bluuebunny/crossref_metadata_2025_split huggingface dataset:
2844 Does Access Matter? A Retrospective Analysis of Patients Undergoing Colonoscopy for Colorectal Cancer Screening Based on Health Insurance
Authors: Chintalapudi Ananya , Koya Laxmi Deepika , Mallavarapu Ramitha , Chintalapudi Mastan , Patel Nishi 
Published: October 2019

INTRODUCTION:
Implementation of the Affordable Care Act (ACA) in 2010 has expanded access to health care for millions of Americans. Although there were few large registry based studies that showed a positive impact of ACA on colorectal cancer screening and early cancer detection there are no published studies from community practice setting. The aim of this retrospective study in a single provider gastroenterology community practice is to study the ultilization of colonoscopy for colorectal cancer screening among patients with health exchange plans.

METHODS:
This is a retrospective study from a single provider gastroenterology community practice. All the patients who had colonoscopy for colon cancer screening between January 1st 2018 and December 31, 2018 were extracted from the database. Colorectal polyp rates based on health insurance plan (health exchange AC insurance/commercial insurance/Medicare and Tricare) were studied.

RESULTS:
A total of 746 (Male 310, Female 436) patient records who had a colonoscopy for screening were reviewed. Median age was 59 years. 54% (400/746) of them had Affordable Care Insurance. 59% (437/746) were found to have polyps. Among those with colon polyps 49% (214/437) had Affordable Care Insurance, 28% had commercial insurance and 22% had Medicare and Tricare. 54% (214/400; median age 59) of patients with health exchange plans, 73% (98/135; median age 69) of patients with medicare/tricare, 59% (120/202; median age 57) of patients with commercial insurance plans had colon polyps.

CONCLUSION:
About half of the patient cohort with colorectal polyps relied on Affordable Care Insurance to receive colorectal cancer screening. About 74% of patients with colorectal polyps were under the age of 65. As expected patients with medicare plan had high rates of colorectal polyps (73%) compared to commercial and health exchange insurance plans. If access to preventive care via ACA is not available a significant proportion of patients with colorectal polyps would have not had their screening. If they were to wait untill they are eligible for medicare to get their colonoscopy for screening a significant proportion of these patients would develop advanced adenomas or cancer. So it is important to have access to preventive health via ACA. This issue is particularly more important now with attention being brought to the ACA and the possibility of it being repealed.
2845 Harm versus Benefit Ratio in Colonoscopy Preparation With Polyethylene Glycol: An Opportunity for Improvement
Authors: Bilal Muhammad , Chang Eric Y. , Umar Anam , Stevens Elyse , Abe Temidayo , Pantangi Pramod 
Published: October 2019

INTRODUCTION:
Colonoscopy is the gold standard for colon cancer screening and has shown to decrease morbidity and mortality. However, the use of colonoscopy is limited by factors such as the patient's fear of the procedure and inadequate bowel preparation. The quality of bowel preparation is directly related to the endoscopist’s ability to detect adenomas. We carried out a retrospective descriptive analysis to assess the degree of preparation, and its effect on colonoscopy outcomes in a safety-net academic center.

METHODS:
We obtained data from the electronic medical record of a large, academic, safety-net hospital. Data for patients who underwent colonoscopy between January-June 2018 were reviewed. The data points extracted included: age, race, gender, indication for the colonoscopy, type of colonoscopy (screening, diagnostic or surveillance), procedure results, degree of the bowel preparation, and recommendations for a repeat colonoscopy. All the patients received polyethylene glycol (PEG).

RESULTS:
Our patient population was predominantly African American (98%). Of the 601 total colonoscopies performed, 454 (76%) were done for screening, 84 (14%) for diagnosis, and 59 (10%) for surveillance. Per documentation by the gastroenterologist, the adequacy of the bowel preparation was excellent in 1.1% (n = 7/601), good in 57% (n = 344), fair in 27% (n = 182) and poor in 10% (n = 66). More than 50% of colonoscopies were affected due to improper bowel preparation. 137 colonoscopies (23%) were canceled secondary to poor bowel preparation and were re-scheduled. 191 patients (32%) were advised to have repeat colonoscopy earlier than recommended guidelines due to inadequate preparation. The odds of a poor preparation versus good preparation having a canceled colonoscopy was 26.04, (CI 15.6-43.5, P =< 0.00001).

CONCLUSION:
Our analysis revealed that in >50% of patients who did not have good bowel preparation, the gastroenterologist’s ability to perform optimal colon cancer screening was negatively affected. This not only increases the risk of missing small polyps which carries the risk of malignant transformation but is also associated with increased cost burden and decreased patient satisfaction. Given that all our patients used PEG for bowel prep, we wonder whether the type, and/or amount of bowel preparation agent is contributory to poor preparation. Further prospective studies are needed to assess the adequacy of bowel preparation in our patient population using other formulas that have been approved by the FDA.
2848 The Impact of Multitarget Stool DNA (Cologuard) Testing in a Real World Population
Authors: Turse Erica , Dailey Francis , Tahan Veysel , Turse John 
Published: October 2019

INTRODUCTION:
Colorectal cancer (CRC) remains the second leading cause of death for carcinomas. Effective screening for CRC is paramount to prevent morbidity and mortality. Several options for screening alternatives exist with the newest, as of 2014, being the recommendation for multitarget stool DNA testing. A cross-sectional study at 90 sites, including private and academic centers, throughout the US and Canada evaluated average-risk patients utilizing stool specimens and follow-up screening colonoscopy. This 2014 study found that sensitivity for stool DNA testing of detecting colorectal cancer was 92.3%, advanced precancerous lesions 42.4%, and high-grade dysplasia 69.2%.

METHODS:
We collected real-world prospective data from January 31, 2017 through May 31, 2019 of 157 patients who had positive stool DNA testing and documented their colonoscopy findings. The patients all underwent colonoscopy at the same outpatient endoscopy center which has four board certified gastroenterologists, all more than 10 years out of training. Patients were all average-risk prior to receiving stool DNA screening.

RESULTS:
The mean age of patients was 68.8 years, with 99 female patients and 66 male patients. Three patients were found to have invasive adenocarcinoma which included the cecum, sigmoid and rectum. A total of 81 patients had no pathology or hyperplastic polyps and 73 patients had polyps that were either tubular adenomas or sessile serrated adenomas.

CONCLUSION:
In our study, 48% of patients had a positive predictive value (PPV) indicating those who had stool DNA testing followed by positive initial screening colonoscopies. We compared our data to the initial 2014 clinical trial by Imperiale et al with a 41.37% PPV. Interestingly, the number needed to treat in the clinical trial found that 166 individuals would have to undergo multitarget DNA testing for any colorectal cancer to be found and 31 for advanced precancerous lesions. Our real-world study determined that it took about 52 patients (3 in 157) to identify colorectal cancer and 1 in 2.15 patients for advanced precancerous lesions. Our study highlights the continued necessity of colonoscopies as the first line therapy for screening, even among average risk populations.
2851 Assessing the Risk of Gastroesophageal Reflux Disease in Patients With Constipation
Authors: Asfari Mohammad Maysara , Sarmini Muhammad Talal , Ellison Steven B. , Vega Kenneth J. 
Published: October 2019

INTRODUCTION:
Constipation is a common gastrointestinal disorder which can result in infrequent stools, difficult stool passage with pain and stiffness or both. Constipation is frequently associated with straining which also can promote GERD. Multiple comorbidities are reported in the literature secondary to chronic constipation but data on the presence of GERD in patients reporting constipation is limited. The aim of this study was to investigate if constipation increases the risk for gastroesophageal reflux disease (GERD) using a large patient database.

METHODS:
Using data from the National Inpatient Sample (NIS) database between 2004 and 2014, we identified patients who were diagnosed with constipation using appropriate ICD 9 coding. The control group were patients who did not have a diagnosis of constipation. Demographic information, tobacco use, hernia presence and GERD diagnosis was then compared between the 2 groups to determine if any association between constipation and GERD existed using univariate and multivariate logistic regression.

RESULTS:
The total population was comprised of 85,317,627 patients, of which 2,419,827 (2.8%) were diagnosed with constipation. Constipated patients were older (62 vs 48 yrs old) and more likely to be females (60.3% vs 58.2%) compared to non-constipated group (P < 0.01 for all). Constipated patients were more obese (9.1% vs 7.4%) , had more tobacco use (11.1% vs 10.1%) and had more diaphragm hernias (3% vs 1%) compared to the control group (P < 0.01 for all). Using Multivariate logistic regression, and after adjusting for age, gender, race, smoking, alcohol, diaphragmatic hernia and obesity, constipated patients had a statistically significant higher rate of GERD (Odds Ratio [OR], 1.599, 95% confidence interval [CI], 1.593 -1.605, P < 0.001) compared to the non-constipated control group.

CONCLUSION:
Constipation is associated with almost 60% increased risk of GERD. Screening for GERD and treating GERD, if present, is essential in the optimal management of constipated patients.
2852 Stenting and Suturing for Esophageal Cancer in Neo-Adjuvant Setting: A Tertiary Community Cancer Center Experience
Authors: Sharma Neil , Gopakumar Harishankar , Krishnakurup Jay , Rumancik Brad , Kota Sharwani , Zelt Christina , Gupta Saurabh 
Published: October 2019

INTRODUCTION:
The place of esophageal stents for dysphagia in the neoadjuvant setting for esophageal cancer has recently been debated with recent Radiation oncology literature calling into question its use. Given the paucity of data and lack of clear guidelines, we performed a review our high volume esophageal cancer practice and analyze the outcomes in patients undergoing esophageal stent placement for malignant dysphagia in the neoadjuvant setting.

METHODS:
The data was collected retrospectively on all patients who underwent esophageal stent placement for malignant dysphagia due to esophageal cancer in a neoadjuvant setting at the Parkview Cancer Institute from September 2015 to November 2018.

RESULTS:
This case series includes 32 patients, collectively underwent placement of a total of 33 stents (fully covered self-expandable metal stents (FCSEMS)) of which 25 were anchored using esophageal suturing. The stent migration was only 6% (n = 2) compared to 30 -50% reported in literature. One key factor contributing to the low incidence of stent migrations could be the high proportion of endoscopic suturing performed. Out of the 33 stents, 25 (75%) were anchored to the esophagus by endoscopic suturing. 13 patients had successful completion of neoadjuvant therapy and subsequent esophagectomy. Seven patients decided not to undergo surgery due to stent unrelated issues. All of the patients had significant improvement in dysphagia immediately following stent placement. Only three patients developed eventual complications that resulted in need for repeat intervention with removal or replacement of stent. Overall rate of compilations for patients who received stent placement in neoadjuvant setting was 5 out of 33 (15.15%) (Table 1).

CONCLUSION:
This is a single center experience with significantly low number of stent migration, which can be attributed to the fact that all the stents were placed by a single advanced interventional endoscopy trained physician who maintains currently a high volume of esophageal stent placement of at least 15 to 20 procedures annually. This allows for increased proficiency, both in stent selection and placement. We use only fully covered metals stents and are extremely selective in stent length and diameter and almost always when possible, these stents are secured by sutures. This meticulous approach in esophageal stenting, tailoring to each individual patient has significantly contributed to the decrease in patient discomfort, migration and radiation toxicity.
2853 Esophagogastric Junction Outflow Obstruction Association With Mood Disorders: A Retrospective Study
Authors: Haberstroh William , Farah Guillaume , Alkully Turki , Benjamin Stanley , Shafa Shervin 
Published: October 2019

INTRODUCTION:
Esophagogastric Junction Outflow Obstruction (EGJOO) is a manometry abnormality at the level of the lower esophageal sphincter (LES) which is associated with elevated Integrated Relaxation Pressure (IRP). This is similar to achalasia; however, EGJOO has retained peristalsis and it is largely distinguished by poor relaxation at the LES. This diagnosis is becoming increasingly prevalent as use of esophageal High-Resolution Manometry (HRM) becomes more widespread. As EGJOO’s prevalence grows, it is important to augment our knowledge. Our objective from this analysis was to find comorbid associations which may give aide in identifying at risk patients and aide with treatment modalities. Depression and anxiety were focused upon in this study.

METHODS:
We performed a retrospective study of patients who were diagnosed with EGJOO by HRM from 2015 to 2018 at a single tertiary care center. Patients were classified as having EGJOO by the Chicago Classification (version 3). Chart review was performed to assess for comorbid conditions. Statistical significance was performed with a Chi Square Test of Independence.

RESULTS:
We identified 93 patients with EGJOO and a reliable past medical history documented in their chart. Upon analysis of our patient population, it was found that previously diagnosed depression (13.98%) and anxiety (12.9%) were common comorbidities. This was significantly higher than the prevalence of depression (6.7%, P = 0.0049) and anxiety (3.1%, P = 0.0001) in the United States.

CONCLUSION:
Depression and anxiety appear to show increased prevalence within patients diagnosed with EGJOO. EGJOO is generally known to be associated with structural obstructions, but importantly also seen in functional obstruction. This relation to mood disorders could suggest a psychosomatic component within certain subgroups. Whether EGJOO is an incidental finding or a true contributor to symptoms is not entirely clear. These correlations could trigger practitioners to think further about a diagnosis of EGJOO in their patients with anxiety or depression if they are displaying symptoms of dysphagia with associated manometric findings. Current treatment for EGJOO is not clearly established and treatment response is highly variable. Further studies looking into the relation of mood disorders with functional obstruction could lead to potential novel therapies.
2854 High Resolution Esophageal Manometry Findings in Patients With Esophageal Symptoms After Head and Neck Radiation Therapy
Authors: Qureshi Talha , Shafi Mehnaz A. , Husain Nisreen S. 
Published: October 2019

INTRODUCTION:
Head and neck radiation therapy is known to cause esophagitis and esophageal strictures as early and late effects after radiation exposure, respectively. The negative effects of radiation on esophageal motor function have been speculated in case reports but have not been studied in a larger population with high resolution manometry (HRM). The aim of this study was to evaluate HRM findings in patients who received head and neck or mediastinal radiation and presented with esophageal symptoms.

METHODS:
There were a total of 718 patients who received HRM from 2010 to 2018 at the Michael E. DeBakey VA Medical Center. Patients were excluded if they had undergone esophageal surgery, found to have oro-pharyngeal dysphagia, or if they had a mechanical cause on esophagogastroduodenoscopy of esophageal symptoms. Among the cohort, 14 patients met our inclusion criteria of receiving head and neck or mediastinal radiation prior to HRM. Chicago Classification v3.0 was used for HRM diagnoses.

RESULTS:
The most common symptom for which HRM was performed was esophageal dysphagia in 8 patients. Regurgitation and chest pain were each reported in 3 patients. Heartburn (n = 2), odynophagia (n = 1), and hoarseness (n = 1) were also reported symptoms. Seven of 14 patients (50.0%) were found to have abnormal findings on HRM (Table 1). Findings included hypotensive lower esophageal sphincter (LES) (n = 2), hypertensive LES (n = 1), hypotensive upper esophageal sphincter (UES) (n = 1), UES stricture (n = 1), spastic achalasia (n = 1), and ineffective esophageal motility (n = 1). There was no difference in HRM findings based on radiation dose received (Figure 1). There was an association towards increased HRM abnormalities with time since last radiation (Figure 2).

CONCLUSION:
This is one of the largest studies to show the effects of head and neck radiation on esophageal motility using HRM. Fifty percent of patients in this cohort exposed to head and neck radiation had abnormalities on HRM. We have also shown an association towards increased abnormal HRM findings with time, especially greater than five years after radiation exposure. Similar to our study, achalasia and ineffective peristalsis have been reported both early and late after head and neck radiation. Despite reports of esophageal motility complications with increasing doses of radiation, we were unable to demonstrate this. Our findings suggest that patients with esophageal symptoms after radiation exposure should be investigated for esophageal motor dysfunction.
2862 Severity of EGJOO and Correlation to Elevations in IRP
Authors: Farah Guillaume , Haberstroh William , Alkully Turki , Benjamin Stanley , Shafa Shervin 
Published: October 2019

INTRODUCTION:
Esophagogastric Junction Outflow Obstruction (EGJOO) is an abnormality of the lower esophageal sphincter (LES) which is associated with an elevation of the Integrated Relaxation Pressure (IRP). EGJOO is part of a group of disorders associated with impaired relaxation of the LES, however it remains separate from Achalasia (types I-III) due to retained peristalsis. Delayed bolus transit is frequently impaired in EGJOO due to this collection of abnormalities within the esophagus. Our goal with this retrospective analysis was to determine if there existed a correlation between an elevated IRP and solid/viscous bolus transit in patients with EGJOO.

METHODS:
We performed a retrospective analysis of patients who were diagnosed with EGJOO by high resolution manometry from 2015 to 2018 at a single tertiary care center. Patients were classified as having EGJOO by the Chicago Classification (version 3). An IRP of 20 or above was the cutoff in this analysis. This analysis collected a sample size of 100 patients whose manometry studies were consistent with EGJOO.

RESULTS:
A linear regression analysis was performed on the 100 patients reviewed. There was a weakly negative correlation between bolus transit time and an elevation in IRP. However, overall, IRP increase did not have a statistically significant impact on liquid/viscous bolus transit.

CONCLUSION:
In summary, an elevated integrated residual pressure (IRP) coupled with preserved esophageal body peristalsis is required for diagnosis of EGJOO. Our data revealed no statistically significant correlation between an elevated IRP and an increase in liquid/viscous bolus transit time. As such, an increase in IRP may not indicate severity of EGJOO. Therefore, success of endoscopic intervention may not be accurately indicated by observation of IRP by HRM. More data is needed to better correlate endoscopic intervention with IRP values.
2863 Epidemiological and Clinical Characteristics of Esophageal Carcinoma: A Four-Year Experience From Largest Referral Centre of Karachi, Pakistan
Authors: Butt Nazish , Soomro Sabir , Mahesar Ghulam Basit , Abbasi Amanullah , Haider Ghulam 
Published: October 2019

INTRODUCTION:
Esophageal cancer (EC) is an aggressive tumor that carries a poor prognosis. EC is the fourth commonest malignant tumor reported in Pakistan. Objective of this study was to assess epidemiological and clinical characteristics of EC, identified over a 4-year period at the largest referral centre of Karachi, Pakistan.

METHODS:
This retrospective study covered all histopathologically confirmed cases of esophageal carcinoma from endoscopic biopsy, seen within the 4-year period from January 2015 to December 2018.

RESULTS:
Over the period of 4 years, 548 patients with EC had been identified, 45 patients were excluded due to incomplete records. Their ages ranged from 15 to 92 years with a mean of 49.20 years (SD ± 14.35). Female were 286 (56.9%) and male 217 (43.1%). Dysphagia and weight loss were the most common symptoms. Most of the patients were belong to the province of Sindh 420 (83.5%). Beetle nuts, pan and gutka were the most predominant risk factors in 378(75.1%) of patients. The most common cancer subtype was squamous cell carcinoma (SCC), which included 417(83%) patients. Adenocarcinoma (AC) was diagnosed in 86 (17%) of patients. EC predominantly involved mid to distal esophagus (64%).

CONCLUSION:
Esophageal carcinoma is one of the most prevalent cancers in Pakistan, and its incidence is increasing day by day. The reason for raised incidence was associated with increased consumption of beetle nuts and gutka in certain parts of the country. It is hoped that this study will be an important step towards developing a comprehensive laws against consumption of gutka and beetle nuts.