bluuebunny/crossref_metadata_2025_split huggingface dataset:
853 Use of Day Care and Infectious Complications in Children Born to Mothers With Inflammatory Bowel Disease: A Nested Prospective Cohort in the PIANO Registry
Authors: Long Millie D. , Siegel Corey A. , Abraham Bincy , Chiorean Michael , Mahadevan Uma 
Published: October 2019

INTRODUCTION:
Children attending day care have an increased risk of infection. It is unknown whether day care attendance among children of mothers with inflammatory bowel disease (IBD) is associated with an increased risk of infection and whether maternal exposure to biologics potentiates this risk.

METHODS:
The Pregnancy in IBD and Neonatal Outcomes (PIANO) registry is a prospective cohort of over 1500 pregnant women with IBD and their children. Data are collected at each trimester, delivery and at 4, 9 and 12 months postpartum. A sub-set of this cohort completed data on day care exposure. Outcomes of interest included any infection or serious infection (infection requiring hospitalization) in the first year of life. Bivariate analyses were used to compare various clinical characteristics and infectious outcomes by day care use. Logistic regression models were used 1) to determine whether day care independently increased the risk of infections and 2) to determine whether biologic or immunosuppressive medications independently increased the risk of infections among those attending day care.

RESULTS:
A total of 310 pregnant women with IBD and their children were included. Of these, 39% of children attended day care in the first year of life. Clinical characteristics were similar in those that attended day care vs. not, including maternal medication use. Slightly greater numbers of children of non-smokers attended day care (P = 0.007) (Table 1). Children attending day care had a higher rate of any infection in the first year of life than those not attending day care (65% vs. 54%, P = 0.05). However, there were no differences in serious infection rates (6% vs. 8%, P = 0.65) (Table 2). Use of daycare was not significantly associated with any infection after controlling for vaccine use, breastfeeding and preterm birth (OR 1.2, 95% CI 0.71-2.05). Among those attending day care, neither biologic (OR 0.47, 95% CI 0.05-4.86), immunomodulator (OR 0.76, 95% CI 0.04-16.42), nor combination therapy use (OR 0.78, 95% CI 0.06-9.34) was significantly associated with any infection.

CONCLUSION:
Approximately 1/3 of children born to women with IBD in this cohort attended day care in the first year of life. Day care was associated with higher overall infection rates, but not differences in serious infections. There was no further increased risk of infection among children in day care whose mothers were exposed to biologic medications, suggesting that childcare options should not be limited by in utero medication exposure.
857 Oral Mesalamine Use in Crohn's Disease After Implementation of the American College of Gastroenterology Guidelines: A TARGET-IBD Cohort Study
Authors: Gupta Nitin , Sands Bruce E. , Regueiro Miguel , Dubinsky Marla C. , Rubin David T. , Hanson John , Aberra Faten , Weiss Michael , Watkins Stephanie , Gazis Derek R. , Long Millie D. 
Published: October 2019

INTRODUCTION:
American College of Gastroenterology (ACG) guidelines for the management of adults with Crohn's disease (CD) in March 2018 state that oral mesalamine, "should not be used...to treat CD". This abstract estimates the prevalence of any use of mesalamine among patients with CD before and after the implementation of the guideline. It also aims to describe current utilization patterns of mesalamine in CD by disease phenotype, location and concomitant use of biologic agents.

METHODS:
TARGET-IBD is a longitudinal cohort of IBD patients receiving usual care in the US; this abstract includes CD patients enrolled between March 2017 and December 2018. Medication use was captured as any use in the follow up period. Use of mesalamine was stratified into patients who were on mesalamine alone or patients on mesalamine and a biologic. The proportion of patients on mesalamine was estimated in time windows after the policy change to discern penetration into usual practice.

RESULTS:
732 patients from TARGET-IBD who had baseline data prior to the new recommendation were included. Of these, 14% used mesalamine only, 8% used mesalamine plus a biologic and 78% did not use mesalamine. A total of 65% received care in academic centers and the median duration of disease at enrollment was 12 years. The distribution of patient characteristics was similar after the policy change. Six months after the ACG recommendation, 11% of patients used mesalamine only, 7% were on mesalamine plus a biologic and 82% did not use mesalamine. Prevalence of use for the 3 and 6 month time windows were similar. Subsequent therapy changes and additions in patients on mesalamine are shown in Figure 1. Location (colon vs ileum) and type of CD (inflammatory vs fistulizing) were statistically significant predictors of the odds of any mesalamine use both before and after the policy change (OR 3.233 (CI 1.725-6.061) and 3.334 (CI 1.931-5.755, respectively)).

CONCLUSION:
Mesalamine use remained stable in the TARGET-IBD CD population, despite the release of the ACG guideline. Individuals with colonic, inflammatory disease were more likely to receive mesalamine, as were Medicare recipients. There was little difference between academic and community practice in implementation of the new standards. Given that the guidelines are relatively new, it is important to follow these participants over a longer period and to monitor practice differences and ways to reinforce the practice recommendations to improve quality and cost of care.
860 A Novel Quality Improvement Initiative to Reduce Inpatient Opioid Analgesic Use in Inflammatory Bowel Disease: The “IBD Pain Ladder”
Authors: Kaimakliotis Pavlos , Ramadugu Ajit , Kang Jennifer , Trivedi Itishree 
Published: October 2019

INTRODUCTION:
Opioid analgesic use is associated with increased mortality, higher readmission rates, and reduced quality of life among patients with inflammatory bowel disease (IBD). Evidence-based strategies to reduce inpatient opioid use in this population have been lacking.

METHODS:
We have initiated a quality improvement study using an educational intervention, targeting internal medicine (IM) and emergency medicine (EM) house staff with a goal to reduce in-hospital opioid use among IBD patients admitted to the gastroenterology (GI) service at our tertiary institution. This educational tool, the “IBD Pain Ladder” (Figure 1), was created using exhaustive literature review and with multi-disciplinary expert opinion. The tool is meant to help guide decisions regarding analgesia in this patient population while sparing opioid use. Pre-intervention data was collected from IBD patients admitted during a nine-month period (5/2018-2/2019). Educational intervention and prospective follow-up data for another 4 months was collected. The primary outcome was reduction in total inpatient opioid use in oral morphine equivalents per patient. Secondary outcomes included length of stay, types of opioid, 90-day readmission rates, outpatient opioid prescriptions provided upon discharge, Clostridium difficiledetection rates, fecal calprotectin, and C-reactive protein (CRP) levels. t tests for continuous variables and Fisher’s exact test for categorical variables were used; a P value < 0.05 was considered significant.

RESULTS:
A total of 51 patients with 69 hospitalizations were analyzed (Table 2). Hospitalizations before and after our intervention were compared. There was no statistically significant difference in baseline admission characteristics between the two groups (Table 1). Our primary outcome was achieved with a statistically significant reduction in opioid use (39.1 vs 12.4 mg; P < 0.037). Patients were also less likely to receive any opioid during hospitalizations after our intervention (71% vs 43%; P < 0.034.) Length of hospitalization (5.2 vs 3.9 days; P < 0.11) and readmission rates (41% vs 23.5%; P < 0.55) were decreased post-intervention but did not reach statistical significance.

CONCLUSION:
We believe this intervention, aimed at housestaff education and providing a roadmap for pain management in this patient population, is a cost-effective, readily reproducible strategy that can be widely applied to improve IBD patient care. Results will be published and used for quality improvement in inpatient IBD care.
865 Endoscopic Stricturotomy in the Treatment of Anal Stricture in Patients With Fecal Diversion
Authors: Lan Nan , Shen Bo 
Published: October 2019

INTRODUCTION:
Fecal diversion has been used as a protective measure for newly constructed intestinal anastomoses or to settle chronic refractory inflammation. Fecal diversion had been associated with complications such as diversion-related anal stricture. The aim of this study is to exam the significance and the endoscopic treatment for diversion-related stricture.

METHODS:
All consecutive patients with diversion-associated anal stricture that were treated with endoscopic stricturotomy (ESt) in our interventional IBD center (i-IBD) were extracted from patient medical charts from 2010 to 2018. The primary outcome was surgery-free survival.

RESULTS:
A total of 33 patients underwent ESt for their diversion associated strictures. Patients were mostly Caucasian (N = 27, 81.8%) and 18 patients (54.5%) were female. Most of the patients included in this study were diagnosed with ulcerative colitis (N = 22, 66.7%) and most underwent ileal pouch-anal anastomosis (IPAA) with J configuration (N = 24, 72.7%). The most prevalent reason for diversion included anastomotic leaks/sinus/fistula (N = 11, 33.3%), refractory pouchitis (N = 8, 24.2%) and stricturing disease (N = 8, 24.2%). Patients were diagnosed with their stricture at the average age of 43.9 ± 16.1 years. The length of the stricture treated was 2.7 ± 2.2 cm and 32 (97.0%) strictures were nontraversable to endoscope. These patients underwent 2.5 ± 1.9 sessions of ESt in a follow-up of 2.2 ± 1.5 years. Symptomatic improvement was seen in 15/25 (60.0) patients. Subsequent surgery was needed in 4 (12.1%) and 10 (30.3%) had their stoma reversed. No post-ESt complication was reported.

CONCLUSION:
ESt is an effective safe way of treating diversion-related anal strictures. More than half of patients experienced symptomatic improvement and a third of patients had their stoma reversed successfully.
867 Efficacy and Safety of Transoral Incisionless Fundoplication (TIF) in Refractory Gastroesophageal Reflux Disease: A Systematic Review and Meta-Analysis
Authors: Gopalakrishnan Ravikumar Naveen Prasad , Sannapaneni Shilpa , Arora Amita , Sanaka Madhusudhan R. 
Published: October 2019

INTRODUCTION:
Refractory gastroesophageal reflux disease (GERD) is common and can affect up to 40% of patients who are on proton pump inhibitor therapy. Surgical fundoplication (Nissen fundoplication) has proven to be an effective treatment option for these patients but it remains an invasive procedure in this era of minimally invasive surgery. Several endoluminal approaches to GERD management have been developed as a potential bridge between medical management and surgical fundoplication. Transoral incisionless fundoplication (TIF) is a novel endoscopic technique which has shown some promise in early studies; however, its safety profile and efficacy remain uncertain. We aimed to assess the efficacy and safety of TIF in refractory GERD through a systematic review and meta-analysis.

METHODS:
We performed a thorough literature search using PubMed, EMBASE, Cochrane library, Medline, Google Scholar and Science citation index between January 2010 to January 2018. Search terms included MeSH and non-MeSH terms relating to gastroesophageal reflux disease, refractory gastroesophageal reflux disease, endoscopic techniques in gastroesophageal reflux disease and transoral incisionless fundoplication. Additional case-reports, case series, and abstracts were retrieved by searching from references of relevant studies. Primary outcomes measured were cumulative technical success rate and adverse events. Secondary outcomes measured were the improvement in Gastroesophageal Reflux Symptom Score (GERSS), DeMeester score and Reflux symptom index (RSI).

RESULTS:
Based on our search criteria, 41 studies were identified and 6 were excluded after careful review. 35 studies which included 1586 patients (49.4% males) were analyzed. The overall technical success rate of TIF was 98.4% (95% confidence interval [CI] 96 to 99, P < 0.001) and had an adverse event rate of 3.2% (95% CI 1 to 4, P < 0.001). Post TIF, there was a significant improvement in GERSS score (mean difference 17.29, 95% CI 17.26 to 18.28, P < 0.001), RSI (mean difference 14.37, 95% CI 13.39 to 15.19, P < 0.001) and DeMeester score (mean difference 9.78, 95 % CI 8.12 to 11.89, P < 0.001).

CONCLUSION:
TIF is a technically feasible and effective endoscopic therapeutic option for refractory GERD with good clinical responses. However, more controlled trials are required in future to compare the efficacy and safety between TIF and Nissen fundoplication.
868 Coils and Dermabond: A Large County Hospital Experience With Gastric Varices
Authors: Glass Jason , Suarez Jorge , Tavakkoli Anna , Agrawal Deepak 
Published: October 2019

INTRODUCTION:
Bleeding from gastric varices (GV) is associated with high mortality and morbidity. EUS-guided injection of coils, cyanoacrylate glue or both is an emerging modality for treatment of gastric varics. We present our experience using EUS injection of coils (Nester Embolization Coil; Cook Medical) and 2-Octyl-cyanoacrylate (Dermabond) glue in the treatment of bleeding gastric varices in a large county hospital setting.

METHODS:
Medical records of consecutivepatients undergoing EUS guided treatment of gastric varices with glue and coils between mth/yer to mth/year were reviewed.Patient characteristics were recorded including presence of cirrhosis, variceal characteristics (size, location), and intervention type. Outcomes included technical success (defined as deployment of glue and coils inside the varix with cessation of blood flow on Doppler evaluation), rebleeding events, and subsequent one month follow up were recorded.

RESULTS:
Total of 16 patients were treated with EUS guided injection of coils and/or glue. Three (18.8%) had active bleeding and four (25%) had stigmata of recent bleeding at the index endoscopy. The remaining 9 (46.2%) had history of bleeding from gastric varices. 15/16 patients were treated with both coils and glue injection. One patient with small varices was treated with glue injection alone. Technical success was achieved in all 16 (100%) patients. None of the patients had active bleeding at the end of the procedure. The mean number of coils inserted was 3.9 and the mean volume of glue injected was 2.1 mL. Rebleeding, defined as having repeat endoscopy for gross gastrointestinal bleeding, occurred in 3 patients within one month of the initial EUS. In one patient, rebleeding was from gastric varices and was again treated with coils and glue injection. There were no significant adverse events including pain or embolization of glue or coils. One patient had extrusion of coils into the lumen of the stomach with no active bleeding identified.

CONCLUSION:
In this series, we demonstrate the high technical success and efficacy of EUS guided coil and glue injection in treatment of bleeding or secondary prophylaxis of gastric varices.
871 Impact of Patient Screening Process on Diagnostic and Therapeutic Yield of Double Balloon Enteroscopy
Authors: Wang Xiao Jing , Liu Mengfei , Anderson Bradley , Chakraborty Subhankar , Garg Sushil , Kane Sunanda , Sanchez William 
Published: October 2019

INTRODUCTION:
Double balloon enteroscopy (DBE) is an important tool for evaluation of obscure GI bleeding but is a limited resource given time and expertise required. Patient selection is important to help optimize diagnostic yield and subsequent successful management of small bowel bleeding. To maximize the efficiency of DBE performed, our endoscopy group established a screening protocol (Figure) prior to approval of any procedure. We developed a quality improvement project to assess the efficacy of this screening protocol and to evaluate which components of screening were most predictive for procedural success.

METHODS:
A retrospective chart review was performed on all patients who underwent anterograde or retrograde double balloon enteroscopy for suspected GI bleeding from January 2016 to December 2017. Our screening protocol was implemented on February 1st, 2017. Data was obtained on patient demographics, clinical presentation, laboratory evaluation, and prior investigation for bleeding evaluation. Endoscopy outcomes were separated into procedural success, defined as lesion identified, and clinical success, defined as resolution of bleeding. Success rates were compared pre and post intervention. Regression analysis was performed to evaluate which components best predicted a successful procedure.

RESULTS:
We reviewed 114 DBE procedures in 89 patients, 53.5% male (n = 61) with a mean age of 62.8 + 13.3 years. Of these, 86% (n = 98) were performed prior to initiation of the screening protocol. Overall, there was no significant difference in procedural success pre and post intervention as defined by presence of recurrent bleeding, persistent anemia, or transfusion need (Table 1). On univariate analysis of clinical success, defined as lack of recurrent bleeding, gender, anticoagulation use, and presence of lesion on CE were significant (Table 2). Identification and intervention on a lesion during the balloon endoscopy did not impact future anemia, bleeding, or transfusion requirements.

CONCLUSION:
The patient screening protocol was successful in decreasing the number of procedures performed but did not improve our lesion detection rate on endoscopy and did not improve clinical outcomes as measured by rebleeding. Patients on anticoagulation and those who had prior lesions identified on capsule endoscopy had higher odds of rebleeding, indicating clinical failure. This data may help modify patient selection to maximize success of DBE procedures in the future.
877 Impact of Prior Myocardial Infarction or Revascularization on Outcomes of Adult Patients Undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP): An 8-year Nationwide Inpatient Outlook
Authors: Patel Harsh K. , Desai Rupak , Doshi Shreyans , Lakhani Neet , Chudasama Jay , Singh Sandeep , Vyas Ankit , Vyas Manan , Varma Yash , Goyal Hemant 
Published: October 2019

INTRODUCTION:
Considering its inflammatory potential Endoscopic retrograde cholangiopancreatography (ERCP) can prompt myocardial infarction in patients with preexisting coronary artery disease (CAD). However, the data regarding the impact of previous MI/revascularization procedures are non-existent. We aimed to compare the outcomes of adult patients undergoing ERCP with vs. without any such prior history.

METHODS:
Using the ICD-9 CM codes in the National Inpatient Sample (2007 -2014) we identified adult patients undergoing ERCP who had a prior history of MI, PCI or CABG. Primary endpoints- inpatient mortality and post-ERCP complications. Secondary endpoints- discharge disposition, mean length of stay and total hospital charges. SPSS version 22 (IBM Corp, NY, USA) was used for all analyses. Categorical and continuous variables were compared using the Chi-square test and Student’s t-test, respectively. A two-tailed P value ≤ 0.05 was set as the cutoff for the statistical significance.

RESULTS:
Of total 1,374,773 ERCP procedures performed between 2007 to 2014, 120,418 (8.8%) were performed in patients who had a prior history of MI, PCI or CABG (study cohort) and the rest were considered the control cohort. The study-cohort had older (mean age 74y vs. 58y) population and more males (63.9% vs. 37.6%), who were admitted non-electively (88.1% vs. 87.3%) as compared to the control cohort (P < 0.001) Figure 1. compares baseline characteristics between both cohorts. There is an increasing trend of performing ERCP in study group between 2007 to 2014 (7.5% to 9.5%; P
trend = 0.022) with a decrease in inpatient mortality from 1.8 to 1.4% (Figure 1). All-cause inpatient mortality was also higher (1.7% vs. 1.5%, P < 0.001) in the study cohort (Figure 1). Post-ERCP cardiopulmonary complications, sepsis, and haemorrhage were all higher in the study group (P < 0.001) (Table 2). However, post-ERCP pancreatitis (14.1% vs. 15.4%, P < 0.001) was lower in the study group without any difference in cholecystitis (0.4% vs. 0.4%, P = 0.180). The mean length of stay (6.8 days vs 6.6 days) was marginally higher in the study cohort without any difference in the hospitalization charges.

CONCLUSION:
In this nationwide retrospective study, we determined higher inpatient mortality and cardiopulmonary complications, sepsis, and haemorrhage in adult patients undergoing ERCP with a prior history of MI, PCI or CABG. Future prospective studies are warranted to delineate the impact of prior infarction or revascularization on the outcomes of ERCP.
878 Prophylactic Antibiotic Administration in EUS-Guided Aspiration of Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis
Authors: Elkafrawy Ahmed A. , Nehme Fredy , Elkhouly Mohamed A. , Zafar Yousaf 
Published: October 2019

INTRODUCTION:
EUS guided fine needle aspiration (FNA) of pancreatic cystic lesions (PCL) has become the standard diagnostic modality for pancreatic cysts. Current American Society of Gastrointestinal Endoscopy (ASGE) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommended the use of periprocedural prophylactic antibiotics (PA), although data is equivocal. Our aim was to perform a systematic review and meta-analysis to evaluate the efficacy of PA in preventing cyst infection during EUS-guided aspiration of PCL and assess the rate of complications related to antibiotic use.

METHODS:
We included studies evaluating the outcomes of using PA in EUS-guided FNA of PCL. We searched PubMed, Embase, and Google Scholar through April 2019. Eligible studies were searched for variables of interest including infection of PCL and antibiotic-related complications. All statistical analyses were performed using the R Programming Language. Pooled rates of variables were reported as Relative risks (RR) with 95% confidence interval and heterogeneity was reported as I2 statistics.

RESULTS:
A total of 9 retrospective studies were eligible and included in the analysis. 6 studies compared the use of PA to no antibiotics while the other 3 did not have a comparison group. There were 1183 subjects in the antibiotic group and 579 subjects in the non-antibiotic group. Duration of antibiotics varied from a single intraprocedural dose to 3-5 days following the procedure. Multiple antibiotic regimens were used including ceftriaxone, quinolones, amoxicillin, and piperacillin/tazobactam. There was no statistically significant difference in the rate of cyst infection between patients receiving PA and those who did not (RR = 0.6, 0.21-1.75; I2 = 0%) (Figure 1). 1.2% of patients receiving PA developed adverse events related to antibiotic use. In addition, there was no difference among subgroups when stratifying subjects by single dose and 3-5 days of antibiotics (P = 0.619) (Figure 2).

CONCLUSION:
The incidence of infectious complications after EUS-guided FNA of PCL appears very low and the use of PA did not substantially reduce the risk. Antibiotic use is not free of adverse events. Further randomized controlled trials are needed to evaluate the appropriateness of current recommendations.