bluuebunny/crossref_metadata_2025_split huggingface dataset:
A94 RECURRENT HEPATOCELLULAR CARCINOMA: EVALUATION OF 8 POST-TRANSPLANT SCORING SYSTEMS
Authors: Aziz S , Qumosani K , Teriaky A 
Published: February 2020

Abstract

Background
Recurrence of hepatocellular carcinoma (HCC) after liver transplantation is a major cause of morbidity and mortality. It is well known that there is a discordance between pre-transplant imaging and post-transplant pathology that affect risk of recurrence. Several risk assessment tools have been developed, although to date, there is no widely accepted tool to predict HCC recurrence.

Aims
The aim of the current study is to determine which pathologic risk assessment score has the best predicative ability.

Methods
We retrospectively evaluated 152 patients over a twelve-year period that underwent liver transplantation for HCC. Using explanted pathology reports, each patient was stratified according to the pathologic risk score and followed over time for HCC recurrence. We evaluated eight pathologic risk scores and determined predictive ability by assessing the area under the receiver operating characteristic curve (AUROC).

Results
Out of 152 consecutive liver transplants for HCC, recurrence occurred in 21 patients (14%) with a mean follow-up of 59.5 months. 54% of patients were within Milan criteria prior to transplant. According to explant pathology, microvascular invasion was seen in 16% of patients, with majority of the tumors being moderately differentiated (48%), tumor size ≥ 3cm (52%), and 26% of tumors in both lobes of the liver. Preliminary data suggests that the Parfitt et. al score has the best predictive ability, with 60% of recurrence occurring in those considered high-risk. Further assessment via AUROC will be required to confirm the preliminary data.

Conclusions
Preliminary data suggests the Parfitt et al. score may have the best predictive ability to detect recurrence. This risk assessment tool can help tailor a surveillance strategy for early detection or early adjuvant therapy to improve long-term survival.

Funding Agencies
None
A129 THE VALUE OF REPEAT MANOMETRIC TESTING
Authors: Pandey A , Liu A , Buresi M C , Gupta M , Nasser Y , Curley M , Li D Y , Andrews C N , Woo M 
Published: February 2020

Abstract

Background
While motility disorders may evolve over time, there is scant guidance around the role of repeat high-resolution esophageal manometry (HRM). Given the invasive nature of HRM and the implications on financial cost and patient discomfort, it is obvious that the emphasis should be on minimizing unnecessary repeat examinations. However, there are no recommendations around indications or timing of repeat HRM.

Aims
We aimed to determine the outcomes in patients who underwent repeat manometry and look for predictors of progression to achalasia or major motility disorder.

Methods
Consecutive reports from HRM studies performed between Aug 2013 – May 2017 were retrospectively analyzed. All patients with ≥ 2 HRM studies were included. Studies without a Chicago classification diagnosis were excluded. Chi-squared analysis was performed to determine if initial HRM diagnosis was associated with change in diagnosis on follow-up HRM. Initial and follow-up manometric parameters were compared with paired T-tests. Binary logistic regression analysis was performed to look for predictors of progression to achalasia or major motility disorder.

Results
134 patients underwent ≥ 2 HRM studies. Initial diagnoses were IEM (45 patients [33.6%], EGJOO (34 [25.4%], absent peristalsis (18 [13.4%], achalasia (11 [8.2%], DES (4 [3.0%]), and JH (3 [2.2%]; 29 (14.2%) of patients had a normal HRM. 109 (81.3%) patients underwent 2 HRM, 18 (13.4%) 3 HRM, 4 (3%) 4 HRM, and 3 (2.2%) 5 HRM.
The final follow-up HRM occurred after a median 496 [80 – 1823] days. 72 (53.7%) of patients had no change from their initial diagnosis. Patients with an initial diagnosis of DES were significantly more likely to have a change in diagnosis on the final follow-up (3 normal:1 IEM) (p = .043). No other classes reached significance. Patients with IEM had a significantly higher mean DCI (395.1 [0 - 3248] vs 790.8 [0 – 10715.0], p = .006) and IRP (4.5 [-10.4 – 14.2] vs [6.6 [-6.2 – 21.0], p = .017) on their follow-up HRM.
4 patients without achalasia (3 EGJOO:1 IEM) on their index HRM had a diagnosis of achalasia on their final HRM. The median IRP in non-achalasia patients with a diagnosis of achalasia on final HRM (22.3 [8.4 – 30.7] was significantly higher than those without a diagnosis of achalasia on final HRM (6.6 [-10.4 – 39.8]) (p = .013); however no manometric criteria or initial HRM diagnoses predicted progression to achalasia or major motility disorder on binary logistic regression analysis.

Conclusions
In most patients, repeat manometry did not change the manometric diagnosis. Patients with DES were significantly likely to have their diagnosis change with repeat HRM, and most of these patients had normalization of their HRM. Manometric parameters in IEM appear to improve over time. This finding could reflect interval therapy, or shed some light on the natural history of this disease.

Funding Agencies
None
A132 SMOOTH MUSCLE BIOPSIES FROM POEM PROCEDURES FOR ACHALASIA SHOW LACK OF FUNCTIONAL INNERVATION
Authors: Rodrigues D , Lourenssen S , Bechara R , Blennerhassett M G 
Published: February 2020

Abstract

Background
Idiopathic achalasia is a disease of the esophagus causing impaired peristalsis and absent lower esophageal sphincter relaxation. The etiopathogenesis of the disease is unclear but most histopathologic studies from surgical resections show an absence of nitric oxide-producing neurons in the myenteric plexus. The peroral endoscopic myotomy (POEM) procedure has evolved in the last decade to treat achalasia and has provided a unique way to sample diseased tissue from an otherwise inaccessible tissue compartment.

Aims
To study the effects of achalasia on innervation of smooth muscle and smooth muscle phenotype.

Methods
Patients with a diagnosis of achalasia based on high resolution manometry undergoing a POEM at Kingston general hospital were approached for enrollment between June 2017 to September 2018. Demographic information including age, symptom duration, previous treatments, and Eckhardt score was collected. Intraoperatively, biopsies of the circular smooth muscle (CSM) layer were taken at the proximal and distal extents of the myotomy and placed in formalin. Tissue was embedded in wax, sectioned and stained using immunocytochemistry (ICC) for neuronal, axonal and smooth muscle cell markers. This was compared to control tissue from patients undergoing gastroesophagectomy for adjacent malignancy.

Results
Control tissue from 3 separate esophagectomies were obtained. Samples were obtained from a total of 25 patients (13 males), with a median age of 50 (IQR 38–67). Most patients had Type 2 achalasia (19 [76%]) followed by Type 1 and 3 (2, [8%] respectively). Two cases had conflicting manometric findings. The median duration of symptoms was 3 years (IQR 1.5–10.5) and the median Eckhardt score was 6.5 (IQR 5–9). In sample tissues, no neuronal cell bodies were detected in the CSM layer. ICC for the axonal marker PGP9.5 showed that CSM of achalasia samples were almost completely devoid of axon structure, independent of the subtype of achalasia, compared to abundant axon presence in control tissues. In parallel, ICC showed that cholinergic (ChAT) or nitrergic (nNOS) axonal subtypes were absent in biopsy CSM while abundant in controls. CSM cells displayed hypertrophy with no detection of proliferation by ICC (KI67) or alterations in the phenotypic marker SM-22.

Conclusions
Preliminary results from advanced immunohistochemical techniques show the absence of functional innervation of the CSM layer of all patients with achalasia. This is characterized by a depleted excitatory and inhibitory axon population. Further studies are focused on defining differences in smooth muscle phenotype and the presence or absence of inflammatory cells within the CSM.

Funding Agencies
None
A134 RATES OF PARENTERAL NUTRITION-ASSOCIATED CHOLESTASIS/LIVER DISEASE AND GROWTH PRE- AND POST-SMOFLIPID INTRODUCTION IN NEONATES AND INFANTS WITH INTESTINAL FAILURE
Authors: Tyminski N , Hudson A , Turner J , Silverman J 
Published: February 2020

Abstract

Background
Parenteral nutrition (PN) is essential for survival in infants with intestinal failure (IF). PN-associated cholestasis (PNAC) and liver disease (PNALD) are life-threatening complications of long-term PN use. SMOFlipid (soybean oil, medium-chain triglycerides, olive oil, and fish oil) has recently been approved as an off-label alternative to the conventional soy-based lipid emulsion (Intralipid). It is thought to have anti-cholestatic properties due to its more diverse lipid composition. Due to its’ recent approval in Canada (2013) and the USA (2016), data remains sparse.

Aims
We aim to determine if infants with IF receiving SMOFlipid had significantly lower rates of PNAC and improved growth compared to those receiving Intralipid.

Methods
All patients (≤1 year old at start of PN therapy) who received PN of any duration at two tertiary pediatric hospitals in Edmonton (2010–2018) were identified from the shared pharmacy database. Those with IF who received one type of PN continuously for ≥6 weeks total were included. Individuals with an initial serum conjugated bilirubin &gt;50 µmol/L and/or who had PN interruptions &gt;5 days were excluded. Data on liver parameters, growth, and complications were collected. Non-parametric tests (Mann-Whitney U test for continuous variables and χ2 test for categorical variables) were used to compare PNAC/PNALD (serum conjugated bilirubin &gt;34umol/L during PN) and growth (weight/length/head circumference z-scores) between SMOFlipid and Intralipid.

Results
1777 patients were reviewed; 40 infants (55% male), median age 4 weeks (range 0–48 weeks) at the time of PN initiation, met the inclusion criteria. Reasons for exclusion (n=1737) were receiving PN &lt;6 weeks total (n=1485), duplicate patients (n=154), receiving multiple types of PN with each less than 6 weeks total (n=62), an initial serum conjugated bilirubin &gt;50umol/L (n=21), more than 5 consecutive days off of PN (n=12), and older than 1 year old at time of PN initiation (n=3). Twenty-one patients (53%) received SMOFlipid, 15 (38%) Intralipid, and 4 (10%) Omegaven for ≥6 weeks. The majority (92%) were in an intensive care unit (neonatal or pediatric). No patients were septic when starting PN. Individuals received PN over a median of 7.9 weeks (range 6–27 weeks).

Conclusions
As expected, neonatal onset intestinal failure is rare in Edmonton. In our tertiary pediatric institutions, 2010–2018, SMOFLipid was the predominant lipid choice for infants with intestinal failure, followed by Intralipid. Omegaven was used rarely. This dataset will now allow us to compare the rates of PNAC at six weeks post-PN initiation and differences in growth between infants with IF receiving SMOFlipid versus the traditional Intralipid in our Canadian setting. Analysis is currently underway.

Funding Agencies
Women and Children’s Health Research Institute (WCHRI) at the University of Alberta
A142 ENDOSCOPIST EDUCATIONAL INTERVENTIONS ARE ASSOCIATED WITH IMPROVEMENTS IN ADENOMA DETECTION RATE: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: González Moreno E , Bishay K , Calo N , Scaffidi M A , Grover S C , Forbes N 
Published: February 2020

Abstract

Background
Screening-related colonoscopy reduces the overall morbidity and mortality associated with colorectal cancer. In order for screening-related colonoscopy to be effective and safe, endoscopists must be well trained. However, a significant degree of variation exists between endoscopists in terms of adenoma detection rate (ADR) and cecal intubation rate (CIR). ADR in particular is an important colonoscopy quality metric that has been directly and inversely related to the rate of post colonoscopy colorectal cancer (PCCRC). Educational interventions aimed at endoscopists have been developed in an attempt to optimize the performance of colonoscopy. It is unknown what benefit these have on colonoscopy quality indicators or outcomes, if any.

Aims
We performed a systematic review and meta-analysis to determine whether there is an association between educational interventions aimed at endoscopists and improvements in colonoscopy quality indicators or outcomes.

Methods
An electronic search was conducted through August 2019 for studies reporting on targeted endoscopist educational interventions and associations with ADR or other colonoscopy quality indicators, or outcomes. Interventions such as hands-on training modules, skills enhancement courses were included Pooled rate ratios (RR) and weighted mean differences (WMD) were calculated using DerSimonian and Laird random effects models. A priori subgroup and sensitivity analyses were performed to assess for potential methodological or clinical factors associated with any of the outcomes of interest.

Results
From 2,253 initial studies, 14 were included in the systematic review, and 8 were included in the meta-analysis for ADR, representing 76,373 colonoscopies. Educational interventions were associated with improvements in ADR (RR 1.28, 95% confidence intervals, CI, 1.19–1.38). Educational interventions were also associated with improvements in overall polyp detection rate, PDR (RR 1.17, 95% confidence intervals, CI, 1.02–1.35). Educational interventions were not associated with longer withdrawal times (WMD -0.03 minutes, 95% CI, -0.57 - 0.51) or improved CIR (RR 1.00, 95% CI, 0.99 to 1.02), though unadjusted CIR was high in both the pre- and post-intervention groups, at 94.5% and 95.0%, respectively. Figure 1 shows Forest plots comparing pre-intervention and post-intervention rates for A) ADR, b) PDR and c) CIR.

Conclusions
Our study provides evidence that educational interventions aimed at endoscopists significantly improve ADR and overall PDR. Educational interventions did not impact withdrawal time or cecal intubation rates, and thus, the specific mechanisms for their benefit remain incompletely clear. As part of quality improvement programs to optimize colonoscopy performance, educational interventions should be considered.

Funding Agencies
None
A143 IMPACT OF A SIMULATION-BASED AUGMENTED REALITY CURRICULUM ON POLYPECTOMY SKILLS AMONG NOVICE ENDOSCOPISTS: A RANDOMIZED CONTROLLED TRIAL
Authors: Khan R , Scaffidi M A , Gimpaya N , Tham D , Atalla M , Al-Mazroui A , Gholami R , Satchwell J B , Walsh C M , Grover S C 
Published: February 2020

Abstract

Background
Polypectomy is an essential endoscopic skill. Training in polypectomy has been identified as a major deficiency for endoscopists worldwide as polypectomy occurs ad hoc during a colonoscopy when a polyp is detected, and a lack of standardized curricula. Augmented reality (AR), which superimposes computer-generated images on a user’s view of the world, can address these gaps by standardizing encounters with polyps while completing simulated procedures and enabling polypectomy-specific teaching.

Aims
Evaluate the impact of a simulation-based augmented reality curriculum on polypectomy performance among novice endoscopists.

Methods
This study includes two cohorts of participants from 2019 to 2020. In 2019, participants were randomized into either: (1) a control curriculum, involving 6 hours of simulation-based training (SBT) supplemented by expert feedback, interlaced with 4 hours of small group teaching on the theory of colonoscopy; or (2) the augmented reality curriculum (ARC), in involving the same curriculum with integrated AR, wherein participants engaged with an AR-enhanced video demonstrating relevant therapeutic and pathologic details during polypectomy. The SBT for all participants involved a progressive curriculum starting on a bench-top model and then moving to the EndoVR® virtual reality simulator. The primary outcome was polypectomy-specific performance using the Direct Observation of Polypectomy Skills (DOPyS) tool during a simulated polypectomy after training, with a maximum score of 100.

Results
Demographic characteristics are summarized in Table. In 2019, 21 novice endoscopists were enrolled. Immediately after training, the mean DOPyS score among ARC group participants was 76.2 (SD=17.9) compared to 71.8 (SD=13.2) among control group participants (Figure). In this interim analysis, there was no significant difference between groups. Data analysis will be completed after 2020 participants complete the study.

Conclusions
Interim results show a trend towards improved polypectomy performance with no significant difference. The results of this study have the potential to impact polypectomy education among novices. Simulation-based AR interventions may allow learners to progress towards achieving competency in polypectomy in a risk-free environment prior to first patient contact.

Funding Agencies
None
A146 MANAGEMENT OF ANTITHROMBOTIC THERAPY AFTER GASTROINTESTINAL BLEEDING: A MIXED METHODS STUDY OF HEALTHCARE PROVIDERS
Authors: Little D H , Pinto T , Douketis J , Dionne J , Holbrook A , Xenodemetropoulos T , Siegal D 
Published: February 2020

Abstract

Background
Oral anticoagulants (OAC) are permanently discontinued in up to 50% of patients after gastrointestinal (GI) bleeding despite ongoing thrombotic risk and evidence of benefit to restarting. The reasons for permanent discontinuation of OAC are unclear, but likely include concerns about re-bleeding and a lack of high-quality evidence. There are no studies evaluating healthcare provider values and preferences following OAC-related GI bleeding and their influence on decision-making about whether and when to resume OACs.

Aims
We aimed to (i) identify key factors (attributes) that influence healthcare provider decision-making regarding resumption of OAC after GI bleeding, (ii) determine the relative importance of these attributes, and (iii) to identify preference groups.

Methods
We conducted focus group discussions (FGD) with healthcare providers involved in the care of patients with OAC-related GI bleeding. Participants ranked the relative importance of the attributes identified during the FGD through a dot voting exercise. Transcripts were reviewed and themes (attributes) were identified. Results of the FGD informed a discrete choice experiments survey developed and analyzed using the Sawtooth software platform (Sawtooth Software, USA). The survey was pilot tested and modified by iterative feedback. A sample choice task is shown in Image 1. Hierarchical Bayes analysis was used to estimate preference coefficients (utilities) for each attribute. Latent class analysis was used to identify preference groups.

Results
There were 4 FGD involving 29 participants. The most important attributes identified and included in the survey were thrombosis risk, indication for OAC, index bleed severity, re-bleeding risk, and patient characteristics. There were 130 survey respondents practicing in hematology (n=68), internal medicine (n=30), gastroenterology (n=7), cardiology (n=4), family medicine (n=3), and others (n=18). The mean age was 45 years (±11) and 51% were male. Thrombosis risk and re-bleeding risk equally had the highest utility followed by index bleed severity, patient characteristics, and indication for OAC. Two preference groups were identified. The dominant preference group (78% of respondents) placed the highest utility on thrombosis risk and re-bleeding risk, while a minority (22% of respondents) placed the highest utility on index bleed severity.

Conclusions
Thrombosis risk and re-bleeding risk are equally the most important factors influencing OAC resumption following OAC-related GI bleeding. The severity of the index bleed is the most important factor in decision-making for a minority segment of healthcare providers. Further research on the dose, type and timing of OAC resumption is needed to determine the optimal balance between thrombosis and re-bleeding.

Funding Agencies
Heart and Stroke Foundation
A153 INCIDENCE OF DEEP VEIN THROMBOSIS (DVT) & PROPHYLAXIS PRACTICES IN DECOMPENSATED CIRRHOSIS INPATIENTS
Authors: Sarker A , Yelle D , Wooller K , Kelly E M 
Published: February 2020

Abstract

Background
The coagulation cascade is disturbed in cirrhosis. Patients are at risk for bleeding and coagulation through an imbalance of pro and anticoagulant factors.

Aims
We evaluated the incidence of DVTs and prevalence of DVT prophylaxis in hospitalized patients with decompensated cirrhosis.

Methods
A retrospective study of decompensated cirrhotic patients admitted to a tertiary care hospital. We evaluated the incidence of DVTs and use of DVT prophylaxis in this cohort. We also evaluated differences in patient characteristics in those who received DVT prophylaxis and between patients who did or did not develop DVTs.

Results
This study consisted of 520 cirrhotic patients, of which 258 patients (49.6%) received DVT prophylaxis. Of the remaining 262 patients who did not receive DVT prophylaxis, 199 (75.9%) had a documented contraindication to prophylaxis (bleeding, thrombocytopenia, both, or other). Compared to patients without DVT prophylaxis, patients who received prophylaxis were older (61.2 ± 11.2 vs 56.6 ± 10.9, p= 0.00001), had less varices (16.2% vs. 46%, p=0.0048), had more severe liver disease (MELD-Na 21 ± 6.5 vs 19.7 ± 7.3, p = 0.032), and fewer incidents of variceal (3.4% vs. 35.1%, p &lt;0.001) and non-variceal (5.4% vs. 17.1%, p &lt;0.001) gastrointestinal bleeding. DVT prophylaxed patients also had higher mean platelet values (149 ± 89 vs 112 ± 84, p &lt;0.001), but similar baseline INRs (1.6 ± 0.4 vs 1.7 ± 0.8, p= 0.16), and were more likely to be admitted for non-bleeding complications of liver disease, including incidence of hepatic encephalopathy (37.9% vs 25.1%, p = 0.002) and spontaneous bacterial peritonitis (12.1% vs 6.5%, p=0.029). The incidence of radiographically identified DVT events in cirrhotic patients receiving DVT prophylaxis and those not receiving DVT prophylaxis was similar at 1.1 and 0.7%, respectively (OR 1.52, 95% CI 0.254 to 9.1, p = 0.65). There was no difference in liver disease severity between those with DVTs to those who did not develop DVTs, including similar MELD-Na, INR, platelets and hemoglobin values. Compared to patients without DVTs, those who developed DVTs had a higher bilirubin (95.8 ± 78.0 vs. 64.1 ± 24, p = 0.202) and INR (2.1 ± 0.7 vs. 1.6 ± 0.6, p = 0.07), as well as lower platelets (81.8 ± 23.3 vs. 131.4 ± 88.9). These groups had comparatively similar MELD-Na, albumin, creatinine, and hemoglobin levels.

Conclusions
DVT prevalence in this cohort of decompensated liver disease patients was overall low. DVT prophylaxis rates were moderate overall, however taking into account perceived contraindications such as thrombocytopenia or bleeding, patients appeared to be appropriately prophylaxed when indicated. Further study is required to identify which cirrhotic patients are at highest risk for DVTs and the safety of prophylaxis among patients with deranged lab values such as low platelets and elevated INR.

Funding Agencies
None