFs and the EMT process. PDGFR have a crucial role in tumor progression and could be a main target for microenvironment control in CRC treatment.
168 Fecal Microbiota Transplant in Graft-versus-Host Disease of the Intestines: A Comprehensive Pooled Analysis
Authors: Hadi Yousaf , Khan Ali , Naqvi Syeda Fatima , Jannat Rida Ul , Khan Maimoona , Kupec Justin T.
Published: October 2019

INTRODUCTION:

Graft versus host disease (GVHD) of the intestines is a feared complication after hematopoietic stem cell transplantation (HSCT), and carries high morbidity and mortality. Recently fecal microbiota transplant (FMT) has been explored as a treatment modality for intestinal GVHD. The aim of our study was to pool data from individual feasibility studies to explore the efficacy and safety of FMT for gut GVHD.

METHODS:

A systematic search was performed for studies in PubMed, Embase, Cochrane database and ClinicalTrials.gov. All studies that reported data on FMT in patients who had previously undergone HSCT were included. Two independent authors conducted the systematic search. Pooled analysis was conducted for safety and efficacy of FMT in HSCT patients.

RESULTS:

A total of 15 studies comprising a total of 99 patients reported FMT outcomes after HSCT. Indication of FMT was restoration of microbiome in 41, Clostridium difficile infection in 21, and intestinal GVHD in 37 patients. All studies were single center pilot trials. Five studies with 37 patients reported efficacy outcomes for intestinal GVHD. A total of 57 FMTs were performed. All patients had previously failed at least one immunosuppressant regimen. All patients were either steroid resistant or steroid dependent. Overall complete response rate of 62.1% was observed (23 patients). Three additional patients partially responded to FMT. Positive response was accompanied by a decrease in stool volumes and frequency in all patients; reduction in use of anti-motility agents, and cessation of total parenteral nutrition was observed in all responders. All studies reported successful tapering of immunosuppressant and steroid dosage. FMT was generally well tolerated. No treatment-related mortality was reported. Minor adverse events included abdominal pain, nausea, mucosal tears, and minor aspiration without sequelae. Serious adverse events included bleeding in one patient, and grade 3 abdominal pain in one patient (resolved within 24 hours of capsule ingestion). Infections were reported in three patients after FMT (two with bacteremia), but could not be attributed to FMT with certainty.

CONCLUSION:

FMT is a promising modality for management of intestinal GVHD and carries low morbidity. It appears to be safe and acceptable as a salvage therapy for intestinal GVHD based on the current limited data. The need to withhold antibiotics to allow persistent engraftment may prove challenging in this severely immunocompromised population.
170 The Efficacy of Uceris in the Treatment of Microscopic and Allergic Colitides
Authors: Rzepczynski Allison , Van Jeremy , Lodhi Maham , Keshavarzian Ali , Fogg Louis
Published: October 2019

INTRODUCTION:

Chronic non-bloody diarrhea is a common complaint seen by gastrointestinal physicians. About 10–20% of these cases are secondary to the microscopic colitides (MC), which include collagenous colitis and lymphocytic colitis, and 30% are due to allergic colitides (AC), including eosinophilic colitis and mast cell enteropathy. Entocort has previously been studied as a treatment option for MC with remission rates as high as 96%. Uceris is a budesonide formulation that does not dissolve in acid and is therefore released at a controlled rate throughout the colon. This study aimed to determine whether Uceris would provide symptomatic response in patients with MC. Additionally, this study aimed to determine whether Uceris would be effective in treating AC, which currently does not have any well-established treatment options.

METHODS:

This was a retrospective study using the electronic medical record (EMR) and an established database of histologic findings on biopsies obtained during colonoscopies performed at Rush University Medical Center. The EMR was used to obtain demographic data and to identify what treatment medication was used (Uceris, Entocort, H1/H2 blockers, other – anti-diarrheal and stool bulking agents). Eligible subjects were contacted by telephone and asked about symptom severity pre- and post-treatment for colitis using the Modified Harvey Bradshaw Index (MHBI, Table 1). Data was analyzed using SPSS analysis of variances.

RESULTS:

There were 50 subjects enrolled in this study. Demographics are listed in Table 2. The mean total MHBI score for the MC subjects was 9.75 pre-treatment with all therapeutic agents and 2.13 post-treatment, and for the AC subjects was 6.83 pre-treatment and 2.89 post-treatment. There was a greater improvement in MHBI scores in the MC group compared to the AC group (P < 0.031, F = 4.97, df = 1,48). For each treatment drug, there was an improvement in MHBI scores after therapy for both MC and AC (Table 3).

CONCLUSION:

For subjects with MC, there was greater improvement in MHBI scores with Entocort. However, the mean MHBI pre-treatment scores for MC subjects were greatest in those treated with Uceris. It is possible that Uceris was reserved for subjects with more significant symptoms or for those who failed treatment with other agents. There was a greater improvement in MHBI scores in subjects with AC that received Entocort and Uceris, suggesting that steroids may be helpful in controlling symptoms. This study was limited by small sample size and recall bias.
172 Multiplex Polymerase Chain Reaction Stool Testing Detects Pathogens Not Frequently Detected on Concurrent Stool Culture With Ova and Parasite Exam
Authors: Main Michael , Hong Soonwook , Hine Ashley M. , Cadwell Ken , Axelrad Jordan E.
Published: October 2019

INTRODUCTION:

Rapid, highly sensitive and specific multiplex polymerase chain reaction-based stool assays for gastrointestinal pathogens (GI PCR) are increasingly being used alternatively to conventional stool culture. We investigated the concordance between simultaneous GI PCR and stool culture with an ova and parasite (O&P) exam in outpatients presenting with symptoms of infectious gastroenteritis.

METHODS:

We performed a cross-sectional study of outpatients who received a FilmArray GI PCR test for acute diarrhea at an academic medical center from September 2015 to February 2019 to identify patients who had a concomitant stool culture with an ova and parasite exam (conventional testing) at the same time, on the same stool sample. The primary outcome was detection of an infection on GI PCR or conventional stool testing. Correlation was evaluated using McNemar's test for pathogens detected on both tests. Other categorical variables were compared with Chi-square analysis.

RESULTS:

We identified 150 outpatients who received GI PCR and stool culture with an ova and parasite exam for an episode of acute gastroenteritis. 106 (71%) patients had a pathogen isolated on GI PCR for 144 total pathogens including 128 (88%) bacteria, 13 (9%) viruses, and 3 (2%) parasites; 21 (14%) patients had a pathogen isolated on conventional testing for 18 total pathogens including 9 (50%) bacteria and 9 (50%) parasites (Table 1). Multiple pathogens were found in 38 (26%) GI PCR tests. PCR testing most commonly identified Enteropathogenic Escherichia coli (EPEC), representing 42 (33%) positive PCR tests. Conventional testing most commonly identified Campylobacter jejuni with 13 (54%) positive tests. Of 28 total C. jejuni infections, 15 (54%) were positive only on PCR, 3 (10%) only on conventional testing, and 10 (36%) on both modalities, showing that conventional testing missed 54% of all infections (P = 0.008). Conventional testing missed 4/6 (67%, P = 0.125) Salmonella infections and 9/14 (64%, P = 0.0215) Yersinia infections, nor did it detect any viral or diarrheagenic E. coli infections. Overall, PCR detected 144 of 191 (75%) of possible pathogens whereas conventional testing detected 47 of 179 possible pathogens (26%).

CONCLUSION:

GI PCR testing identified multiple pathogens unidentified by conventional testing, such as enteric viruses and pathogenic strains of E. coli. Conventional testing missed 88% of enteric bacteria showing poor concordance between simultaneous GI PCR testing and stool culture with an ova and parasite exam.
174 The Effectiveness of Right vs. Left-lateral Starting Position in Unsedated Colonoscopy With Modified-Water Immersion Method Colonoscopy
Authors: Bayupurnama Putut , Ratnasari Neneng , Indrarti Fahmi , Triwikatmani Catharina , Maduseno Sutanto , Nurdjanah Siti , Leung Felix
Published: October 2019

INTRODUCTION:

Water immersion (WI) which emphasizes removal of infused water during withdrawal significantly reduced pain and increased willingness to repeat unsedated colonoscopy compared with air insufflation (JIG 2013;3:12). One study in sedated patients with air insufflation colonoscopy method showed that right-lateral (RLP) vs. left-lateral (LLP) starting position improved abdominal discomfort and reduced cecal intubation time (AJG 2015;110:1576). We aim to determine if RLP may reduce the pain score and improve other parameters comparing with LLP in unsedated patients examined with a modified water immersion (m-WI) method which involved episodic water infusion and suction to facilitate insertion.

METHODS:

Consecutive symptomatic patients meeting the inclusion criteria were consented, enrolled and randomized. Both patients and colonoscopists were unblinded. Patients underwent unsedated colonoscopy with m-WI method with room temperature water. The suction procedure during insertion in this study was not only for fecal debris evacuation but also used as a method to facilitate passage through difficult colonic flexures. We infused the water as needed. The air pump was turned off during insertion. The examinations were performed by PB. The primary outcome of insertion pain was recorded by a visual analogue scale (VAS). We proposed bowel visualization scale (BVS) as shown in Figure 1 to evaluate the interference of fecal debris with cecal intubation rate and time (NCT03489824).

RESULTS:

Interim analysis was conducted for 105 recruited patients (54 in RLP and 51 in LLP) (74% of sample size). The procedural parameters are shown in Table 1. Changed patient position during colonoscopy showed that fixed position (RLP or LLP) was found in 8 RLP patients and 2 LLP patients; changed only into supine position: 36 patients in RLP and 30 patients in LLP; 3 RLP patients changed into supine then left lateral decubitus and 12 LLP patients changed into supine then right lateral decubitus. Table 1 shows that there was no significant difference between pain score of RLP and LLP. LLP showed faster cecal intubation time in general, in constipation sub group, and also in scale 2 of BVS as shown in Table 2.

CONCLUSION:

This study support that LLP may a better choice than RLP in performing m-WI colonoscopy examination in unsedated patients. Limitation: The endoscopist (PB) did not have RLP colonoscopy experience before the study was started.