bluuebunny/crossref_metadata_2025_split huggingface dataset:
204 Impact of Antibiotic Therapy on the Development and Response to Treatment of Immune Checkpoint Inhibitor-Mediated Diarrhea and Colitis
Authors: Abu-Sbeih Hamzah , Herrera Lauren Nicholas , Altan Mehmet , Chaftari Anne-Maria , Okhuysen Pablo , Jenq Robert , Wang Yinghong 
Published: October 2019

INTRODUCTION:
The gut microbiome impacts the efficacy of immune checkpoint inhibitor (ICI) therapy and the development of ICI-mediated diarrhea and/or colitis (IMDC). Antibiotic therapy, especially that with anaerobic activity, has profound effects on the gut microbiome. Therefore, we sought to assess the effect of antibiotics on the development of IMDC.

METHODS:
Patients who received ICI therapy from January 2016 to January 2018 were examined retrospectively. A Cox regression model was used to assess factors associated with overall survival.

RESULTS:
A total of 826 patients were included. Of these patients, 51.6% received inhibitors of programmed cell death protein-1 or its ligand, 32.0% received inhibitors of cytotoxic T-lymphocyte-associated antigen-4, and 16.5% received a combination of the two. IMDC developed in 52.5% of the patients after a median of 8 weeks. Overall, 569 patients (68.9%) received antibiotic therapy. Antibiotic use at any time was associated with reduced IMDC occurrence and recurrence rates but also with frequent hospitalization and intensive care unit admission for IMDC as well as increased IMDC severity. Compared with patients who received antibiotic therapy only before ICI therapy initiation, those receiving it after ICI had a higher IMDC rate and more often needed immunosuppressive therapy and hospitalization for IMDC. Antibiotics with anaerobic activity were included in 51% of the antibiotic therapy regimens and were associated with increased immunosuppressant use, hospitalization, intensive care unit admission for IMDC, and IMDC grades (Table 1). Forty-one patients received empiric prophylactic antibiotic therapy at IMDC onset. These patients more often needed immunosuppressive therapy, intravenous steroids, and infliximab/vedolizumab; had more frequent and longer hospitalization for IMDC and higher IMDC grades; and more frequently had IMDC recurrence than did patients who did not receive antibiotic therapy at the time of IMDC symptom onset (Table 2).

CONCLUSION:
Whereas antibiotic therapy appeared to be protective against IMDC onset, use of antibiotics, especially those with anaerobic activity, after ICI therapy was associated with increased risk of severe IMDC.
212 Retrospective Analysis of Liquid Nitrogen Cryospray Ablation in the Colon
Authors: Battish Raman , Kisiel Kym , Kachaamy Toufic , Vashi Pankaj 
Published: October 2019

INTRODUCTION:
Liquid nitrogen cryospray ablation (CA) is a modality for targeted destruction. Ablation of malignant strictures, premalignant conditions, and for hemostasis have been described. Active venting is required for use of this device in the GI tract due to rapid expansion of liquid nitrogen to gas, thus restricting use. There is limited data on liquid nitrogen CA in the colon.

METHODS:
Retrospective analysis of electronic health record, billing and endoscopic databases from 10/1/2013 to 6/1/2019. This study was determined to be IRB exempt by our research committee.

RESULTS:
17 subjects underwent 28 CA procedures in the colon. The most common indication was tumor bleeding. The average age of subjects was 56. Dosimetry was typically 3 cycles of 30 seconds per site for tumor bleeding and 10 seconds per site for radiation proctopathy. Treatment for stent patency was 30 seconds per site. The most proximal treated portion of the colon was 30 cm in a subject with colonic stent. All subjects underwent cancer directed treatment and CA was part of a multimodality approach. 9 subjects had radiation treatment prior to CA and four subjects had it following CA. CA has been used as a bridge to chemoradiation in anal cancer and to palliative radiation treatment for tumor bleeding. There were no immediate or delayed complications following procedures. No subjects required hospitalization within 30 days of procedure. CA was effective for hemostasis of tumor bleeding. Tumor bleeding was the indication for 3 of 4 subjects undergoing repeat CA. Stent patency required repeat CA in one subject. The time interval for repeat procedures ranged from 2 weeks to one year. Stent patency was maintained for 17 and 11 months respectively in 2 subjects. Both subjects eventually required placement of a second colonic stent. In this series, when radiation proctopathy was the indication repeat CA was not needed.

CONCLUSION:
Our data suggests CA is technically successful and safe in the colon. Furthermore it can be used as part of multimodality cancer directed treatment without additional complications. Prospective studies are needed to determine optimal interval for repeat treatments for stent patency and tumor bleeding. Other areas that warrant attention regarding CA are analgesic effects, abscopal effect, potential survival benefit, and proximal extent active venting can safely be performed in the colon. This series highlights the safety and efficacy of CA in the colon as part of multimodality cancer treatment.
219 Impact of Hospital Size and Teaching Status on Patients With Clostridium difficile Colitis Treatment Outcomes
Authors: Berry Davis B. , Abougergi Marwan S. , Khan Ahmad , Gupta Kamesh 
Published: October 2019

INTRODUCTION:
The efficiency and delivery of care has been at the center of the current healthcare debate and reform. Clostridium Difficile Infection (CDI) is the leading cause of hospital acquired infectious diarrhea. This study sought to investigate the effect of hospital size, urban location and teaching status on in-hospital mortality and resource utilization among patients admitted to hospital with 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 exposure of interest was hospital size, urban location and teaching status. Multivariate regression analysis was utilized to account for confounders.

RESULTS:
19,580 patients were included in this 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. After adjusting for confounders, the odds of in-hospital mortality were similar for patients at rural, urban teaching and urban non-teaching hospitals as well as at small, medium and large hospitals. However, patients treated at urban teaching and non-teaching hospitals had significantly longer LOS compared with those treated at rural hospitals. Similarly, patients treated at large and medium hospitals had significantly longer mean LOS compared with those treated at small hospitals. Patients treated at urban teaching and non-teaching hospitals had significantly higher mean total hospitalization charges compared with those treated at rural hospitals, and patients treated at large and medium hospitals had significantly higher mean total hospitalization charges compared with those treated at small hospitals.

CONCLUSION:
Despite significantly higher resource utilization (LOS and total hospitalization charges) at larger urban teaching hospitals, CDI in-hospital mortality was similar to those treated at small, rural non-teaching hospitals. One possible explanation lies in the complexity of CDI larger teaching referral centers. Another possibility is the variable adherence to C. difficile infection guidelines.
227 A Retrospective Evaluation of Compliance to Clostridium difficile Treatment Guidelines
Authors: Aslam Rida , Tabbaa Hazem , Yarbrough Alex 
Published: October 2019

INTRODUCTION:
Nearly half a million Americans suffered from Clostridium difficile (C. diff.) infections in a single year according to a study released by the Centers for Disease Control and Prevention (CDC). Studies indicate that C. diff. has become the most common microbial cause of Healthcare-Associated Infections found in U.S. hospitals driving up healthcare costs in acute care facilities alone. Our goal with this study is to investigate via retrospective chart review over the past 12 months to find out how often proper treatment was administered for patients admitted with a diagnosis of C. diff. infection.

METHODS:
This study is a retrospective chart review on patients admitted between Feb 2018–Feb 2019 at Franciscan Health St James Olympia Fields. Subjects were randomly selected with ICD-10 code for CDI. Age, gender, comorbidities, admission laboratory values, admission and discharge dates, and clinical course were obtained from EMR. The compliance to guidelines was assessed at initial treatment and as subjects further stratified into the categories non-severe, severe and fulminant disease. Compliance to guidelines was determined by type and duration of therapy. Secondary endpoints such as clinical outcomes such as 90-day mortality, therapy escalation and clinical cure which were also evaluated.

RESULTS:
A total of 118 patients were included in this study. This study shows that physician adherence to evidence-based guidelines for treatment of CDI was poor (50%). The study also found that compliance was lower in subjects with severe and fulminant disease. Overall, mortality associated with Clostridium Difficile treatment was 19.4% across all patients diagnosed with CDI regardless of severity of illness.

CONCLUSION:
CDI is a highly morbid condition and places a heavy burden on the healthcare system. Failing to adhere to the guidelines for treatment of Clostridium Difficile is detrimental to patients and results in worse clinical outcomes. This study identified that compliance to treatment guidelines is poor and barriers to compliance still exist despite education and guideline availability. To improve compliance to treatment guidelines in our hospital, we are currently developing an electronic order set through EPIC based on guidelines to allow for accurate treatment delivery and provide better outcomes.
234 Higher Serrated Detection Rate Is Associated With Lower Risk for Post-Colonoscopy Colorectal Cancer
Authors: Anderson Joseph C. , Butterly Lynn F. , Robinson Christina N. , Mackenzie Todd 
Published: October 2019

INTRODUCTION:
The serrated pathway may account for a significant proportion of colorectal cancer (CRC). Achieving adequate serrated polyp detection rates (SDR) may reduce the incidence of post colonoscopy CRC (PCCRC). We used data from the New Hampshire Colonoscopy Registry (NHCR) to determine if exams performed by endoscopists who have a clinically significant serrated polyp detection rate (CSSDR) of 7% or greater, proposed by Anderson/Butterly (GIE 2017), had a reduced incidence of PCCRC. In addition, we compared CSSDR to the adenoma detection rate (ADR), the currently used benchmark.

METHODS:
We defined PCCRC as any CRC diagnosed between 6 and 36 months after an exam with an adenoma on index and between 6 and 60 months following a normal exam. Exclusion criteria were any CRC diagnosed at index or within 3 months, incomplete exams, IBD, and genetic syndromes. Clinically significant serrated polyps (CSSP) were defined as any sessile serrated polyp, traditional serrated adenoma, serrated polyp >1 cm anywhere in the colon and any serrated polyp >5 mm proximal to the sigmoid. CSSDR was defined as number of screening exams with at least one CSSP divided by all screening exams. The exposure variable was a CSSDR of 7% and adenoma detection rate of 25%. Cox regression was used to model the risk of PCCRC in terms of the covariates at index exam. Covariates were age, BMI, smoking, index findings (large serrated polyp, advanced adenoma or any adenoma), followup time (months), bowel prep quality, having more than 1 surveillance exam and family history of CRC. We also compared receiver operating characteristics (ROC) for CSSDR 7% to an ADR 25% using probabilities derived from a logistic regression analysis.

RESULTS:
In our sample (142,950 index exams) 75 CRCs were diagnosed during the 6–60 month period (45 CRCs diagnosed between 6–36 months) after the index exam. The hazard ratio (HR) for CSSDR of 7% (HR = 0.37 95% CI 0.17–0.83) was similar to that for an ADR of 25% (HR = 0.45 95% 0.23–0.89) (Table 1). The ROCs were similar for CSSDR and ADR and the combination of the 2 rates did not alter the ROC (Table 2).

CONCLUSION:
Having an exam performed by an endoscopist with a CSSDR of 7% or greater was associated with a decrease incidence of PCCRC (HR = 0.37). The performance of CSSDR and ADR for PCCRC incidence were similar. These data suggest that a CSSDR of 7% or greater may be associated with lower PCCRC rates. However, it may not add an information to that provided by the current primary colonoscopy benchmark, ADR.
254 Young Onset Rectal Cancer: A Growing National Concern?
Authors: Ramai Daryl , Ofosu Andrew , Aloredi Khalil , Etienne Denzil , Reddy Madhavi 
Published: October 2019

INTRODUCTION:
The incidence of rectal cancer in the United States is increasing at an alarming rate among patients under the age of 45 years. The objective of this study was to investigate the incidence, demographics, tumor characteristics, treatment, and survival of rectal cancer in patients under 45 years of age.

METHODS:
Data on young-onset rectal cancer between 2000 and 2016 was extracted from the Surveillance, Epidemiology and End Results Registry. The clinical epidemiology of these tumors was analyzed using SEER*Stat. Only malignant cases were included. American Joint Committee on Cancer (AJCC) staging was used. IBM SPSS Statistics was used for Cox proportional hazard regression modeling to determine predictors of survival. Survival was calculated for primary rectal cancer only. Cases in which survival duration was unknown were excluded.

RESULTS:
A total of 10,375 patients with young-set rectal cancer were identified where 54.7% were male. Median age at diagnosis was 40 ± 5.7 years. The overall age-adjusted incidence of rectal cancer between 2000 and 2016 was 1.24 per 100,000 per year. Incidence increased with age, with the highest incidence occurring in the 40–44 year age group. Over the 16-year study period, the annual incidence of rectal cancer increased by 3.0% in a given year. Most tumors on presentation were moderately differentiated (48.3%) while the most common stage at presentation localized disease (40.7%). Moreover, 78.4% of these tumors were surgically resected while 50.9% received radiation, and 60.6% received chemotherapy. One- and 5-year cause-specific survival for rectal cancer was 92.7% and 70.8% respectively. On Cox proportional hazard regression analysis, worse outcomes were noted with Asians or Pacific Islanders [HR] 1.12, 95% confidence interval [CI] 1.03–1.21, P = 0.011), and increasing N stage (N1 HR 1.18, 95% CI 1.10–1.28, P = 0.000). Surgical intervention reduced mortality by 30% (HR 0.70, 95% CI 0.65–0.76, P = 0.000), while radiation therapy reduced mortality by 15% (HR 0.85, 95% CI 0.78–0.94, P = 0.001). Chemotherapy did not significantly affect survival outcomes (HR 1.04, 95% CI 0.94–1.15, P = 0.452).

CONCLUSION:
Our study highlights an increasing incidence of rectal cancer in the younger population under the age of 45 years. Further research is needed in understanding factors contributing to this alarming rise, and inform screening guidelines aimed at decreasing the incidence and mortality of this potentially curable disease in this population.
290 Exploring Interventions to Improve the Efficacy of Fecal Immunochemical Testing in an Ambulatory Care Clinic for the Underserved Population
Authors: Oldfield Edward C. , Marcuard Maurice , Mendel David , Tahhan Sami G. , Johnson David A. 
Published: October 2019

INTRODUCTION:
We previously conducted an initial analysis on the effectiveness of fecal immunochemical test (FIT) screening at our Ambulatory Care Clinic (ACC) for the underserved population during the first year of FIT implementation and first year of patient follow up. Although we met our initial goal of FIT completion of >60% (actual 81.8%), the follow up rate for repeat FIT testing was only 18% for patients with an initial negative FIT test (Figure 1). Recognizing these shortcomings, we implemented interventions to improve the follow-up FIT completion rate for those with initial negative testing.

METHODS:
All patients with initial negative FIT testing without a repeat FIT test after 1 year of follow-up were sent a letter notifying them of need for a repeat FIT test, which could be picked up from the front desk of the clinic (Figure 2). After two months, patient compliance was re-assessed and those who had still not completed the FIT test were given individualized phone calls with the same information. FIT completion rates were then assessed 1 month after these phone calls.

RESULTS:
A summary and patient flow diagram is shown (Figure 3). Among the 49 remaining active patients at the start of the intervention period, 9 patients (18%) completed a FIT test within 2 months of receiving the letter. No patients completed a FIT test within one month of receiving a phone call.

CONCLUSION:
1. Neither intervention significantly increased the rate of repeat FIT completion, although our 18% FIT completion at two months after the letter is near the published 23.5% completion rate.
1
2. Significant patient dropout occurred, adding up to 120 patients (71%) during a 6-month window immediately prior to our intervention period. This predominately occurred due to patients becoming inactive at the clinic over lack of follow-up or patients qualifying for insurance through the Virginia Medicaid expansion which started in January 2019. 3. There is clear need to refine our follow-up interventions and consider alternative tools, such as mailing FIT tests, automated text messaging, or incorporating FIT testing into well visits or existing clinic navigation tools. Additionally, the low rates of follow-up in this patient population will need to be monitored closely, as this may be a limiting factor for FIT testing which requires annual screening compared to other screening measures with longer interval screening periods.
293 Receptive Anal Sex in Women and Risk of Colorectal Cancer (2009–2014): A Retrospective Analysis of NHANES
Authors: Ramprasad Chethan , Major Vincent J. , Zhang Yian , LaBove Hannah , Haghighat Shida , Fass Ofer , El-Ashmawy Mariam 
Published: October 2019

INTRODUCTION:
Risk factors for early presentation of colorectal cancer is a topic of particular current interest. Prevalence of receptive anal sex has not been well researched, although some studies suggest that it is increasingly popular. The objective of the current study is to examine if there is an increased risk for colorectal cancer in women who engage in receptive anal intercourse as compared to patients who have not engaged in receptive anal sex.

METHODS:
The National Health and Nutrition Examination Survey (NHANES) was considered for women who answered the sexual health questionnaire (SXQ) during the survey cycles that included a SXQ item referring to anal sex (2009–2014). The questionnaire assessed sexual health behaviors including history of receptive anal intercourse in women. Additional NHANES data was matched for demographics, including race, as well as medical diagnoses, such as colorectal cancer and HPV infection. Statistical analysis was conducted using the statistical software, R.

RESULTS:
A total of 7,781 women completed the NHANES SXQ between 2009 and 2014 but only 6,596 answered the question mentioning receptive anal intercourse. A total of 2,203 women (28.3%), stated that they had a history of receptive anal intercourse at least once. The rate of reported history of receptive anal intercourse did not significantly increase across the 3 cycles: 2009–2010 (789, 29.0%) to 2013–2014 (782, 29.6%). From 2009 to 2014, there were a total of 19 participants (0.29%) with a diagnosis of colorectal cancer, with 5 patients who had both a diagnosis of colorectal cancer and history of anal intercourse. The risk of a diagnosis of colorectal cancer with a history of receptive anal intercourse in women was 0.0023, whereas the risk of a diagnosis of colorectal cancer with no history of receptive anal intercourse was 0.0032. There was no significant evidence that receptive anal intercourse in women is associated with risk of colorectal cancer. There was insufficient data for concurrent HPV infection and CRC in those without a history of anal sex, thus we are unable to test for significant difference between risk of CRC for women with HPV as compared to women without HPV.

CONCLUSION:
Results from the questionnaire did not suggest an increasing trend of receptive anal intercourse from 2009 to 2014. No significant difference was found in relative risk of diagnosis of colorectal cancer in women who engaged in anal intercourse as compared to those who did not engage in anal intercourse.
296 Antibiotic Use and Risk of Colorectal Neoplasia: A Systematic Review and Meta-Analysis
Authors: Aneke-Nash Chino , Yoon Garrett , Du MengMeng , Liang Peter S. 
Published: October 2019

INTRODUCTION:
Colorectal cancer (CRC) is the third most prevalent cancer and the third leading cause of cancer death for women and men in the United States. There is emerging evidence that the gut microbiome plays a role in CRC development, and antibiotics are one of the most common exposures that can alter the gut microbiome. We performed a systematic review and meta-analysis to characterize the association between antibiotic use and colorectal neoplasia risk.

METHODS:
We searched Pubmed, EMBASE, and Web of Science for articles describing the relationship between antibiotic exposure and colorectal neoplasia (cancer or adenoma) through October 2018. A total of 5342 citations were identified, which were reviewed independently by two investigators. After screening, we evaluated 15 articles and included 5 in the final analysis. We assessed the association between any antibiotic use as well as intensity of antibiotic use (defined as number of courses or duration of therapy) and colorectal neoplasia risk. Random effects meta-analysis was performed.

RESULTS:
Four studies provided five estimates for the association between any antibiotic use and risk of colorectal neoplasia. There was a 4% increased risk of neoplasia among individuals exposed to antibiotics (RR 1.04, 95% CI 1.02–1.07, Figure 1), with no evidence of heterogeneity (P = 0.96, I2 = 0%). Five studies provided 13 estimates of the association between antibiotic intensity and colorectal neoplasia. Individuals with the highest intensity of antibiotic exposure had a 13% higher risk of colorectal neoplasia than those with lowest exposure (RR 1.13, 95% CI 1.06–1.21, Figure 2). However, significant heterogeneity was observed (P = 0.04, I2 = 45%). Given the small number of studies, sub-group analyses on antibiotic class could not be performed.

CONCLUSION:
Antibiotic exposure is associated with a subsequent increased risk of colorectal neoplasia. Furthermore, this relationship appears to be dose-dependent. Given the widespread use of antibiotics in childhood and early adulthood, additional research to further characterize this relationship is needed.