bluuebunny/crossref_metadata_2025_split huggingface dataset:
202  Colorectal Cancer Incidence and Demographic Trends in Patients Less Than 50 Years Old in a Large Integrated Healthcare System
Authors: Luong Angeline , Fahmy Marianne , Wu Bechien U. 
Published: October 2019

INTRODUCTION:
Recent studies show increasing incidence of colorectal cancer (CRC) in adults less than 50 years, though there is limited data about this population. The primary aim of this study was to calculate trends in CRC incidence and average annual percentage change (AAPC) in patients less than 50 years old within a regional integrated health care system. The secondary aim was to determine demographic trends associated with CRC incidence in this younger population.

METHODS:
This is a retrospective cross-sectional study of Kaiser Permanente Southern California (KPSC) members, age 20–49 years from 1996–2016. Unadjusted incidence rates and AAPC were calculated by age (20–29, 30–39, 40–49) and year, and stratified by Surveillance, Epidemiology, and End Results Program (SEER) staging (early stage SEER 0–II; late stage SEER III, IV, VII). Incidence rate ratios (IRR) were calculated based on gender (male, female), age (40–49, 20–39), race/ethnicity (white, Asian, black, Hispanic), and stratified by staging, and location (proximal, distal).

RESULTS:
Among 3,125,389 patients, there were 2,883 (0.09%) age 20–49 years diagnosed with CRC from 1996–2016. Incidence increased up to 2.9% annually; in 20–39 year-olds, late stage colon cancer increased 1.9% annually (95% CI: 0.3, 3.5; P < 0.0001) and late stage rectal cancer increased 3.9% annually (95% CI: 0.6, 7.2; P < 0.0001). Compared to 20–39 year-olds, 40–49 year-olds had up to 5× risk for CRC at any stage and location (IRR 5.86; 95% CI: 4.94, 6.95; P < 0.0001). Men had increased risk for CRC compared to women, with 45% increased risk for proximal tumors (IRR 1.45; 95% CI: 1.24, 1.71; P < 0.0001). Whites and Asians had increased risk for distal tumors, up to 2× risk (IRR 2.0; 95% CI: 1.64, 2.45; P < 0.0001). Both also had higher risk for rectal cancer, up to 2.22× risk (IRR 2.22; 95% CI: 1.84, 2.68; P < 0.0001) compared to Hispanics and up to 56% increased risk (IRR 1.56; 95% CI: 1.24, 1.98; P = 0.0002) compared to blacks. Compared to whites and Asians, blacks had up to 43% increased risk for proximal tumors (IRR 0.57; 95% CI: 0.42, 0.78; P = 0.0003). Hispanics had the lowest risk for CRC at all stages and locations.

CONCLUSION:
The CRC incidence in 20–49 year-olds are increasing, particularly in cases of late stage CRC and among patients between 40–49 years of age. Distribution of tumor location varied by sex as well as race/ethnicity. Further studying of these demographic trends may help inform future screening and prevention strategies.
207 Fecal Microbiota Transplantation With Oral Capsules for Clostridium difficile Infection: Inconsistencies Among Reporting and Impact on Remission Rates
Authors: Chalikonda Divya M. , Kistler Charles , Bhurwal Abhishek 
Published: October 2019

INTRODUCTION:
Fecal microbiota transplantation (FMT) has emerged as a safe and effective treatment for recurrent Clostridium difficile infection (rCDI). FMT can be delivered via the upper gastrointestinal tract (UGIT) or lower GIT. Recently, oral capsule delivery has been demonstrated to be non-inferior to other routes. However, oral administration lends the capsule susceptible to pH changes and intestinal microbiota exposures prior to reaching the colon. There is a lack of consistency between studies evaluating FMT capsules with respect to multiple factors. This systematic review aimed at identifying factors within these studies that could impact remission rates such as type of capsule preparation, prior acid suppression therapy and colon preparation before treatment.

METHODS:
An electronic search was conducted using PubMed, Scopus, EMBASE and Cochrane Central Register of Controlled Trials. The search strategy was not limited by language. Search terms for both the free text and medical subject heading (MeSH) included “fecal microbiota transplantation” and “capsule.” Eligibility criteria included clinical trials using FMT for rCDI and delivery by capsule. Exclusion criteria included lack of capsule manufacturing description or endpoints related to CDI resolution.

RESULTS:
The initial search strategy yielded 93 publications. 30 duplicates were removed. 37 were excluded after screening titles and abstracts. 26 full papers were reviewed and of these, 11 met our eligibility criteria (See Table 1). A total of 425 patients were evaluated who underwent FMT via capsule delivery. Remission rates among studies ranged from 68% to 100%. Timeframe defining remission varied among studies, though 10/11 defined remission as resolution of diarrhea at least 8 weeks after FMT. The pooled remission rate was 86.6% in those receiving colon prep prior to FMT, 83.9% in those who received double-encapsulated formulations and 75.4% in those using PPIs prior to FMT (See Table 2). Heterogeneity among reported study protocols prohibited statistical analysis of these factors.

CONCLUSION:
Oral administration of FMT capsules greatly simplifies this treatment option for patients with rCDI. This systematic review highlights inconsistencies in reporting of the methodology used in FMT capsule studies, which can be contributing to variable remission rates. Future randomized trials are needed to compare the various factors outlined above.
208 Neostigmine to Treat Colonic Pseudo-Obstruction in Cancer Patients
Authors: Avila Meera , Ali Sara , Kukreja Keshav , Ahmed Osman , Lee Jeffrey H. 
Published: October 2019

INTRODUCTION:
Acute colonic pseudo-obstruction, or Ogilvie's syndrome, usually develops in patients post-operatively or during severe illness. It is defined as massive dilation of the colon without mechanical obstruction. Ogilvie's may resolve with conservative management, but frequently colonic decompression is needed to prevent bowel injury. Neostigmine is a drug used to treat Ogilvie's that can be tried prior to endoscopic decompression. It is a reversible acetylcholinesterase inhibitor, enhancing colonic motor activity. We aim to evaluate the demographics and clinical history of patients with Ogilvie's and the efficacy of neostigmine administration in treating Ogilvie's in our cancer population.

METHODS:
Retrospective data analysis was performed on patients from 2000 to 2018 who had colonic dilation, defined as >8 cm in part of the colon on x-ray or cross-sectional imaging, and received neostigmine.

RESULTS:
The total number of patients in the study was 29. The mean age of patients was 66.7 years old (range: age 46.5–81.0). Of the 29 patients, 5 patients were female (17.2%). Leukemia was the primary malignancy in 10 patients (34.5%) and solid tumor in the other 19 patients (65.5%). Metastatic disease was found in 15 patients (51.7%). Recent chemotherapy was administered to 21 patients (72.4%). The average number of hospitalization days was 34.7 days (range: 2–120 days). Pan-dilation of the colon was noted in 10 patients (34.5%) and cecal dilation alone was noted in 7 patients (24.1%). The mean diameter of dilated colon segment was 10.8 cm (range 8.0–15.0 cm). Post-operative Ogilvie's was noted in 5 patients (17.2%). Active infection was identified in 18 patients (64.2%). One dose of neostigmine was required in 20 patients (71.4%) and remaining patients required 2 or 3 doses. Improvement of Ogilvie's was noted in 23 patients (79.3%) and complete resolution in 13 patients (44.8%). Colonoscopy was needed after a trial of neostigmine in 10 patients (34.5%). Bradycardia due to neostigmine was noted in 3 patients (10.3%) without other complications noted.

CONCLUSION:
In our study evaluating cancer patient, Ogilvie's was more common in elderly male patients with solid tumors and active infection. Metastatic disease was noted in about half of the study patients. It was most common to have pan-colonic dilation and isolated cecal dilation. Administration of neostigmine led to improvement of colonic pseudo-obstruction in the majority of patients (79.3%) with complete resolution noted in 44.8% of patients.
211 Increased Synchronous Neoplasms Among Patients With Small and Diminutive Proximal Hyperplastic Polyps
Authors: Sowa Piotr , Duh Erica , Karnes William 
Published: October 2019

INTRODUCTION:
Small right-sided sessile serrated polyps (SSPs) are associated with increased risk of synchronous neoplasia. These lesions are difficult to distinguish from non-precancerous hyperplastic polyps (HPs). Hamoudah et al. published a retrospective cohort study showing that diminutive proximal HPs and SSPs are associated with similar increased rates of synchronous advanced neoplasia among screening colonoscopies. Verification of these findings could impact guidelines that currently consider proximal diminutive HPs as surveillance-irrelevant.

METHODS:
Our data was extracted from UCICQD—a prospective database (est 2012) with polyp location, size, and pathology. Study design was modeled after that of Hamoudah et al, and included screening colonoscopies divided into: Group 1 (G1)—cases with 1–3 proximal HPs ≤10 mm; Group 2 (G2)- cases with no proximal SSPs or HPs; and Group 3 (G3)—cases with 1–2 proximal SSPs ≤10 mm. Synchronous and advanced neoplasms were compared between G1–G3.

RESULTS:
Compared to G2, G1 had higher per case rates of synchronous adenomas (52% vs 43%, P = 0.001), 2 or more SSPs (0.6% vs 0.1%, P = 0.046) and 2 or more adenomas (12.4% vs 8.3%, P = 0.01). Compared to G2, G3 had higher per-case rates of synchronous adenomas (50% vs 43%, P = 0.041), SSPs > 9 mm (3.6% vs 0.1%, P < 0.0001) and advanced neoplasms (16.2% vs 11.9%, P = 0.034) (Table 1). Odds ratios (OR) for G1 relative to G2 was significant for 2 or more adenomas (1.48 [1.06–2.08], P = 0.021). For G3 relative to G2, OR were significant for SSP >9 mm (31.05 [9.50–101.55], P < 0.0001). Considering G1 and G3 together, OR relative to G1 were significant for finding of any adenoma (1.19 [1.02–1.38], P = 0.027), SSP > 9 mm (12.72 [3.91–41.44], <0.0001) and >2 adenomas (1.37 [1.04–1.81]) (Table 2).

CONCLUSION:
Our data confirms Hamoudah et al's findings. Proximal diminutive and small serrated polyps are associated with increased rates and OR for synchronous surveillance relevant and advanced neoplasia. The higher rate of advanced neoplasia among small and diminutive proximal serrated neoplasia was largely accounted for by large SSPs. The surveillance-relevance of proximal small and diminutive serrated lesions is also supported by the increased rate and OR of cases with >2 adenomas. However, studies such as this showing “synchrony” may be insufficient to warrant change in surveillance guidelines, which should be based on “metachrony.”
215  Efficacy and Safety of Upadacitinib as an Induction Therapy for Patients With Moderately-to-Severely Active Ulcerative Colitis: Combined Results From 382 Subjects in the Phase 2b Study U-ACHIEVE
Authors: Higgins Peter , Hébuterne Xavier , Siffledeen Jesse , Zhou Wen , Cataldi Fabio , Xie Wangang , Lacerda Ana , Danese Silvio 
Published: October 2019

INTRODUCTION:
We assessed efficacy/safety of upadacitinib (UPA) in a ph 2b induction study (part 1) in pts with moderately-to-severely active ulcerative colitis (UC). Additional Pts were enrolled in part 2. We present the efficacy and safety of the combined results of part 1 and part 2

METHODS:
Adults with moderately-to-severely active UC (Adapted Mayo Score 5–9 points and centrally-read endoscopy subscore 2–3) were randomised 1:1:1:1:1 to receive extended-release UPA7.5, 15, 30, 45 mg once daily (QD) or placebo for 8 wks (N = 250). In part 2, 132 pts were randomised to UPA30 or 45 mg QD with 1:1 allocation for 8 weeks. Pairwise comparisons between UPA and PBO for primary endpoint of clinical remission per Adapted Mayo Score at Week 8 (defined as stool frequency subscore ≤1, rectal bleeding subscore = 0, and endoscopic subscore ≤1) and ranked secondary endpoints were conducted using Cochran-Mantel-Haenszel test stratified by previous biologic use, BL corticosteroid use, and BL Adapted Mayo score. No multiplicity adjustments were applied. Non-responder imputation was used for missing values in 13% of pts. Treatment emergent adverse events (AEs) were reported from first dose of study drug to up to 30 days after last dose.

RESULTS:
A total 382 pts were randomised with mean (SD) age of 42.7 (14.3) yrs and disease duration of 8.4 (7.4) yrs. Primary endpoint of clinical remission, and secondary endpoints of endoscopic improvement, clinical response per Adapted Mayo score, clinical response per Partial Mayo score, endoscopic remission, and histologic improvement were significantly higher with UPA doses ≥30 mg QD vs PBO (Table 1). Incidences of AEs were similar across UPA groups and numerically higher in PBO group. Rates of serious AEs were 10.9%, 0%, 4.1%, 4.3% and 4.9% for PBO and UPA 7.5, 15, 30, and 45 mg QD, respectively. Serious infections occurred in pts receiving PBO (4.3%, n = 2), 15 mg QD (2.0%, n = 1), 30 mg QD (0.9%, n = 1), and 45 mg QD (1.6%, n = 2). One case of herpes zoster and pulmonary embolism (PE)/deep vein thrombosis (DVT) with UPA 45 mg QD were reported. PE/DVT was reported 26 days after study drug discontinuation due to UC worsening and hospitalization. No deaths were reported.

CONCLUSION:
In this combined analysis, primary and ranked secondary endpoints consistently met statistical significance with UPA doses ≥ 30 mg QD vs PBO in pts with moderately-to-severely active UC. These results are consistent with part 1 intention-to-treat analysis.1,2 UPA was well-tolerated and no new safety signals were identified.
218 Regional Variation in Treatment Outcomes in Clostridium difficile Colitis: A Nationwide Analysis
Authors: Berry Davis B. , Abougergi Marwan S. 
Published: October 2019

INTRODUCTION:
Treatment outcomes for many medical and surgical conditions have been shown to vary significantly between the different regions of the United States. This study was aimed to determine the regional differences in in-hospital mortality and resource utilization among patients admitted to the hospital with Clostridium Difficile infection (CDI).

METHODS:
This is a retrospective cohort study using the National Inpatient Sample (NIS) 2016. NIS is the largest publicly available all-payer inpatient care database in the United States. Patients were included if they had a principal diagnosis of CDI and were excluded if they were younger than 18 years. The primary outcome was in-hospital mortality. The secondary outcome was resource utilization as measured by hospital length of stay (LOS) and total hospitalization charges. The Northeast, Midwest, South and West regions were compared. Multivariate regression analysis was utilized to account for confounders.

RESULTS:
19,580 patients were included in the study. The mean age was 64 years and 64% of patients were females. Adjusted odds ratios (aOR) and mean differences (aMD) are presented in Table 1. The odds of in-hospital mortality were significantly lower among patients treated in the Midwest compared with the Northeast, West and South (aOR: 0.66, 95% confidence interval (CI): 0.45–0.99, P = 0.04). In addition, patients treated in the Midwest (aMD: −0.74 days, CI: −1 to 0.48 days, P < 0.01) and West (aMD: −0.40 days, CI: −0.67 to 0.12 days, P < 0.01) had significantly shorter mean length of stay compared with those in the Northeast and South. Finally, compared with patients treated in the Northeast, those treated in the Midwest and South had significantly lower mean total hospitalization charges (aMD −$12,693, CI: −$16,075 to −$9,312, P < 0.01 and −$5,647, CI: −$9,074 to −$2,220, P < 0.01, respectively) while those treated in the West had significantly higher mean total hospitalization charges (aMD: $9,796, CI: $5,186–$14,406).

CONCLUSION:
Among patients hospitalized with CDI, in-hospital mortality and resource utilization (LOS and total hospitalization charges) vary significantly across the four United States regions. The lowest mortality rates and resource utilization are in the Midwest. Complex socioeconomic variables likely explain this variation, along with possible variable physician adherence to treatment guidelines. Further research is needed to elucidate this point.
225 Barriers to Endoscopic Mucosal Resection of Large Colorectal Lesions: Results of a Nationwide Survey
Authors: Holmes Ian , Yu Jessica X. , Millar Morgan M. , Malvar Carmel , Nguyen-Vu Tiffany , Gawron Andrew J. , Kwon Richard , Roy Soetikno , Kaltenbach Tonya 
Published: October 2019

INTRODUCTION:
Over 90% of complex colon polyps that lack overt features of cancer can be removed using endoscopic mucosal resection (EMR) techniques. EMR is more cost-effective and is associated with less morbidity and mortality than surgery. However, rates of surgical resection have been rising even though extensive evidence suggests endoscopic resection should be first line for the management of complex colon polyps. We aimed to assess perceived barriers towards the utilization of EMR for >2 cm polyps among American endoscopists.

METHODS:
We administered a 21 question web-based survey with Qualtrics software (Provo, UT, USA). The American College of Gastroenterology distributed the survey to their mailing list on January 24, 2019 and closed it on February 21, 2019. We assessed endoscopist and practice characteristics as well as perceived barriers and facilitators of EMR, and compared responses between providers who performed 0–1 EMR per month with 2 or more EMR per month to determine which barriers and facilitators influence the utilization of EMR.

RESULTS:
A total of 8,797 practitioners received the survey, with 415 replies (4.7%). Provider demographics are summarized in Table 1. 275 providers (66.7%) reported performing 2 or more EMRs per month. 146 providers (35.1%) felt their fellowship prepared them poorly for large polyp resection. 237 providers (57.1%) felt that the incorporation of EMR training into fellowship would be very beneficial, followed by higher reimbursement (N = 176, 42.4%) and training on EMR technique (N = 154, 37.1%). Providers who performed 1 or fewer EMR per month were significantly more likely to report that lack of structured training, fear of complications, and uncertainty regarding which lesions were amenable to endoscopic management were barriers to routine use of EMR than providers who performed 2 or more EMR per month (Figure 1). They were also more likely to report improved training to be a facilitator for EMR utilization whereas providers who performed 2 or more EMR per month were more likely to report increased reimbursement as a facilitator for EMR utilization (Figure 2).

CONCLUSION:
We found that endoscopists identified lack of training to be a major barrier to performing EMR, especially for low-volume providers. Increasing reimbursement and training were important potential facilitators identified in our study. Future quality improvement efforts should target these key practice aspects to optimize the endoscopic management of complex colon lesions.
226 Impact of Propofol Sedation on Colonoscopy Quality Metrics: A Population-Based Cohort Study
Authors: Rahman Sheikh H. , Sey Michael , Khanna Nitin , Brahmania Mayur , McDonald Cassandra , Blier Marc-André , Hindi Zaid , Yan Brian , Chakraborty Debarati 
Published: October 2019

INTRODUCTION:
The use of propofol during colonoscopy has gained increased popularity due to deeper anesthesia compared to conscious sedation. Whether propofol sedation leads to improved colonoscopy quality metrics is unknown and the aim of our study.

METHODS:
We examined the association between use of propofol sedation and colonoscopy quality metrics, including adenoma detection rate (ADR), polyp detection rate (PDR), cecal intubation, and perforation, using colonoscopy quality data prospectively collected by the Southwest Regional Cancer Program, a division of Cancer Care Ontario. All colonoscopies performed for any indication across 21 hospitals in Southwest Ontario between April 2017 and December 2018 were identified. Data collected included patient and endoscopist demographics, procedural indication, bowel preparation quality, type of sedation, cecal intubation, polyp detection, and histology. Multi-variable models were built to assess the relationship between propofol sedation and adenoma detection rate (ADR), polyp detection rate (PRD), cecal intubation, and perforation risk.

RESULTS:
In total, 23,903 colonoscopies were identified, of which 8,533 (35.6%) procedures were performed with propofol sedation. There were no significant differences in ADR (22.6% vs. 21.6%, P = 0.156), PDR (43.9% vs. 42.6%, P = 0.05), or cecal intubation rates (97% vs 96.7%, P 0.192) between the two groups on univariate or multivariate analyses. The event rate for perforation was too low for a meaningful comparison in this analysis (1 propofol vs. 2 events for non-propofol).

CONCLUSION:
In this large colonoscopy cohort, propofol sedation was not associated with improved ADR, PDR, or cecal intubation rates.
228 Variability in Colonic Eosinophilia in 277 Consecutive Patients
Authors: Saulino David , Chandran Aswathi , Ambelil Manju , Conyers Jeffrey , Al Salihi Suhair , Ertan Atilla , DuPont Andrew , Cash Brooks D. , Younes Mamoun 
Published: October 2019

INTRODUCTION:
There is no acceptable method for the histopathologic evaluation and reporting of eosinophils (Eos) in colorectal biopsies because there is no agreement among pathologists as to what constitutes an abnormal finding. This study evaluated differences in Eos count relative to known clinical and pathologic features.

METHODS:
H&E slides from 277 subjects who underwent colonoscopy with biopsies were reviewed. Eos/mm 2 were counted in the area with highest concentration then correlated with clinical and pathologic findings. Normal histology (NL) was defined as biopsy without significant histopathologic changes.

RESULTS:
There were higher numbers of Eos/mm2 in the right colon than the left colon and rectum (mean 177 vs 122, respectively P < 0.0001). In the right colon, the mean Eos/mm2 was higher with pathologic diagnosis of colitis (P < 0.001), males (204 vs 164, P = 0.022), abnormal endoscopy (208 vs 148, P < 0.001), and ulcerative colitis (UC) (226 vs 158, P < 0.001), but lower with history of abdominal pain (158 vs 208, P = 0.003) and IBS-D (130 vs 185, P = 0.023). In the left colon and rectum, mean Eos/mm2 was higher with pathologic diagnosis of colitis (P < 0.001), males (154 vs 107, P < 0.001), abnormal endoscopy (155 vs 92, P < 0.001), and a diagnosis of UC (192 vs 95, P < 0.001) but lower with history of abdominal pain (108 vs 145, P = 0.003) and IBS-D (83 vs 128, P = 0.010). In NL biopsies, the right colon showed higher mean Eos/mm2 in Asians (228 vs 139, P = 0.019), and diagnosis of UC (205 vs 136, P = 0.004) but was lower with abdominal pain (132 vs 167, P = 0.028), and did not show significant differences with history of IBS-D, Chron's disease (CD), or abnormal endoscopy. In the left colon and rectum the mean Eos/mm2 with higher in males (102 vs 77, P = 0.036), and a diagnosis of CD (117 vs 78, P = 0.007) but did not show significant differences with history of UC, abdominal pain, IBS-D, or abnormal endoscopy.

CONCLUSION:
The mean number of Eos/mm2 in colorectal biopsies varies significantly by location, associated histopathologic changes, and clinical diagnosis, and is also influenced by sex. Of particular interest is the association between high Eos/mm2 in right colon biopsies with otherwise normal histology and diagnosis of UC and in left colon and rectum biopsies with history of CD. Additional larger studies are needed to define the significance of colorectal eosinophil counts in clinical practice.