bluuebunny/crossref_metadata_2025_split huggingface dataset:
159 The Role of Loperamide in Conjunction With Fecal Microbiota Transplantation (FMT) for Recurrent Clostridioides difficile Infection (rCDI)
Authors: Nayi Vipul , Brandt Lawrence , Aroniadis Olga 
Published: October 2019

INTRODUCTION:
FMT has been shown to be a highly effective therapy for rCDI. It has been proposed that giving loperamide prior to FMT could further improve the effectiveness of FMT for rCDI because it can increase the amount of time donor stool is in contact with the recipient's colon before being expelled. Older studies, however, suggest that the use of loperamide during CDI may predispose to megacolon. The goal of this study was to evaluate whether loperamide given before FMT for treatment of rCDI, improves resolution rates.

METHODS:
A retrospective observational cohort study was conducted at Montefiore Medical Center in the Bronx, NY of pts 18–75 yrs old who underwent FMT for treatment of rCDI from 2014 to 2017. rCDI was defined as ≥3 bouts of CDI with recurrence of symptoms within 8 weeks of completion of antibiotic therapy. Participants were excluded if they had severe or complicated CDI; had IBD, IBS or a motility disorder; were immunocompromised; or did not complete the follow-up telephone survey. Data pertaining to loperamide use before FMT and resolution of diarrhea were obtained by chart review and telephone survey of participants. Cure of rCDI was defined as resolution of diarrhea at 8 weeks of FMT. Bivariate analyses were performed to compare rCDI cure rates and adverse events between those who did and did not take loperamide before FMT.

RESULTS:
15 pts who underwent FMT for rCDI met inclusion criteria. Most participants were female (n = 12, 80%). Mean age was 53 ± 20 yrs. Participants had undergone an average of 2.5 ± 0.7 different courses of antibiotics before FMT. 14 of 15 pts reported resolution of diarrhea at 8 weeks (93%). 6 of the 15 pts took loperamide peri-procedurally (40%), all of whom experienced cure of rCDI compared with 8 of 9 pts who did not take loperamide (100% vs 89%, respectively; P > 0.99). Pt-reported FMT-related adverse events included subjective fever (n = 2, 13.3%), lactose intolerance (n = 1; 0.7%), celiac disease (n = 1, 0.7%) and rectal bleeding (n = 1, 0.7%), all of which occurred in the group who did not take loperamide.

CONCLUSION:
In our cohort, FMT was highly successful for the treatment of rCDI. rCDI cure was similar between groups who did and did not receive loperamide, which may be attributable to the overall high rCDI cure rates reported. In our small study, loperamide did not result in increased FMT-related adverse events. A future trial randomizing patients with rCDI to loperamide vs placebo might provide additional insight.
160 Endoscopic Full-Thickness Resection of Gastrointestinal Lesions With the Over-The-Scope Device: A Single Center Experience
Authors: Fahmawi Yazan , Kumar Manoj , Bercier Baret , Mando Rufaat , Mizrahi Meir 
Published: October 2019

INTRODUCTION:
While endoscopic transmural resection (EMR) and endoscopic submucosal dissection (ESD) are the conventional endoscopic resection methods for gastrointestinal (GI) lesions, endoscopic full-thickness resection (eFTR) is a promising minimally invasive modality for gastrointestinal lesions resection with good outcomes and less complications compared to EMR and ESD. Full thickness resection device (FTRD) is an over-the-scope device that has been developed for one-step eFTR. In this study, we report our experience with FTRD for GI lesions.

METHODS:
We retrospectively analyzed data from 17 patients who underwent eFTR with FTRD at our institution. Complete resection (R0), technical success, and clinical outcomes were studied.

RESULTS:
The indications for eFTR were recurrent/residual adenoma (12 cases), primary non-lifting adenoma (2 cases), submucosal lesions resection (2 cases), and early carcinoma (1 case). Eleven patients were males and six were females. The median age was 60 years (range 32–84). Locations of the lesions were: (3) in the cecum, (8) in the ascending colon, (2) in the transverse colon, (2) in the hepatic flexure, (1) in the rectum, and (1) in the stomach. Technical success rate was 13/17 (76%). Three of the unsuccessful attempts were due to inability to advance the endoscope to the cecum in one case and inability to pull up fibrotic lesions in the other two cases. The fourth unsuccessful case was due to device malfunction as the lesion was snared but the clip was not deployed. The mean maximum diameter of lesions after resection was 18.3 mm (range 13–22). R0 resection rate was 14/14 (100%). Microscopic full-thickness resection was achieved in 43% (6/14). The median procedure time was 67 minutes (range 31–140). The case with the device malfunction was complicated by perforation and delayed minor bleeding. The perforation was managed during the procedure with hemostatic clips. Another case had delayed minor bleeding without requiring blood transfusion. All patients were discharged on the same day except patients with complication as they required 1–2 days of inpatient observation.

CONCLUSION:
Discussion eFTR using FTRD is a safe minimally invasive procedure with good clinical outcomes. eFTR is currently indicated for treatment of non-lifting lesions, incomplete polypectomy, submucosal.
171 Role of Toxin A/B and GDH Negativity Differentiating Colonization Versus Active Infection in Presence of Positive PCR Results
Authors: Curras-Martin Diana , Copca-Alvarez Albino , Carson Michael P. , Rojtman Albert , Liu Edward 
Published: October 2019

INTRODUCTION:
2018 IDSA guidelines recommend testing for Clostridioides difficile infection (CDI) in patients with 3 loose bowel movements in 24 hours and known risk factors for CDI. Optimal testing strategy is not clear although a two-step algorithm is now recommended: glutamate dehydrogenase [GDH] plus toxin EIA; GDH plus toxin, arbitrated by PCR; or PCR plus toxin. C. diff PCR is a sensitive test and can indicate CDI but also may reflect colonization. Many institutions use PCR testing solely in CDI diagnosis, leading to potential overdiagnosis. The aim of this study was to determine, among patients with positive PCR samples at Meridian hospitals, whether a positive GDH and toxin would correlate better with clinical diagnosis of CDI than positive PCR/neg GDH.

METHODS:
Chart reviews of patients positive for toxigenic C.Diff by PCR that detects the tcdC gene was performed. Positive PCR samples were also tested for GDH and toxin A/B by enzyme immunoassay (EIS) using C. DIFF QUIK CHEK COMPLETE (QCC; TechLab, Blacksburg, VA, USA) between 12/2018 and 1/2019 at our institution. Clinical and lab data were obtained to help determine accuracy of lab test results.

RESULTS:
110 patients were positive for PCR and tested also for GDH/toxin. 73 (66%) were female, mean age was 67 years. Primary outcome: 16% (n = 18) were PCR positive but negative for both GDH and Toxin A/B. Among the 92 who were [GDH+], 45 (49%) were also [toxin A/B+]. Among those who were [GDH+] and [GDH−], at the time of diagnosis there were no statistically significant differences between the following: temperature, leukocytosis, creatinine or albumin at time of diagnosis, prior history of CDI, active malignancy, PPI use, recent laxative use, enteral nutrition or iodinated oral contrast (Tables 1 and 2). The mean number of days until diarrhea resolution was longer among [GDH-] (n = 18, 5.3 days) versus [GDH+] (n = 81, 3.6 days). Most patients were treated with oral Vancomycin.

CONCLUSION:
This data shows that a positive PCR for CDI was associated up to a 16% false positive rate with negative GDH. GDH status was not associated with significant differences in measured variables. The primary strength is this is the largest cohort reporting this type of analysis. The limitations of the study include incomplete retrospective clinical data obtained from EMR notes regarding morbidities that could explain the differences in time to resolution of diarrhea. Further study with more data is warranted and subset analysis of GDH+ with +/− Toxin EIA should be done.
188 Egg Breakfast Diet vs. Clear Liquid Diet Before Colonoscopy
Authors: Poudel Rosina , Winstead Nathaniel 
Published: October 2019

INTRODUCTION:
The current regimen of clear liquid diet prior to colon prep is uncomfortable and often fraught with various issues resulting in non-compliance. This has lead to poor colonoscopy preparations delaying diagnosis and treatment, and raising healthcare costs. Recently better-tolerated diets have been studied one of which involves the “low residue diet.” This diet involves various food items that are believed to not only have a short GI course, but also stimulate gut motility. Among them include boiled or scrambled eggs. Several studies have been undertaken with results generally favorable for the low residue diet. No studies, to our knowledge, have been done specifically targeting a low socioeconomic population that may have limited food access or low literacy rates making it difficult to follow specific instructions. This study was designed to target such a group by devising simple and affordable instructions with the overall goal to increase patient satisfaction, compliance, and obtain adequate prep quality.

METHODS:
A single blinded study was devised that involved 72 patients, with 36 patients in the experimental arm (Egg Breakfast/Low Residue) and 36 patients, age and gender matched, in the conventional arm (Clear Liquid Diet). Study was carried out at a single hospital center with the following exclusion criteria: egg allergy, known history of gastroparesis or chronic constipation. Patients were instructed to have 1–2 boiled/scrambled eggs in the morning prior to colonoscopy and continue with clear liquids and then the standard bowel prep that evening. The performing gastroenterologist was not aware of which patients were in the study.

RESULTS:
The quality of the colonoscopy preparations was separated in poor, fair, adequate, and good. The results revealed 75% (27) of the patients in the experimental group with either adequate or good prep quality versus 72% (26) in the conventional group. This left 25% for poor/fair prep in the experimental and 28% in the conventional.

CONCLUSION:
In conclusion, the data collected yielded comparable results between the two arms. Moreover, when considering factors such as tolerably or satisfaction, Egg Breakfast Diet appears to be superior to conventional. Thus, this study despite targeting a challenging group of a low socioeconomic population with poor access to resources, limited funds, low literacy rates achieved its overall goal to increase patient satisfaction yet still maintain standard if not better results with colonoscopy prep quality.
196 Caffeine Consumption and the Colonic Mucosa-Associated Gut Microbiota
Authors: Gurwara Shawn , Dai Annie , Ajami Nadim , El-Serag Hashem B. , Graham David Y. , Jiao Li 
Published: October 2019

INTRODUCTION:
Studies have demonstrated health benefits of caffeine consumption, including decrease in cardiovascular disease, diabetes, and liver diseases. The exact mechanisms are not known. Caffeine consumption may possibly modulate the gut microbiome and therefore affect health and disease risk. We examined the association between caffeine consumption and the composition and structure of the colonic-gut microbiota.

METHODS:
In this study, 34 participants underwent a screening colonoscopy and had endoscopically normal colons. We obtained a total of 97 snap-frozen colonic mucosa biopsies from various segments of colon from these individuals. Microbial DNA was extracted, and subsequently amplified for the 16S rRNA gene V4 region and sequenced using the Illumina MiSeq platform. We analyzed the sequencing data using the UPARSE and SILVA database for operational taxonomic unit (OTU) classification. Self-administered BLOCK Food Frequency Questionnaire was used to ascertain daily caffeine consumption. We compared the diversity and relative abundance of bacterial taxonomies by high (≥82.9 mg) vs. low (<82.9 mg) consumption of caffeine. False discover rate (FDR) P-values were reported and <0.05 indicated statistical significance.

RESULTS:
The alpha diversity was the greatest in high caffeine consumers (Shannon index P < 0.0001). The beta diversity differed significantly between high vs. low caffeine drinkers (P = 0.0001). The composition of microbiomes did not differ at the phylum level based on caffeine consumption. At the genus level, high caffeine consumption was associated with increased relative abundance of Faecalibacterium (P < 0.0005) and Roseburia (P = 0.02), but decreased levels of Erysipelatoclostridium (P value <0.001) and an OTU belonging to the Lachnospiraceae family (Unc8895) (P < 0.0005). The observed association was seen regardless of age and dietary quality. Other bacteria commonly detected in gut microbiomes, including Odoribacter, Dialister, Fusicatenibactor, Alistipes, Blautia, and multiple members of Lachnospiraceae, were significantly more abundant (P < 0.05) in participants with higher caffeine consumption (Table 1).

CONCLUSION:
Higher caffeine consumption was associated with increased richness and evenness of the mucosa-associated gut microbiota, and higher relative abundance of anti-inflammatory bacteria, such as Faecalibacterium and Roseburia and lower levels of potentially harmful Erysipelatoclostridium.
200 Diagnostic Yield of Colonoscopy in Young Adults With Lower Gastrointestinal Symptoms in Multicenter Midwest Cohort
Authors: Lu Ray , Dave Devashree , Klair Jagpal S. , Kassim Thamer , Ashfaq Muhammad , Chandra Subhash , Murali Arvind 
Published: October 2019

INTRODUCTION:
Serious gastrointestinal (GI) pathologies are common in older adults compared to young adults (≤40 years). There is a lack of data on the diagnostic yield of colonoscopy and flexible sigmoidoscopy in young adults with lower GI symptoms. We aimed to evaluate diagnostic yield of colonoscopy and compare overall diagnostic yield of colonoscopy versus flexible sigmoidoscopy in young adults with lower GI symptoms.

METHODS:
We reviewed diagnostic colonoscopies performed in young adults by 18 gastroenterologists at two different academic institutions between October 2016 to April 2019. Patients with family history of colorectal carcinoma were excluded. Diagnostic yield was calculated based on proportion of abnormal colonoscopy defined as having inflammatory bowel disease (IBD), microscopic colitis, advanced adenoma, or colorectal cancer (CRC). Presence of pathologies in left colon was considered for diagnostic yield of sigmoidoscopy.

RESULTS:
We included 454 patients with mean (SD) age was 31 (3) years, 162 (36%) were males and mean (SD) BMI was 30 (8.5). BRBPR was the indication for colonoscopy in 194 (43%) patients, 260 (57%) patients had colonoscopy for other lower GI symptoms (abdominal pain, diarrhea, constipation) but without BRBPR (Table 1). The overall diagnostic yield (DY) of colonoscopy in young adults with lower GI symptoms was 16%; IBD was seen in 43 (10%) patients, microscopic colitis 10 (2%), and advanced neoplasia/CRC 20 (4%) (Table 1). Overall DY in patients with BRBPR was significantly higher than patients without BRBPR (22% vs 11%, P = 0.001) (Table 2). The DY for IBD was also higher in young adults with BRBPR vs without BRBPR (15% vs 6%, P = 0.003) (Table 2). The overall DY was higher with colonoscopy compared to the predicted DY with flexible sigmoidoscopy (13.5% vs 9%) (Table 3).

CONCLUSION:
Significant proportions of young adults with BRBPR have abnormal pathology (22%) justifying endoscopic evaluation. For other lower GI symptoms, necessity of endoscopic evaluation should be determined clinically on a case-to-case basis as diagnostic yield is low. Colonoscopy rather than flexible sigmoidoscopy should be first line endoscopic evaluation in young patients with BRBPR due to the risk of missing IBD and advanced adenomas.
209 Improving the Diagnostic Stewardship of Clostridioides difficile Infection in a Health System
Authors: Elkafrawy Ahmed A. , Tomaw Andrew , Numan Laith , Saeed Lyla , Kaddourah Osama , Bennett Nicholas T. , Boyd Sarah 
Published: October 2019

INTRODUCTION:

Clostridioides difficile infection (CDI) has been a significant burden for the US health care system in the US with an increasing number of cases diagnosed with CDI annually. Infectious Diseases Society of America (IDSA) and American College of Gastroenterology (ACG) have made recommendations for improved testing of C. difficiletoxin (CDT). This study aims to evaluate a quality improvement initiative to limit inappropriate CDT testing based on established testing criteria.

METHODS:
In December 2017 a new policy was implemented for CDT testing by polymerase chain reaction (PCR) in the eight acute care hospitals in the midwestern United States. The microbiology lab was granted authority to reject specimens for testing of CDT if the stool sample was formed, the patient had less than three loose bowel movements within 24 hours, used laxatives in the last 48 hours, was tested positive for CDT in the past 14 days or negative in the past 7 days. We performed a 12-month period pre and post-implementation assessment for patients with completed orders for CDT detection by PCR and the number of patients who were diagnosed with CDI over the defined periods. We looked at total tests performed as well as patients who had initial test orders canceled by the lab and then a second order which met the criteria for testing in the same hospital admission. These subgroups were classified to a positive or negative testing result for the CDT test. Patients characteristics, indicators of CDI severity, and clinical comorbidities were correlated between both groups.

RESULTS:
The number of completed orders for CDT detection with PCR and the number of cases diagnosed with CDI over the 12 months after policy application decreased by 36% and 35% respectively (Figures 1 and 2). 360 patients had CDT testing rejected by the lab post-implementation. Only 80 patients had CDT testing reordered and 16 patients of these tests were positive. In a comparison of the reordered testing, the only independent predictors of a positive test were age above 63-year-old (P 0.013) and serum creatinine (SCr) above 1.5 gm/dl (P 0.025) (Table 1).

CONCLUSION:
Stricter criteria for CDT testing decreased the number completed CDT ordered tests by 36% and overall CDI cases by 35%. Age greater than 63 and SCr above 1.5 gm/dl may be considered as indications for CDT testing even without fulfilling the criteria for testing. Further prospective studies are needed to identify other risk factors that should be considered independently for CDT testing.
221 Risk of Bone Density Loss in Microscopic Colitis
Authors: Greenberg Ian , Yen Eugene 
Published: October 2019

INTRODUCTION:
Microscopic colitis (MC) is an inflammatory bowel disease of the colon that presents with chronic watery diarrhea. These patients have many risk factors for osteoporosis including female predominance, mean age in the 60s, lower body-mass index (BMI) and active smoking. Additionally the mainstay of therapy is a corticosteroid, budesonide. Bone density has not been rigorously studied in the population. Our aim was to evaluate for bone mineral density in patients with a diagnosis of MC with and without the use of corticosteroids.

METHODS:
We queried our prospective MC patient registry at NorthShore University HealthSystem, a clinical database of biopsy-confirmed patients with MC. Patients were included if they had a dual energy X-ray absorptiometry (DEXA) scan. DEXA measurements of the radius, femoral neck, and lumbar spine were used to evaluate bone mass. Baseline clinical factors were also collected, particularly tobacco use, BMI, and treatments for MC including corticosteroids. In this case-control study, age and gender-matched controls without diarrhea served as the control population.

RESULTS:
Of the 192 subjects in our registry, only 94 patients had undergone or had available bone density evaluations. The mean age at diagnosis was 69 years (range 42–91), with 91% female. No significant difference in rates of osteoporosis or osteopenia was observed in patients with MC (OR 1.58 [95% 0.75–3.30, P = 0.22]). Bone loss, defined as osteopenia or osteoporosis, was present in 82% of MC patients, compared to 75% in the controls. 76% of patients with MC received prolonged treatment with budesonide, and 24% received no steroids. A significant difference in bone mass was not appreciated between MC patients treated with a steroid, compared to controls (OR 1.15 [95% 0.33–4.03, P < 0.83]).

CONCLUSION:
Patients with MC have increased rates of osteopenia or osteoporosis compared to controls. However, our control cohort had a significantly higher degree of bone loss than current US estimates of 45–55%, which likely affected our statistical significance. Thus, bone loss is an underappreciated but important problem in microscopic colitis. With increased awareness, DEXA scans should be performed routinely in MC patients, particularly in those who have known risk factors for osteoporosis.
222 Biofeedback Therapy for Dyssynergic Defecation Is Effective Among Patients With Opioid Exacerbated Constipation
Authors: Spilman Samantha , Kunkel David 
Published: October 2019

INTRODUCTION:
Up to 90% of patients on opioids complain of constipation (Wurzelmann et al, 2007). Among opioid users, causes of chronic constipation can be multifactorial and related to other contributing factors such as dyssynergic defecation (DD). Biofeedback (BFB) therapy has been shown to be effective in patients with DD, but has not been studied among those who have DD and are on opioids.

METHODS:
This study was a retrospective analysis of patients enrolled in BFB for DD between 2015 to 2018 at a tertiary referral motility program. For patients that had greater than two sessions, survey and high resolution anorectal manometry (HR-ARM) data were collected at baseline and during each BFB visit.

RESULTS:
117 patients met criteria, of these, 20 patients were on active opioid therapy. Compared to those not on narcotic analgesics, opioids users were more likely to have a higher baseline defecation index (DI), intrarectal pressure divided by intra-anal pressure during simulated defecation (0.669 vs. 0.456 P < 0.0007). Decreased rectal sensation at baseline was seen in 20% of opiate patients and 19% of those not on opioids (P = 1.0). Opiate users compared to those not on narcotic analgesics also had a lower baseline health rating on the SF-36 scale (3.9 vs. 3.4 1-5 Likert scale P = 0.05) and were more likely to withdraw before completing a full course of BFB (P < 0.01). On stool diary, opiate users did not report a significant improvement in global bowel satisfaction rating (2.9 to 4.2, 10-point Likert scale P = 0.13), in contrast to non-opiate users who did repot improvement (2.7 to 4.9, P < 0.0001). Opiate users, however, had a significant decrease in number of stooling medications used (1.8 to 1.1 P = 0.04). On HR-ARM, there was a greater change in DI among non-opiate users as compared to opiate users. After BFB, opiate users effectively normalized their dyssynergia (79% improved) (P < 0.0001). Non-opiate users also showed significant improvement in normalizing their dyssynergia (74%) (P < 0.0001).

CONCLUSION:
Patients with opioid exacerbated constipation and DD showed meaningful clinical improvement in both subjective outcomes as well as manometric parameters. While they had lower baseline health rating at the outset and did not report significant improvement in global bowel satisfaction rating, unlike the non-opioid users, they nevertheless clearly benefited from BFB therapy. Overall, this data suggests that opioid users with DD may benefit from enrollment in BFB therapy.