bluuebunny/crossref_metadata_2025 huggingface dataset:
Keamanan Vaksin Dengue pada Anak
Authors: Satari Hindra Irawan , Adilla Sharfina Fulki
Published: October 2019

Latar belakang. Insidens dengue meningkat 30 kali lipat dalam 50 tahun terakhir. Penemuan vaksin dengue diharapkan dapat menurunkan angka ini. Vaksin dengue telah mendapatkan izin edar di 19 negara di dunia pada tahun 2015 dan di Indonesia pada tahun 2016. Pada tahun 2017, produsen vaksin menyatakan terdapat kemungkinan dengue berat pada pasien yang belum pernah terinfeksi dengue sebelumnya. Tahun yang sama, Filipina melaporkan tiga kasus kematian terkait dengan vaksin dengue. Hal tersebut menimbulkan keresahan di masyarakat mengenai profil keamanan vaksin dengue. Tujuan. Mengetahui keamanan vaksin dengue untuk individu seronegatif dengan usia >9 tahun.Metode. Penelusuran pustaka database elektronik, yaitu Pubmed dan Cochrane. Hasil. Studi oleh Garcia dkk, memperoleh bahwa risiko relatif rawat inap karena dengue yang terkonfirmasi secara virologis pada resipien seronegatif usia >9 tahun adalah 0,937 (IK95% 0,24-4,37). Studi lainnya yaitu, Shridar dkk, suatu case-cohort, mendapatkan hal yang sama yaitu risiko rawat inap karena dengue pada resipien seronegatif adalah 1,41 (IK95% 0,74-2,68), dan untuk dengue berat 2,44 (IK95% 0,47-12,56). Keduanya memberikan hasil yang tidak signifikan.Kesimpulan. Pemberian vaksin dengue pada individu seronegatif >9 tahun tidak mempengaruhi risiko rawat inap dan dengue berat secara signifikan.
30 Systematic Review on Viral Hepatitis-Induced Acute Pancreatitis
Authors: Imam Zaid , Simons-Linares Roberto , Chahal Prabhleen
Published: October 2019

INTRODUCTION:

Viral hepatitis that concomitantly causes acute pancreatitis (AP) has been reported but not comprehensively studied. We sought to investigate the frequency of viral hepatitis that concomitantly causes AP, its impact on AP and the clinical features of the disease.

METHODS:

A comprehensive review of PubMed's database of English language until April 12th, 2019 was performed using all relevant MeSH (medical subject headings) keywords. AP diagnosis and severity were defined as per the Revised Atlanta Classification (RAC). Viral infections were diagnosed by serology and/or histology. A diagnosis of viral infection, with a concurrent AP diagnosis, a temporal resolution of both entities and the attempt to exclude the most common etiologies of AP defined viral induced AP. Graft pancreatitis studies and non-English publications were excluded. Two independent blinded reviewers (Z.I, C.R.S.L.) reviewed the publications. Bias risk was assessed with the Murad tool derived from the Newcastle-Ottawa scale.

RESULTS:

71 cases of viral hepatitis causing concomitant AP were found. 20 AP cases were attributed to Hepatitis A virus (HAV), 16 AP cases to Hepatitis B virus (HBV), and 35 AP cases to Hepatitis E virus (HEV). Mean ages were 24.3 ± 1.9, 40.5 ± 3.1, and 31.5 ± 3.05 for HAV, HBV, HEV cases respectively. Male to female ratio were 2.25:1, 4.33:1 and 8:1 respectively. 37.5% of HBV AP patients were immunocompromised (IC). Latency of AP from jaundice onset was 6.7 (range: 0–21), 11.9 (0–60), 8.8 (0–37) days respectively. Mean AST levels were 1042 (44–5520), 1550 (514–3200), 362 (71–3690) and ALT levels were 1406 (20–6680), 1894 (72–7521), 1093 (103–5214) respectively. AP severity: mild and moderately severe AP were reported in 80% of HAV-attributed cases, 31.3% of HBV-attributed cases and 82.9% of HEV-attributed cases. Severe AP was reported in 20%, 66.7% and 14.3% of HAV, HBV and HEV-attributed cases respectively. Mortality was reported in 25% of HAV-attributed cases, 56.3% of HBV-attributed cases and 11.8% of HEV-attributed cases. Only one case of HCV-attributed AP was reported. Findings are summarized in Table 1.

CONCLUSION:

Viral hepatitis causing concomitant AP is a rare entity and outcomes vary depending on the type of hepatitis virus. HEV AP appears to have a male predominance. Over one-third of HBV attributed AP occurred in IC patients, with higher mortality. Direct acinar injury by active viral replication has been suggested as the mechanism of injury.
34 Natural History of Pancreatic Fluid Collections in Acute Pancreatitis
Authors: Pulipati Priyanjali , Unnisa Misbah , Reddy Nageshwar D. , Talukdar Rupjyoti
Published: October 2019

INTRODUCTION:

Pancreatic fluid collections (PFCs) resulting from acute pancreatitis (AP) can be associated with infections and mass effect. The aim of this study was to evaluate the natural history of PFCs in AP.

METHODS:

In this study, we so far included 65 patients with PFCs retrospectively (presented to the Pancreas clinic with a history of AP) and 44 prospectively (hospitalized patients). In this abstract, we will present data on only the retrospectively enrolled patients. Patients underwent a thorough demographic and clinical history. We also recorded PFC morphology, presence of venous thrombosis and need for interventions at baseline and each follow-up visit.

RESULTS:

The mean (SD) age of the patients was 36.45 ± 13.49 years with 58 (89.2%) males. The etiology included alcohol in 26 (40%), smoking in 5 (7.6%), cholelithiasis in 5 (7.6%), and idiopathic in 29 (44.6%) patients. 63 (96.9%) patients had moderately severe while 2 (3%) had severe disease. At presentation, the first episode of AP was seen in 22 (33.8%), recurrent in 27 (41.5%) and acute on chronic in 16 (24.6). The type of fluid collections included APFC in 7 (10.8%), ANC in 5 (7.7%), pseudocyst in 4 (6.2%) and WOPN in 49 (75.4%). During the first 3 months, the mean volume of fluid collections was 326.4 ± 637.3 and venous thrombosis developed in 21 (32.3%) patients. 17 (26.1%) patients required interventions in the first 3 months while 5 (7.7%) in the next 3 months. Venous thrombosis developed in 8 (12.3%) additional patients during the next 3 months. Overall, the most common intervention was EUS guided cystogastrostomy (CG) with SEMS placement in 7 (10.6%), followed by PCD in 6 (9.2%), surgical CG in 5 (7.7%), EUS guided plastic stent placement in 1 (1.5%) and combined procedures in 3 (4.6%). Among patients not undergoing intervention during the first 3months, spontaneous complete resolution was seen in 13 (20%) patients, while a reduction and increase in size was seen in 18 (27.6%) and 17 (26.2%) patients respectively. Among the patients who did not undergo intervention between 3rd to 6th months, complete resolution was observed in 36 (55.4%) patient, while a decrease and increase in size were seen in 11 (16.9%) and 9 (13.8%) patients respectively. Among the patients who underwent interventions during the first and next 3 months, relapse/increase in PFC size was seen in 4 (6.2%) and 2 (3.1%) patients respectively.

CONCLUSION:

3/4th of PFCs undergo spontaneous resolution within 6 months while most relapses and venous thrombosis occur within the first 3 months.
72 Vitamin D and Red Blood Cell Distribution Width: The Search for Predictive Markers in Primary Biliary Cholangitis Patients Receiving UDCA Continues
Authors: Alomari Mohammad , Al Momani Laith , Aasen Tyler , Nehme Fredy , Young Mark , Romero-Marrero Carlos
Published: October 2019

INTRODUCTION:

Serum Vitamin D and red blood cell distribution width (RDW) levels have been recently proposed as potential biomarker models to predict primary biliary cholangitis (PBC) severity and response to treatment. However, most of these studies were small with considerable limitations. Therefore, we aimed to investigate the predictive value of these novel markers in patients with PBC receiving ursodeoxycholic acid (UDCA).

METHODS:

We retrospectively reviewed PBC patients who received UDCA (13–15 mg/kg/day) at our tertiary care center between November 1998 and February 2017. Adverse events were defined as liver transplantation or liver-related death. Transplant-free survival (TFS) was estimated by Kaplan-Meier method. Serum Vitamin D and RDW levels were extracted from manual chart review at baseline and after one year of UDCA therapy.

RESULTS:

We identified 352 patients, 50 (14%) were male, 319 (91%) were Caucasian, with a median age of 55 years at diagnosis. Twenty-two (6%), 47 (13%), and 55 (16%) patients had adverse events within 5, 10, and 15 years after diagnosis, respectively (Table 1). In 197 patients of our cohort, we evaluated vitamin D levels at baseline and after 1 year of UDCA therapy while RDW levels were evaluated in all 352 patients. Median vitamin D levels before and after 1 year of UDCA treatment were 15.9 (range: 7.2–21.8) and 16.0 (range: 12.8–45.4) in patients with adverse events (P = 0.05) vs. 13.7 (range: 7.0–88.6) and 13.8 (range: 7.5–63.0) in patients with no adverse events (P = 0.72), respectively. Median red cell distribution width (RDW) before and after 1 year of UDCA treatment in patients with adverse event vs. no adverse event were 16.9 (range: 7.0–66.0) and 16.5 (range: 8.8–160.0), P = 0.14, vs. 17.0 (range: 4.5–62.3) and 16.4 (range: 8.9–69.5), P = 0.06, respectively (Figure 1). Moreover, RDW pre/post UDCA treatment ratio was not a reliable marker for treatment response (overall ratio 1; P = 0.048).

CONCLUSION:

Our study doesn't support the routine use of the newly suggested biomarker prognostic models in patients with PBC receiving UDCA. Presence of multiple confounding factors such as sun exposure, vitamin D or iron supplementation, anemia, folate and vitamin B 12 levels limit the clinical utility of RDW and Vitamin D levels as predictive models for PBC patients.
104 AGT Score as a Predictor of Common Bile Duct Stone Using Endoscopic Ultrasound (EUS) in Patients With Intermediate Probability Criteria According to ASGE Guidelines
Authors: Yaseen Raja Taha , Ul Haque Muhammad Manzoor , Urrehman Adeel U.
Published: October 2019

INTRODUCTION:

The performance of intermediate criteria guideline for the prediction of choledocholithiasis (CL) has been validated in very few studies. The objective of our study was to prospectively assess the accuracy of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines intermediate criteria for the identification of CL. Furthermore, to identify the noninvasive predictors of CL.

METHODS:

A one-year prospective assessment of ASGE intermediate criteria was performed for the prediction of CL considering endoscopic retrograde cholangiopancreatography (ERCP) as gold standard test. Each patient underwent endoscopic ultrasound (EUS) prior to ERCP. Lab investigations were performed for all the patients and AGT score was calculated as a noninvasive predictor for CL. AGT score was calculated for each individual as. Sensitivity and specificity was calculated for predicting CBD stone by using AGT score.

RESULTS:

A total of 71 patients were suspected for choledocholithiasis according to ASGE intermediate probability criteria. The Mean age of patiens were 52.9 + 11.9 years and there were 42 (59.1%) males. At presentation, 66 (92.9%) had abdominal pain, five patients (7%) had gall stone pancreatitis and three (4.2%) had jaundice. On Endoscopic ultrasound (EUS), sludge was found to be in 7 patients (9.9%) and stones were reported in 43 (60.5%). On ERCP, 47 patients (66.2%) were found to have CL. Whereas, it was found in the study that TLC (8.11 vs 6.97 and P = 0.03), ALP (398 vs 197, P = 0.0001) and GGT (313 vs 215, P = 0.046) was significantly raised in stone positive group as compared to stone negative group. The product of Alkaline phosphatase (ALP) and GGT was also found to be significantly raised in stone positive group (130360 vs 57254 and P value 0.002). Using these variables AGT score was formulated and it was found to be significantly associated with presenct of CL (P = 0.001, 90222 vs 46746). Area under ROC of AGT score is 0.83. At a cut off value of 50069 the sensitivity, specificity, NPV and PPV were 82.9%, 76.1%, 88.64% and 66.6% respectively for AGT score in predicting choledocholithiasis.

CONCLUSION:

Performance of intermediate probability criteria for the prediction of CL was accurate in 66.2% of patients. Total bilirubin, gamma glutamyle transferase and AGT score was found to be the predictor of CBD stone.
123 Single Day Low Residue Diet Prior to Colonoscopy Shows Improved Bowel Preparation Quality and Patient Tolerance Over Clear Liquid Diet: Final Results From a Randomized, Single-Blinded, Dual Center Study
Authors: Samarasena Jason , El Hage Chehade Nabil , Yu Allen , Tran Elise , Mai Daniel , Thieu Daniel , Parekh Nimisha K. , Karnes William , Chang Kenneth J. , Jamal Mazen
Published: October 2019

INTRODUCTION:

Patients often cite bowel preparation and associated dietary restrictions as the greatest deterrents to having a colonoscopy completed or performed. Large studies comparing low residue diet (LRD) and clear liquid diet (CLD) are still limited. The aim of this study was to compare LRD and CLD with regards to bowel preparation quality, tolerance, and satisfaction among a diverse patient population.

METHODS:

This study is a dual center, randomized, single blinded, prospective trial involving adult patients undergoing outpatient colonoscopy at the University of California Irvine Medical Center and a Veterans Administration hospital. Patients were randomized to consume either a CLD or a planned LRD for the full day prior to colonoscopy. Both groups consumed 4L split-dosed PEG-ELS. The adequacy of bowel preparation was evaluated using the Boston Bowel Preparation Score (BBPS). Adequate preparation was defined as a BBPS ≥7. Hunger and fatigue pre and post procedure were graded on a 10-point scale. Nausea, vomiting, bloating, abdominal cramping, overall discomfort, satisfaction with the diet, willingness to repeat the same preparation and overall experience were assessed.

RESULTS:

A total of 170 subjects who underwent colonoscopy from October 2014 to October 2017 were included. The mean BPPS for the LRD and CLD groups was 7.98 and 7.54, respectively. There was a significantly higher number of adequate preparations in the LRD group compared to CLD (P = 0.05). Evening hunger scores just before starting the bowel preparation were significantly lower in the LRD than CLD group, 5.5 vs 7.03, respectively (P = 0.006). Subjects in the LRD group showed significantly less nausea (P = 0.047) and bloating (P = 0.04). Symptom scores for vomiting, abdominal cramping, and overall discomfort were similar between the groups. Satisfaction with diet was significantly higher in the LRD group than CLD, 100% vs 33% respectively (P < 0.001). The overall colonoscopy experience and the satisfaction with the preparation itself were also better reported in the LRD group (P = 0.002).

CONCLUSION:

This study demonstrated that the use of a LRD before colonoscopy achieves a superior bowel preparation quality compared to CLD. Low-residue diet also improves patient satisfaction and results in significantly better tolerability of bowel preparation. As a less restrictive dietary regimen, low-residue diet may help improve patient participation in colorectal cancer screening programs.
258 Screening of Colorectal or Uterine Cancers for Lynch Syndrome Should Be Limited to Younger Patients
Authors: Harrigan Jack , Davis Christian , Chauhan Mahak , Madan Rashna , Saeed Anwaar , Bansal Ajay
Published: October 2019

INTRODUCTION:

Universal screening of colorectal and uterine cancers is an effective strategy for diagnosis of Lynch syndrome, but the utility of testing for Lynch syndrome in older patients remains unclear.

METHODS:

We conducted a single- center study in which all patients with a diagnosis of colorectal or uterine cancer between January 1, 2016 to June 30th, 2018 were included. Specialized text-based search of the pathology lab information systems identified the patients. To capture all patients, the search results were tallied with the local cancer center database. A structured RedCap electronic database was created to systematically collect data about demographics, PREMM scores, genetic testing and a detailed 3-generation family pedigree. All patients underwent screening for lynch syndrome using immunohistochemical or microsatellite instability-based testing. Final diagnosis of Lynch syndrome in patients with abnormal screening was based on well- established commercial assays. The yield of Lynch syndrome was compared across five age groups: ≤50, 50–59, 60–69, 70–79, and >80. Statistical analysis was performed using ANOVA and Student's T-test.

RESULTS:

Of a total of 737 patients with either colorectal or uterine cancer (demographics shown in Table 1), the final diagnosis of Lynch syndrome was made in 2.7% (20/737). As Table 2 shows, 90% of the patients diagnosed to have Lynch syndrome were under 60 years of age. The two cases of Lynch syndrome in the age groups 60–69 and 70–79 had PREMM scores of >5%. All of the colorectal or uterine cancers after age 80 tested negative for Lynch syndrome.

CONCLUSION:

Screening of colorectal or uterine cancers for Lynch syndrome should be limited to patients less than age 60 or with abnormal PREMM scores in patients >60. Lynch screening should not be performed after age 80. If confirmed by further studies, our results could further streamline the current recommendation of universal screening of all colorectal and uterine cancers for Lynch syndrome and lead to cost savings.
328 Community Clinic Report Card on Utilization of Screening Colonoscopies: How Well Are We Doing?
Authors: Shah Rucha M. , Acharya Priyanka , Shah Jimmy , Linder Jeffrey , Schwartz Armond , Kedia Prashant , Tarnasky Paul
Published: October 2019

INTRODUCTION:

Screening colonoscopy is an integral but underutilized diagnostic tool in preventing colorectal cancer (CRC). Reasons for delays in CRC screening include incorrect referrals, shortage of physician availability and endoscopy capacity, and limited access to care for uninsured and minority patients. The aims of our study were to measure the time from referral to screening colonoscopy and to define predictors of noncompliance to CRC screening.

METHODS:

A retrospective chart review of patients referred to our clinic for screening colonoscopy was conducted from 7/2017 to 9/2018. Inclusion criteria were age appropriate CRC screening; patients with positive FOBT/FIT for purely screening reasons were also included. Patients younger than 45 or older than 85 years, or those referred for a diagnostic (evaluation of anemia, hematochezia, weight loss) or surveillance colonoscopy (prior adenomatous polyps or adenocarcinoma) were excluded. Patient demographics, referral data, and medical histories were reviewed.

RESULTS:

180 patients met inclusion criteria. Follow-up throughput is shown in Figure 1. 63% patients were deemed non-compliant (not making an appointment, missing scheduled appointment, or not completing recommended colonoscopy). Appointments for 60% of patients were canceled because of missed pre-GI visit registration or patient no showed. 52% of referrals came from outside the health system. 53% of all patients referred were never seen by GI. 71% of patients ordered to have a screening colonoscopy completed their procedure. A final total of 28% of all patients referred eventually underwent colonoscopy.Non-compliant patients were more likely to be uninsured (P-value = 0.04), come from outside referral (P-value = 0.014), have more days from referral reviewed to appointment (81.8 vs 71 days, P value = 0.01), and have less medical problems (1.2 vs 1.5, P value = 0.04). There was no statistical difference between gender, age, race, Hispanic, language, marital status, tobacco use, Charlson Comorbidity Score, or days from clinic appointment to colonoscopy.

CONCLUSION:

Our study identified outside referrals, lack of insurance, and more days from referral received to appointment as predictors of non-compliance to screening colonoscopy.Further interventions should address optimization of utilization of screening colonoscopies, such as targeted navigational resources for uninsured patients from outside referrals, minimizing steps to GI clinic visit, and educating patients on the value of CRC screening.
371 Evaluation of Additional Spatial and Temporal Information Increases the Overall Accuracy of an Objective Risk Prediction Assay in Patients With Non-Dysplastic Barrett’s Esophagus
Authors: Frei Nicola , Konté Kadere , Bossart Emily , Zhang Yi , Critchley-Thorne Rebecca , Pouw Roos , Bergman Jacques
Published: October 2019

INTRODUCTION:

An automated, quantitative multiplex immunofluorescence assay has previously been shown to objectively identify non-dysplastic Barrett’s esophagus (NDBE) patients with an increased risk of malignant progression, independently of current clinical variables. These studies evaluated esophageal biopsies from a single level from one endoscopy. We investigated the results produced by this risk prediction assay at multiple endoscopic levels and multiple endoscopies in NDBE patients to determine whether assessment of additional spatial and temporal information can increase the accuracy of the assayin predicting progression from NDBE to high grade dysplasia (HGD) or esophageal adenocarcinoma (EAC).

METHODS:

A blinded, nested case-control cohort was derived from a community based BE cohort with and without progression. 76 patients with a diagnosis of NDBE of whom 38 progressed to HGD/EAC (progressors) and 38 patients did not progress (non-progressors) were matched for age, sex and maximal BE length. Baseline was defined as the endoscopy 2-5 years prior to the endpoint for progressors or last follow up for non-progressors. All random biopsy levels from the baseline endoscopy and all available prior endoscopies were retrieved and tested by the risk predictionassay in a blinded manner. The assay classifies patients into low-risk (LR), intermediate-risk (IR) and high-risk (HR) for progression to HGD/EAC within 5 years.

RESULTS:

76 BE patients (58 male), mean age 63 ± 1 years, were studied. Median time between baseline endoscopy and progression was 3 years, and median surveillance time in non-progressors was 6 years. Sensitivity of the risk prediction assay (HR and IR combined vs. LR) at the baseline endoscopy was 39.5 % when a single biopsy level was selected for risk assessment (biopsy closest to the gastroesophageal junction (GEJ)). Sensitivity increased to 65.8% when all available baseline biopsy levels were assessed, and further increased to 73.7% when all available baseline and pre-baseline biopsies were assessed by the risk prediction assay (Table 1).

CONCLUSION:

Evaluation of spatial and temporal information increases the sensitivity and overall accuracy of an automated, quantitative risk prediction assay in patients with NDBE. The assay allows for objective risk stratification which may be a practical and effective solution to aid decision-making on surveillance intervals and therapeutic interventions in the management of NDBE patients.
413 Assessment of Procedural Performance and Compliance With Standardized Interpretation of High Resolution Esophageal Manometry Studies Post-Quality Improvement Initiative at a Large Community Hospital
Authors: Saboori Shadi , Seminara Brittany , Jarvis Mackenzie , Vickers Dawn , Sinclair-Moore Teneshia , Clark Barbara , Moshiree Baha
Published: October 2019

INTRODUCTION:

Accurate performance of esophageal manometry (EM) is essential for the diagnosis and treatment of esophageal motility disorders. The American Neurogastroenterology and Motility Society (ANMS) proposed minimal quality measures (QMs) for performance and interpretation of EM in 2017. Many community practices are not adhering to standardized guidelines. We previously assessed the compliance to ANMS QMs in terms of procedural performance guidelines and adherence to the Chicago Classification Guidelines for interpretation of studies (Seminara et al (1)). Our aim now is to present our post-quality improvement (QI) initiative results with respect to performance and interpretation of the EMs.

METHODS:

Motility Nurses were sent to the ANMS Clinical training course with additional weekly training by a GI motility physician with review of standard protocols. A procedural checklist was established and implemented for all subsequent EMs. GI physicians were provided detailed data with articles and books regarding utilizing the Chicago Classification for interpretation of EM results but did not receive 1:1 formal training. Twenty-seven EM studies conducted between January to March 2019 were reviewed since the training. Three main procedural QMs were assessed for compliance: 30 second swallows, 10 attempted wet swallows, and at least 7 evaluable swallows with solids swallows. All 27 studies previously interpreted by community GIs were reread by a motility expert and assessed for: correct diagnosis, missing items based on the Chicago Classification, treatment / referral plan, and the appropriateness of surgery referral.

RESULTS:

In all three procedural QMs, nursing compliance improved to 100% post QI initiative (n = 27) (see Table 1). For the interpretation segment: 78% (n = 21/27) made an incorrect diagnosis, 92% (25/27) had at least one missing item, 26% (7/27) had no treatment plan, 26% (7/27) were referred to surgery 3 of which was for an incorrect diagnosis.

CONCLUSION:

This QI initiative effectively increased compliance by nursing staff performing EM up to 100% as assessed by the ANMS validated procedural QMs. However, our study revealed poor data interpretation by physicians despite adequate performance of EMs resulting in a high degree of incorrect diagnoses and possibly treatments. Future QI initiatives should focus on formally improving physician education on the interpretation to increase diagnostic accuracy.
561 Appropriateness and Safety of Direct Access Endoscopy (DAE) in Hospitalized Patients
Authors: Ratnaraj Felicia , Almuhaidb Aymen , Early Dayna , Thoelke Mark
Published: October 2019

INTRODUCTION:

Direct access endoscopy (DAE) allows hospitalists to refer patients for endoscopy without first being seen by a gastroenterologist (GI), potentially decreasing wait time, improving patient turn over, and facilitating earlier discharge from the hospital. This study aims to evaluate the efficacy and safety of DAE for low-risk endoscopic procedures. DAE has previously been employed in an outpatient setting, but this is the first study exploring DAE use in an inpatient setting in the US.

METHODS:

A retrospective chart review was performed comparing patients who underwent a DAE requested by hospitalists, with patients who underwent an endoscopy ordered by GI physicians from August 2017 till December 2018 at a tertiary medical center. The indication for each procedure obtained from endoscopy reports and hospitalist progress notes prior to each procedure. The appropriateness of each procedure was determined based on guidelines from the American Society for Gastrointestinal Endoscopy (ASGE). Endoscopic procedures were performed by the same endoscopist on the same day and findings were recorded and clinical significance was determined. Major complication(s) that occurred during and after the procedure were also assessed.

RESULTS:

A total of 110 patients were included in this study; 40 were DAE and 70 were ordered by GI physicians. The mean age was 55.5 years with 69 males and 41 females. In the DAE group, there were 31 EGD and 9 colonoscopies ordered, while in the GI group, there were 58 EGD, 11 colonoscopies, and 1 enteroscopy ordered. All of the procedures met ASGE criteria, with 73 procedures having clinically relevant findings. Of these 73 procedures, 20 were DAE (50% had clinically significant findings) and 53 were ordered by GI physicians (76% had clinically significant findings). There were two major complications: one was an apneic episode during the procedure (DAE patient); the other was oozing from a major vessel during the procedure (GI patient).

CONCLUSION:

DAE allows a physician to send a patient for an endoscopy without prior consultation with a GI physician. This study showed that all of the procedures requested by hospitalists met ASGE criteria for appropriateness, with 50% having clinically-relevant findings. There was no difference in adverse events between the groups. These results suggest that DAE is effective and safe in evaluating hospitalized patients for low-risk endoscopy.
575 No-show Endoscopy Appointments: An Analysis of Patient Characteristics
Authors: George Nayana , Syeda Hafsa Bareen , Goel Akshay , Perisetti Abhilash , Khan Salman Ali , Thandassery Ragesh , Garg Shashank , Inamdar Sumant , Tharian Benjamin
Published: October 2019

INTRODUCTION:

Patient no-show for scheduled endoscopy is a widespread health-problem. We reviewed patients who did not show up for the procedure to identify key characteristics of this population.

METHODS:

All patients scheduled for endoscopy in a 6 month period and did not show up were included. Demographics and appointment waiting times were obtained through review of medical charts. Descriptive statistics were used to define study population.

RESULTS:

495 patients did not show up during study period. Mean age was 55+/- 12.5 years. 59.8% were females. No significant racial difference. Majority were unemployed or disabled. Patients with waiting times less than 4 weeks were fewer (13.13%) compared to those with wait 4 to 12 weeks (23.23%), 12 to 24 weeks (24.04%) and more than 24 weeks (39.6%). Longer waiting time for endoscopy was associated with higher no-show rates.

CONCLUSION:

Among patients who did not show up, most patients did not have a partner and were unemployed or disabled, were current or former smokers. Long wait times to endoscopy appointment was the major modifiable risk factor identified. Further studies are needed to identify factors that predict no-show. This will help design interventions to reduce no-show rates and improve health care delivery.
655 Tumor Necrosis Factor Antagonists Are Superior to Ustekinumab and Vedolizumab for the Prevention of Postoperative Recurrence in Adult Crohn's Disease
Authors: Nakamura Takahiro , Main Michael , Chang Shannon , Click Benjamin , Hudesman David , Axelrad Jordan
Published: October 2019

INTRODUCTION:

Relapse of Crohn's disease (CD) is common after surgical resection. Prior data have demonstrated that postoperative tumor necrosis factor antagonists (anti-TNF) may reduce recurrence, although little is known about the efficacy of other biologic therapies. The aim of this study was to compare biologics for preventing postoperative objective recurrence in adult CD patients.

METHODS:

We performed a retrospective chart review of CD patients who underwent intestinal resection from 2012 to 2018. Demographics, IBD history, pre- and postoperative course were obtained from the electronic medical record. The primary outcome was postoperative recurrence during follow up, defined as a composite of endoscopic (Rutgeerts grade > i2), biochemical (increase in CRP >5 mg/dL), or radiographic (presence of active inflammation) disease recurrence stratified by postoperative biologic exposure, including anti-TNF, vedolizumab (VDZ), ustekinumab (UST), and no therapy. Student's t-test, Pearson's chi-squared, logistic and Cox regression analyses were used to detect differences in the composite and components of the outcome among these groups.

RESULTS:

123 patients were included. CD recurrence occurred in 36.6% of patients (13.0% biochemically, 24.4% endoscopically, 16.3% radiographically) at a median of 6.9 months (IQR 3.3-14.1) from surgery (Table 1). The number of patients in the anti-TNF, VDZ, UST, and no therapy groups were 57 (46.7%), 6 (4.9%), 13 (10.7%), and 46 (37.7%), respectively. Biologic therapy was initiated after ileostomy reversal within 3 months for 55 patients (72.4%), between 3-6 months for 11 patients (14.5%), and between 6-12 months for 10 patients (13.2%). Adjusting for prior resection and anti-TNF exposure, any biologic initiation within 6 months of surgery was superior to initiation after 6 months for preventing postoperative endoscopic recurrence (OR 0.24, 0.06-0.92), but not for the composite outcome. There were statistically significant differences among biologics for recurrence (Figure 1). Adjusting for prior resection and anti-TNF exposure, less patients relapsed under anti-TNF exposure compared to UST (HR 3.46, 1.45-8.23) for the composite outcome, and compared to UST (HR 3.95, 1.43-10.9) and VDZ (HR 4.42, 1.02-19.1) for endoscopic recurrence (Figure 2).

CONCLUSION:

Among CD patients, initiation of biologics within 6 months and anti-TNF agents were superior in preventing postoperative recurrence compared to other management strategies.
685 Red Cell Distribution Width as a Differentiating Marker for Patients With Inflammatory Bowel Disease
Authors: Navabi Seyedehsan , Gorrepati Venkata Subhash , Yoo Esther , Pattison Zachary , Groff Andrew , Akhtar Nabeel , Stuart August , Tinsley Andrew , Williams Emmanuelle D. , Coates Matthew , Clarke Kofi
Published: October 2019

INTRODUCTION:

Anemia is a common systemic manifestation in patient with Inflammatory Bowel Disease (IBD). It can be caused by malabsorption and/or chronic blood loss and is more prominent in Crohn's disease (CD) compared to ulcerative colitis (UC), likely due to the distribution of lesions in entire gastrointestinal tract. Red Cell Distribution Width (RDW) is a reliable index of anisocytosis and has the highest sensitivity for iron deficiency in patients with anemia. We postulated that RDW could be used additional differentiating test for IBD patients.

METHODS:

The database consists of various demographic variables, nutritional and inflammatory markers, medication use, anatomic demarcation and endoscopic disease severity information. High RDW was defined as RDW >14.2 after analysis of receiver operator curves (ROC). Categorical variables were compared using chi-square test and continuous variables using t-test. Univariate logistic regression was used to explore the relationship between high RDW, type of IBD, endoscopic disease severity, and anatomic location. Analysis was performed using SAS University edition v9.4.

RESULTS:

Six hundred seventy-one IBD patients (214 UC, 431 CD, and 25 indeterminate colitis) were included n this study. Among patients with CD or UC, 347 (53.7%) were female. 261 patients had high RDW (67 UC vs. 89 CD) and 410 patients had normal RDW (147 UC vs. 243 CD). After adjusting for demographic variables, ultivariate analysis suggests that RDW is a significant differentiating factor for diagnosis of IBD with odds of having CD 1.69 times greater if RDW > 14.2 {OR CD vs. UC = 1.67 (95% CI: 1.17-2.38), P = 0.002)}. There was no significant correlation noted between RDW and endoscopic severity or location of the disease in both CD and UC patients. However, there was a near significant trend noted in RDW and disease extent in UC (proctitis 16% vs. left sided colitis 25% vs. pancolitis 38%, P = 0.056). There were no differences in RDW in relation to gender, ethnicity or smoking status.

CONCLUSION:

RDW can be used as an additional, simple, inexpensive differentiating tool in IBD patients. Patients with CD have higher odds of having abnormal RDW compared to patients with UC. Given the simplicity and inexpensiveness of RDW, these findings support utilization of this test as an additional method for differentiating IBD disease subtypes, even by healthcare providers without extensive background in IBD management.
724 Does Zinc Deficiency in IBD Predispose Patients to Repeat C. difficile Infection?
Authors: Hunold Thomas , Dickson Zachary , Baray Merwise , Hays R. Ann
Published: October 2019

INTRODUCTION:

Clostridiodes difficile infection (CDI) is the most common hospital-acquired infection in the United States. CDI is more common in patients with inflammatory bowel disease with a greater risk in ulcerative colitis patients compared to Crohn's disease patients. Recent literature revealed an association between decreased zinc levels and CDI via the activation of Th17 cells through the STAT3 pathway. We aimed to investigate the relationship of Zinc levels with the risk of recurrent CDI in IBD patients.

METHODS:

We performed an IRB retrospective cohort study of patients aged 18-75 with a history of IBD and a positive Clostridium Difficile PCR between January 1, 2012 and December 31, 2016 at a tertiary care center. A second CDI diagnosis within 3 months of the first was defined as recurrent CDI (rCDI). A second diagnosis after 3 months, but within 3 years of the first diagnosis was defined as reinfection. All charts were reviewed for zinc level testing at the time of any CDI. The primary outcome was zinc level at the time of primary diagnosis. This was also broken down by type of IBD. Descriptive statistics were calculated for the primary and secondary outcomes using SAS 9.4 (SAS Institute, Cary, NC).

RESULTS:

Of 121 patients with IBD and a positive C. difficile PCR, 23 patients had a zinc level tested. The average Zinc level among patients with only one CDI episode was 0.66, while it was 0.62 for rCDI and 0.62 for CDI reinfection. Of the 23 patients with a zinc level, 12 had Crohn's disease and 11 had Ulcerative Colitis. Only three Crohn's patients had one C difficile infection, four had rCDI, and six had C. difficile reinfection with average zinc levels of 0.66, 0.64, and 0.54 respectively. No ulcerative colitis patients only had a primary infection. The six UC patients with rCDI had an average zinc level of 0.64, while those with C. difficilereinfection had an average level of 0.72.

CONCLUSION:

While the sample size of this study was small, there is a trend for patients with Crohn's disease to have lower zinc levels if they have CDI reinfection compared to primary and rCDI. This could be explained by a sustained increase in the activation of Th17 cells via the STAT3 pathway in Crohn's patients with lower zinc levels. However, the patients with ulcerative colitis in this study did not have a tendency to have lower zinc levels suggesting that a different mechanism may be at play. Further investigation of this relationship in a larger study is required.
731 De novo Inflammatory Bowel Disease After Secukinumab Use: A Population Based Analysis
Authors: Mohy-ud-din Nabeeha , Carleton Neil , El-Hachem Sandra , Baki Heitham Abdul , Syed Aslam , Dulai Parambir , Kochhar Gursimran
Published: October 2019

INTRODUCTION:

Secukinumab is a human monoclonal antibody and an inhibitor of IL-17A. It is indicated for treatment of Psoriatic Arthritis, Psoriasis and Ankylosing Spondylitis. There have been a few case reports documenting new or worsening IBD in patients being treated with secukinumab. However, large patient cohorts reporting this relationship are lacking. The aim of this study is to analyze if the use of secukinumab leads to increased risk of development of IBD.

METHODS:

A retrospective study was performed using a HIPPA-enabled web platform called Explorys (IBM, New York). Explorys contains de-identified data from approximately 62 million electronic health records. Data was obtained using the search criteria of “Secukinumab” and “Inflammatory Bowel Disease.” A temporal relationship was established between secukinumab use and development of de-novo IBD. Demographics and management data were collected and compared using odds ratio with 95% confidence intervals.

RESULTS:

Sixty-two million electronic health records were analyzed. Of them, 2870 patients were noted to use secukinumab. Rates of de-novo IBD after secukinumab use were higher than the prevalence of IBD in the general population [3.2% vs 0.74%, RR-4.2 (95% CI 3.45-5.18)]. Patients with de-novo IBD after secukinumab use were younger [age < 65-78% vs 65%, OR 1.92 (1.17-3.15)] and more obese [BMI >30- 22% vs 7%, OR 3.91 (2.38-6.43)]. Additionally, they had higher proportion of patients with use of immunomodulators [67% vs 10%, OR 17.81 (11.49, 27.61)].

CONCLUSION:

The risk of developing de-novo IBD in patients with secukinumab use is higher compared to the general population. These patients were younger, more obese and more likely to use immunomodulators.
799 Hospital Length of Stay and Mortality in Patients With Inflammatory Bowel Disease and Atrial Fibrillation
Authors: Panchal Dayna , Khawaja Umar Sharif , Motlaghazadeh Yasaman , Nasir Umair M. , Choi Catherine
Published: October 2019

INTRODUCTION:

Proinflammatory markers such as interleukin (IL)-6 have been closely associated with various pathological processes, such as oxidative stress, apoptosis, and fibrosis that promote formation of atrial fibrillation (AF). These markers are characteristically elevated in inflammatory bowel disease (IBD). It has been shown that AF has a higher prevalence in IBD. It is important to analyze the effect of comorbid AF and IBD on hospital length of stay and mortality.

METHODS:

The National Inpatient Sample (NIS) database, representing roughly 20% of all inpatient admissions, was used to identify patients with a primary or secondary diagnosis of Crohn's disease and Ulcerative Colitis from 2012 to 2014. The sample was analyzed to assess for LOS, Charlson comorbidity index (CCI), length of stay (LOS) and inpatient mortality among patients with or without history of AF. The sample was weight to calculate national rates. Categorical variables were analyzed via Chi square test and continuous variables via T-test. Multivariable logistic regression analysis was used to assess the primary outcome of inpatient hospital mortality, with the analysis adjusted for age, sex, race and CCI.

RESULTS:

A total of 249045 patients from the 2012-2014 NIS database were admitted for IBD; of those 3.9% had history of AF. The average LOS was 4.7 days, rate of and mortality during hospitalization was 0.2%. AF was associated with older patients (mean age 70 vs. 43.5 years, P < 0.001) and higher CCI (3.9 vs. 1.2, P < 0.001) when compared to non AF patients. AF was also associated with increased hospital LOS (5 days vs. 4.4 days, P < 0.05) as well as higher mortality rates (0.9% vs. 0.1%, P < 0.001) when compared to non AF patients. After adjusting for possible confounders including age, sex, race and Charlson comorbidity index, the mortality rate was significantly higher in the AF group (odds ratio 1.8, P < 0.001, 95% CI 1.5-2.4).

CONCLUSION:

Our study found that hospitalized patients with comorbid IBD and AF had higher mortality rates as well as increased hospital LOS. IBD leads to a chronic inflammatory state promoting systemic inflammation. It has been proposed that this pro-inflammatory state leads to the development of AF in IBD patients. Given the higher incidence of AF in IBD patients compared to the standard population, and the increased mortality and hospital LOS associated with the two conditions, further studies should be done to explore the cause of mortality and any intervention that could improve outcomes.
889 Enhancing Radiation Safety During Fluoroscopy Procedures in Endoscopy Units
Authors: Chatterjee Ritodhi , Chu Jinna , Varghese Vilu , Smith Jason , Robbins Richard , Cole Rhonda , Velez Eugenia , Jarbrink-Sehgal Maria , Hair Clark , Ketwaroo Gyanprakash Avinash
Published: October 2019

INTRODUCTION:

Fluoroscopy is an imaging technique often used in gastroenterology for endoscopic retrograde cholangiopancreatography (ERCP) procedures, subjecting the endoscopist and staff to radiation. Many studies have proposed best practices around behavior, choices, and equipment that attenuate radiation exposure. Gastrointestinal society guidelines also recommend measuring and documenting fluoroscopy time as an important quality metric for ERCP. Our goal was to ensure adequate safety precautions and reporting are adhered to by gastroenterology (GI) staff during fluoroscopy.

METHODS:

We performed baseline assessments of adherence to radiation safety protocols for fluoroscopy, interviewed interventional radiologists, and reviewed the medical literature to guide development of our intervention. We created an educational presentation on radiation safety and equipment handling with survey administration before and after. The first 4 questions used a Likert scale (1 = poor, 5 = excellent) to assess knowledge of and adherence to various aspects of radiation safety, while the latter 4 were multiple-choice questions regarding content. Second, we designated a radiation safety officer (RSO) to assess yearly reports. Lastly, we created a template with fluoroscopy time and dose recording. All interventions were delivered from 10/1/18 – 10/11/18. We reviewed post-ERCP notes to assess adherence.

RESULTS:

17 individuals responded to pre- and post-intervention surveys (Table 1). Before the intervention, the first four questions had an average rating of 4.1 (SD of 0.70) and last four questions had an average correct response of 48% (SD of 20%); after the intervention, the average increased to 4.6 (SD of 0.17) and 93% (SD of 11%). We reviewed post-ERCP notes from 8/1/18 – 9/30/18 (n = 11) and found recording of the fluoroscopy time and radiation dose at baseline was 3%. After intervention, review of all post-ERCP notes from 10/1/18 – 5/31/19 (n = 94) showed recording to range from 86% - 100%.

CONCLUSION:

Initial audits showed a lack in radiation safety knowledge resulting in poor adherence to radiation safety protocols and documentation among GI staff at our tertiary care center. Interventions on education and facilitating documentation with templates can improve the quality of ERCPs and safe radiation practices dramatically.
1019 Performance of Lab-Based Scoring Tests for the Assessment of Hepatic Fibrosis Compared to the Liver Biopsy Among Patients With Non-Alcoholic Fatty Liver Disease
Authors: Miller Alexander , Li Na , Hinton Alice , Mumtaz Khalid
Published: October 2019

INTRODUCTION:

The prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing worldwide. Hepatic fibrosis is the most important predictor for its prognosis. Various lab-based scoring tests have been developed as non-invasive measures to assess for hepatic fibrosis. The aim of this study was to examine the performance of these tests compared to the liver biopsy.

METHODS:

This is a retrospective study that included 354 biopsy-proven NAFLD patients. The sensitivity, specificity, positive predictive value, negative predictive value and area under the receiver operating characteristic (AUROC) curve of aspartate aminotransferase to platelet ratio (APRI), Fibrosis-4 (FIB-4), and NAFLD fibrosis score (NFS) were compared to histological fibrosis between groups without (F0-2) and with advanced hepatic fibrosis (F3-4).

RESULTS:

The mean age of our study population was 50 ± 13 years. The mean BMI was 33.92 ± 8.51 kg/m2. The majority were whites (87.29%) and females (57.63%). The overall mean prevalence of F0-2 fibrosis and F3-4 were 73.7% and 26.3%, respectively. Patients with NFS ≤0.675 were less likely to have advanced hepatic fibrosis (P = 0.011) compared to those who had NFS >0.675. With NFS ≤0.675 and >0.675, the sensitivity and specificity for advanced hepatic fibrosis were 37.6% and 76.2%, and the AUROC was 0.56. The sensitivities and specificities of NFS, APRI and FIB-4 for detecting advanced histological fibrosis are shown in the Table 1.

CONCLUSION:

This is the largest study comparing various lab-based scoring tests with the liver biopsy. The performance of lab-based scoring tests is overall not satisfactory. Therefore, new tests or a combination of these tests with other modality such as elastography is warranted to reliably assess the stages of hepatic fibrosis.