bluuebunny/crossref_metadata_2025_split huggingface dataset:
399 Safety and Efficacy of Multiband Mucosectomy in Early Barrett's Neoplasia: A Systematic Review and Meta-Analysis
Authors: Dhindsa Banreet , Mubder Mohamad I. , Dhaliwal Amaninder , Mashiana Harmeet , Choa Jacqueline , Sayles Harlan , Ohning Gordon , Singh Shailender , Bhat Ishfaq , Adler Douglas G. 
Published: October 2019

INTRODUCTION:
Endoscopic mucosal resection (EMR) is treatment of choice for early Barrett’s neoplasia. Multiband mucosectomy (MBM) is a type of EMR procedure used for diagnosis and treatment of early Barrett’s neoplasia. This procedure has an advantage over cap-resection as it does not require submucosal lifting. We performed systematic review and meta-analysis to compare the overall safety and efficacy of this procedure for early Barrett’s neoplasia.

METHODS:
We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Web of Science databases, Google Scholar and manual search of references (from inception through May 2019) to identify the studies reporting use of MBM for early Barrett’s neoplasia. The primary outcome was to evaluate the technical success of the procedure which was defined as complete endoscopic resection of a delineated focal lesion. The secondary outcome was to study overall, early and delayed adverse events related to the procedure. The meta-analysis was performed using Der Simonian and Laird random effect model.

RESULTS:
15 studies reporting on 1197 patients with 1487 lesions were included. Majority of the patient population were males (80.8%), with mean age of 64 years. The pooled technical success rates were 99.1% (95% CI 96.76-100, I2 = 81.51) and the total early adverse event rates were 5.87% (95% CI 2.61-10.02, I2 = 78.26). The most common early and delayed adverse events were bleeding (5.09%; 95% CI 1.97-9.19, I2 = 79.59) and strictures (10.99%; 95% CI 5.67-17.53, I2 = 86.84) respectively. Total 5 perforations were reported in our patient population. The mean procedure time was 23.3 min reported in six studies. Significant heterogeneity was noted in in our meta-analysis.

CONCLUSION:
Multiband mucosectomy is a safe alternative procedure to endoscopic cap resection for the treatment of early Barrett’s neoplasia with high technical success and lower adverse events. Further large multicenter randomized controlled trials are needed for further validation of our findings.
400 Clinical Overlap Between Lymphocytic Esophagitis and Reflux Esophagitis With Increased Lymphocytic Infiltration
Authors: Irani Malcolm , Jones-Pauley Michelle , Gudsoorkar Vineet , Duhon Daniel , Barroso Alberto 
Published: October 2019

INTRODUCTION:
Lymphocytic Esophagitis (LyE) is an increasingly recognized clinicopathologic entity with an emerging definition. A significant histologic and clinical overlap exists between LyE and reflux esophagitis (RE; however, no specific associations have been elucidated. Previous studies have shown that absence or decrease in the number of granulocytes in esophageal biopsies in patients with LyE have correlated with a different phenotypic presentation from reflux esophagitis, with more patients being predominantly older women with dysphagia. The aim of this study was to help differentiate the two entities based on their clinical characteristics.

METHODS:
A retrospective chart review was performed of all patients with a biopsy diagnosis of LyE between 2009-2018 at a large tertiary academic institution. Biopsies were then re-categorized into two groups: LyE with few granulocytes (LyE-FG), and reflux esophagitis with increased IELs (RE-IEL). Data regarding socio-epidemiologic, clinical, and histologic findings were collected.

RESULTS:
A total of 53 biopsies were reviewed (35 RE-IEL, 18 LyE-FG). Most patients were Caucasian- 78% and 75% in RE-IEL and LyE-FG groups, respectively (P = 0.559). Baseline characteristics were similar between the two groups (Table 1). Dysphagia was the most common symptom in both groups with 70.4% in RE-IEL and 75% in LyE-FG groups (P = 0.767) with heartburn being the second most common symptom (63% vs 60%; P = 0.850) respectively. More patients in the LyE-GF group had inflammatory bowel disease (17.6% vs 6.7%); however, this difference was not statistically significant (P = 0.241). A significant number of patients were on proton pump inhibitor (PPI) at the time of diagnosis (75.9% RE-IEL vs 80% LyE-IG; P = 0.756). Patients with RE-IEL were more often smokers (63.3% vs 40%); however, there was no statistical significance (P = 0.138). There was no statistical significance between rates of NSAID or alcohol use between the two groups. Site of biopsy was not statistically significant between the two groups (P = 0.306) with the majority of biopsies taken from the distal esophagus.

CONCLUSION:
Our study shows the clinical overlap between LyE-FG and RE-IEL. RE and LyE share significant histologic overlap; however, LyE is clinically characterized by dysphagia as the most predominant symptom compared to classic RE, where heartburn and regurgitation are more common.
405 Improving the Reconciliation and Management of Proton Pump Inhibitors: A Quality Improvement Project
Authors: Gonzalez Adalberto , Castillo Michael , Koop Hans , Cortizo Jacqueline , Chin Jodi , Beiro Zaimat , Hagar Kristen 
Published: October 2019

INTRODUCTION:
Proton pump inhibitors (PPIs) are one of the most widely used classes of drugs prescribed in the ambulatory setting. This leads to significant healthcare utilization, as $7 billion was spent in 2009. We performed a quality improvement (QI) project to improve the reconciliation and management of PPIs.

METHODS:
We performed a QI project form January to May 2019. We began by providing education to our resident physicians and clinic nurses regarding guidelines on appropriate PPI management. We constructed a dot phrase in our electronic medical record meant as a decision tool for physicians (Figure 1). From February to May 2019, we performed the intervention. We included all patients on PPIs seen in the ambulatory clinic by our group of six resident physicians from February to May 2019. Nurses were instructed to point out to physicians if patients were on PPIs after rooming the patient. During the time of medication reconciliation, physicians used the decision tree to make a decision to continue, increase, wean off, or discontinue their patient’s PPI. Next, we collected data for our predetermined variables. We used descriptive statistics to analyze our data.

RESULTS:
Our group of physicians saw 558 patients in clinic during our study period. 100 patients were on PPIs. 45 patients (45%) were included in our data analysis; the remaining 55 patients did not undergo reconciliation or documentation of their PPIs. Only 8 patients (17.8%) had their PPIs reconciled in the past one year. 10 of 45 patients (22.2%) had an absolute indication for long term PPI use; 10 patients were appropriately continued on standard dose PPI. 26 (57.8%) patients had a relative indication for long term PPI; 12 of 12 symptomatic patients were appropriately continued on PPI and 14 of 14 asymptomatic patients had their PPIs discontinued. 5 (11.1%) patients had no indication for PPI; all 5 had their PPIs appropriately weaned off. 2 patients (4.4%) with a history of peptic ulcer disease were appropriately taken off PPIs since they were not taking daily aspirin or no steroidal anti-inflammatory drugs (NSAIDs). 2 patients on daily NSAIDs were appropriately continued on PPIs due to risk factors. Overall, the decision tool led to correct management in all cases.

CONCLUSION:
Despite an active effort to improve PPI reconciliation, less than half of PPIs were addressed. Our decision tree allowed for the accurate management of PPIs in all patients. Future methods should be developed to increase PPI identification and reconciliation.
407 Healthcare Resource Utilization in the 12 Months After Diagnosis in Patients With Eosinophilic Esophagitis Compared With a Matched Cohort
Authors: Goodwin Bridgett , Lu Mei , Vera-Llonch Montserrat , Williams James 
Published: October 2019

INTRODUCTION:
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease of the esophagus, characterized by esophageal dysfunction and eosinophil-predominant inflammation. Currently, no licensed therapies exist for EoE in the USA, and data on the real-world burden of EoE on healthcare systems are limited. This retrospective study aimed to investigate healthcare resource utilization (HCRU) in patients with EoE compared with matched controls without EoE in the USA.

METHODS:
The US healthcare claims databases Truven Health MarketScan Commercial Claims and Encounters and the Medicare Supplemental database were used to identify patients diagnosed with EoE from January 2008 to September 2016. HCRU was recorded from the date of diagnosis (index date) throughout the continuously enrolled 12-month study period. A cohort of individuals without EoE was matched 1:1 for age, sex, geographic region, Charlson Comorbidity Index during the 12 months before the index date, and distribution of time from eligibility start date to index date. Logistic regression models were used to compare HCRU between cohorts.

RESULTS:
Each cohort included 16 094 individuals. Mean age in each cohort was 34.3 (SD: 17.9) years; 65.0% were men. Table 1 shows the frequency of HCRU. Of patients with EoE, 73.9% underwent a diagnostic endoscopy during the study period vs 1.7% in the matched cohort. All-cause inpatient admissions occurred significantly more frequently in patients with EoE than in the matched cohort (P < 0.0001). Patients with EoE were significantly more likely to have an outpatient visit than matched controls, including visits to a gastroenterologist or a psychologist (P < 0.0001). Overall, 26.2% of patients with EoE had ≥1 ER visit in the 12-month period, compared with 12.9% of controls. In patients with EoE, these were most commonly associated with food impaction (6.7% of patients; 25.7% of ER visits in patients with EoE vs 0.34% in matched controls) and esophageal stricture (3.2% of patients; 12.1% of ER visits in patients with EoE vs 0.05% in matched controls).

CONCLUSION:
Inpatient admissions and outpatient and ER visits were more frequent in patients with EoE compared with matched controls, highlighting the ongoing burden EoE imposes on patients and healthcare systems. In particular, ER visits for food impaction and esophageal stricture comprise 38% of ER visits for patients with EoE compared with < 0.5% for those without EoE. The lack of an approved treatment for EoE in the USA may contribute to this burden.
411 Association of Eosinophilic Esophagitis With Allergic-Immunologic Conditions: A Population-Based National Study
Authors: Alaber Omar A. , Chandar Apoorva K. , Dahash Basma , Sferra Thomas J. , Chak Amitabh 
Published: October 2019

INTRODUCTION:
Eosinophilic esophagitis (EoE) and asthma are two common chronic conditions that are closely related and likely mediated by similar immunopathologic mechanisms and can be treated with similar treatment modalities. We aimed to examine the association of EoE with asthma using a large nationwide hospital database. We additionally examined the association of EoE with other related allergic-immunologic conditions such as allergic urticaria, eczema, allergic conjunctivitis, allergic rhinitis, and food and environmental allergies.

METHODS:
Data were obtained from a commercial de-identified patient database (Explorys, IBM, Inc.) that integrates electronic health records from 26 major U.S. hospital systems from 1999 to June 2019. Inclusion criteria for cases was all patients with a Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) diagnosis of asthma whereas inclusion criteria for controls was patients without asthma. Odds ratios (OR) and confidence intervals (CI) were calculated for the association of EoE with asthma and other related allergic-immunologic conditions.

RESULTS:
A total of 3,459,740 cases had asthma. Out of these, 4,490 had a diagnosis of EoE which followed in time the diagnosis of asthma. Out of 33,336,680 controls without asthma in the database, 20,390 had a diagnosis of EoE. When compared to controls without asthma, cases with asthma had a 2 (95% CI = 2.06 - 2.19) times higher odds of receiving a diagnosis of EoE following their asthma diagnosis. Similarly, other allergic-immunologic conditions were associated with a much higher odds of having EoE (Table 1). Patients with severe asthma had a 1.75 (CI = 1.37 - 2.23) times greater odds of having EoE when compared to patients with less severe (i.e. mild or moderate) asthma.

CONCLUSION:
There is a higher tendency for EoE to be diagnosed in patients with asthma and other allergic-immunologic conditions. In addition to being a retrospective analysis, inability to fully validate SNOMED-CT codes and unavailability of histology for the diagnosis of EoE could limit generalizability of the study. Nevertheless, patients with pre-existing asthma or allergic-immunologic conditions and symptoms suggestive of EoE (dysphagia, acid reflux or feeding difficulties) may warrant endoscopic evaluation.
412 Effervescent Granules for the Treatment of Esophageal Food Bolus Obstruction
Authors: DeRosa Vincent , Corliss Judy , Li Jeanne , Cleek Cathy , Kenner Catelynn 
Published: October 2019

INTRODUCTION:
Esophageal food bolus obstruction is a common GI emergency without effective medical therapy, often requiring costly emergent endoscopy (EGD) for food bolus clearance. This case-control study compared the efficacy of standard of care treatment with the use of effervescent granules (sodium bicarbonate, citric acid, simethicone) for the treatment of esophageal food bolus obstructions.

METHODS:
Adult patients were recruited from three emergency rooms in a community-based, regional hospital system. A retrospective cohort treated with the standard of care, consisting of glucagon and/or lorazepam and/or IV fluids, was compared with a prospective cohort treated with effervescent granules. The primary end point was efficacy between the two treatment groups.

RESULTS:
From January 2018 – August 2018, 21 patients met the inclusion criteria for the retrospective arm and were treated with the standard of care; from September 2018- April 2019, 33 patients met the inclusion criteria and were treated with effervescent granules for esophageal food bolus obstructions. 3 out of 21 patients from the retrospective arm and 20 out of 33 patients from the prospective arm had successful food bolus clearance without requiring an EGD (success rate = 14.3% vs. 60.6%; P = 0.002.) There was one complication of a Mallory-Weiss tear noted on endoscopy without clinical significance in a patient treated with effervescent granules. The percentage of males was slightly higher in the prospective arm (22 males, 66.7% vs. 10 males, 47.6%; P = 0.27), and patients were slightly younger in the prospective arm (mean = 55.8 years, standard deviation (SD) = 16.8 vs. mean = 64.6, SD = 20.4; P = 0.11.)

CONCLUSION:
Treatment of esophageal food bolus obstruction with effervescent granules is more efficacious than the standard of care, with no clinically significant complications. Effervescent granules should be further studied as a safe and effective medical treatment option for this common GI emergency.
416 Esophageal Body Dysfunction in Patients With Esophagogastric Junction Outflow Obstruction: A Potential Flaw in the Chicago Classification
Authors: DeVault Kenneth , Cheah Ramsah , Chirnaksorn Supphamat , Francis Dawn , Bouras Ernest , Vazquez-Roque Maria , Lacy Brian E. , Houghton Lesley 
Published: October 2019

INTRODUCTION:
High-resolution manometry using the Chicago Classification is standard in the evaluation of esophageal motility. When the relaxation of the esophagogastric junction is impaired and achalasia excluded, esophagogastric junction outflow obstruction (EGJ-OO) is diagnosed and the esophageal body is essentially ignored. We sought to characterize the function of the esophageal body in consecutive patients with EGJ-OO.

METHODS:
Retrospective review of the esophageal manometry findings in consecutive patients where there was computer recognition of EGJ-OO collected over a 2-month period. In each case, the esophageal body was reviewed manually and results reported independent of the suggested computer diagnosis.

RESULTS:
116 patients underwent manometry over a 2-month period and 30 (26%) were identified as having EGJ-OO. The indications for testing included chronic cough (n = 5), GERD (n = 8), dysphagia (n = 9) and esophageal evaluation associated with severe lung disease or transplantation (n = 8). The mean IRP was 20.8 (range 16-33.6) and did not vary depending on indication (P = 0.381). Computer interpretation was EGJ-OO in all patients without mention of the esophageal body. After review, 11 (37%) had an additional esophageal diagnosis. In effective esophageal motility (IEM) was the most prevalent among them (IEM-8, achalasia-2, jackhammer esophagus-1; P = 0.020). The frequency of an additional esophageal diagnosis was significantly different between GERD (0%) and dysphagia (66%; P = 0.004), but not between other groups (i.e. 40% in cough and 37.5% in transplant group). An esophageal body diagnosis was significantly more likely in patients with IRP > 25 (80%) compared with those with IRP < 25 (28%; P = 0.028).

CONCLUSION:
1-EGJ-OO is common in patients referred for esophageal manometry. 2-An additional esophageal body diagnosis is common in those with EGJ-OO.3-Esophageal diagnoses are more common in patients with dysphagia and in those with a very high IRP. The body of the esophagus is important in cases of EGJ-OO and should be reported independent of the computer-generated interpretation of the Chicago Classification.
418 A Review of Timelines and Reporters of Adverse Events From Proton Pump Inhibitors (PPIs) That Are Conveyed to the United States Food and Drug Administration Adverse Event Reporting System (FAERS).
Authors: Kruchko David H. , Patel Ami , Ehrenpreis Eli , Villines Dana 
Published: October 2019

INTRODUCTION:
Recent publications have described potential PPI-associated adverse events (AEs) including cardiovascular disease (CVD), cerebrovascular accidents (CVA) and renal disease (acute interstitial nephritis and CKD). There is public interest and potential for lawsuits for these and other PPI-related AEs. The FAERS is a database of voluntarily reported AEs used for post-marketing surveillance of medications. The aim of this study is to analyze reports of all PPI-associated-AEs to FAERS, focusing on reporter sources. This permits an understanding of the effect of published high-profile PPI-associated AEs on FDA drug surveillance.

METHODS:
A total of 9,144,290 FAERS reports from January 2013 to December 2018 were examined. Analysis of all Primary PPI-related AEs were included (C. difficile, microscopic colitis, atrophic gastritis, hypergastrinemia, hypomagnesemia, hypocalcemia, hypokalemia, hypophosphatemia, vitamin malabsorption, pneumonia, CVD, CVA, renal disease, drug-induced lupus, and dementia). AEs were defined by MedDRA terminology. All reports were categorized according to reporter source (physicians, pharmacists, other health care professionals, consumers, and lawyers).

RESULTS:
Until 2018, overall reporting of PPI-related AEs generally showed steady changes over time. In 2015 there were 7,024 reports for all PPI-related AEs, in 2016, there were 8,043, and in 2017, there were 7,682. Notably, in 2018, reports for all PPI-related AEs spiked to 14,607. For specific AEs, reports for renal disease and CVD from consumers showed marked increases. In 2015 consumers reported 427 CVD cases and 494 renal cases, while consumers reported 627 CVD cases and 1,155 renal cases in 2018 (Figure 1). Reports for lawyers and physicians for CVD and renal disease both increased between 2015 and 2018. Physicians had an increase from 368 to 503 cases of CVD (36.7% increase) and from 676 cases to 1,112 of renal disease (64.5% increase), while lawyers had an increase of 49 cases of CVD to 99 cases of CVD (102% increase) and increase of 4 cases to 974 of renal disease (24,250% increase). This resulted in a rise in percentage of total reports from lawyers (Figures 2 and 3).

CONCLUSION:
Consumers are increasing reporting of CVD and renal disease associated with PPI use. The rapid increase in reports of PPI-associated CVD and especially renal disease by lawyers suggests that lawyers are a potential source of interference on pharmacovigilance.
419 The Costly Case of Proton Pump Inhibitors: A Single Center Experience
Authors: Suresh Kumar Vishnu Charan , Patthipati Venkata Suresh , Elangovan Abbinaya , Goldstein Lawrence 
Published: October 2019

INTRODUCTION:
Proton pump inhibitors (PPI) are one of the cornerstones in the management of upper gastrointestinal bleed (UGIB) with the standard practice being initiating a continuous PPI infusion (CPI). In the recent years, several studies and meta-analysis have shown that there was no significant difference in major outcomes such as re-bleeding rates when using intermittent intravenous PPI (IIP) as compared to a CPI in non-variceal UGIB (2). However, most places in the USA still largely favor using the continuous infusion. Our study aimed to show the difference in patient costs of administering a CPI vs. IIP if evidence based practice was utilized in a single community hospital.

METHODS:
We retrospectively identified 212 CPI using our Electronic Health Record (EHR) and pharmacy database that were ordered at a community hospital in Ohio from June 2018 to May 2019 for patients who were admitted with a diagnosis of non-variceal upper GI bleed. A simple cost comparison analysis was done by Excel 2016 to compare the patient cost between CPI and IIP for the similar duration of use.

RESULTS:
Out of the 212 patients that were started on CPI, 54% were ordered by gastroenterologists as compared to 46% of which were started by all other physicians including internists, intensivists and ED physicians (Figure 1). The duration of the CPI tended to be longer (3.47 days) in adults >50 years as compared to adults < /= 50 years (2.58 days). There was a major difference in the cost of administering a CPI as compared to using IIP for a similar duration (Figure 2). The cumulative cost of CPI was 326,262 USD versus 108,810 USD for IIP (Figure 3).

CONCLUSION:
Although recent studies have showed that there was no difference in major outcomes in non-variceal upper gastrointestinal bleed when using intermittent PPI as compared to a continuous PPI infusion, this has changed neither the guidelines nor our practice of using a CPI. CPI is significantly more expensive as compared to an IIP for a similar duration of administration averaging up to $310 more per day. Our study showed that 217,452 USD could have been saved in 1 year by using IIP instead of CPI. A recent quality improvement study showed a significant reduction in costs when they used IIP instead of CPI in the management of non-variceal UGIB. Further studies comparing the cost effectiveness between CPI and IIP for non-variceal UGIB along with RCTs comparing the two might help revise the guidelines regarding their usage in the future.