bluuebunny/crossref_metadata_2025_split huggingface dataset:
613 Comparison of Clinical Outcomes in Traditional Gastrointestinal Hemorrhage Work-Up Versus Direct Utilization by Push Enteroscopy in Patients With a Left Ventricular Assist Device
Authors: Ghanimeh Mouhanna Abu , Hassan Seemeen , Mazhar Areej , Naffouj Sandra , Isseh Mahmoud , Abuamr Khalil , Kutait Anas , Bkumenkehl Mark 
Published: October 2019

INTRODUCTION:
Patients with left ventricular assisted devices (LVADs) are at considerable risk of gastrointestinal bleeding (GIB) of about 23%. A significant portion of GIB occur in the stomach, duodenum or small intestine as compared with lower intestinal tract. The traditional workup for such patients usually starts with an EGD ± colonoscopy, then proceeds with a small bowel evaluation if the initial workup is negative. This approach requires considerable time and effort which may lead to longer hospitalizations and multiple procedures. Our goal is to compare the traditional work up GIB with an innovative approach of performing push enteroscopy (PE) as the first diagnostic/therapeutic procedure.

METHODS:
This is a retrospective study was performed in Henry Ford Hospital in Detroit, MI. ICD-9 and ICD-10 diagnosis codes were used to generate a list of LVAD patients who were admitted with an overt GIB or worsening anemia in the period from 1/1/2013 to 12/25/2018. Our primary outcomes were the rate of detection of GIB lesion and all-cause mortality. Secondary outcome was the length of hospitalization.

RESULTS:
A total of 227 patients were reviewed. 89 patients were included (Mean age 61.36 years old, 75.28% were males). Most patients presented with either melena or worsening anemia without overt GIB. A total of 71 patients underwent the traditional approach at the first index endoscopy, whereas 18 patients started with PE ± colonoscopy. The source of GIB was detected at the first index endoscopy in 51 patients (36 traditional approach and 15 in PE approach). Arteriovenous malformation was the most common lesion detected and the two most common sites of bleeding were gastroduodenal followed by the small bowel. The PE approach was associated with a higher rate of GI site detection, OR 4.861 (95% CI (1.293-18.271), P 0.012), this was true, especially when patients presented with worsening anemia without overt bleeding, OR 11.2 (95% CI (1.202-104.33), P 0.015). There was no statistically significant difference between both approaches in terms of all-cause mortality (P 0.163). Patients in the PE approach did have a shorter hospital stay (x̅ (SD) 10.78 (13.97) days compared to 18.8 (25.58) days for the traditional approach) with P 0.034.

CONCLUSION:
PE is a safe procedure. It increases the GIB site detection and shortens the length of hospital stay when considered on the initial evaluation of LVAD patients presenting with GIB in general and worsening anemia in specific.
615 GI Bleeding, Risk Factors and Predictors of Endoscopic Evaluation and Severe Complicated Course
Authors: Bella Saif , Hoilat Judie , Alom Md S. , Saleem Atif , Hila Amine 
Published: October 2019

INTRODUCTION:
Acute gastrointestinal (GI) bleeding is a common worldwide clinical problem and continues to be associated with significant morbidity, hospital admission, and mortality. Overall, for patients hospitalized for GI bleeding, 40% occurred in the UGI tract, 25% in the LGI tract and 35% in an undefined location (1). Clinical presentation and outcomes vary. Bleeding from the GI tract is usually mild, self-limited, and the majority heal spontaneously. However, massive hemorrhage can happen. We aim to identify risk factors that predict the need for endoscopy or a complicated hospital course.

METHODS:
This is a retrospective study. We reviewed adult patients who were admitted with GI bleeding diagnosis from 10/2017-10/2018. We looked for risks and predictors of primary and secondary outcomes. The primary outcome was defined as the need for endoscopic evaluation (EGD or colonoscopy) within 14 days of admission. Secondary outcomes: 30-day hospital readmission and complicated course. A complicated course was defined with any of the following: ICU admission; Blood transfusion; increase the length of stay (7 days or more) and need for surgical intervention or death.

RESULTS:
Preliminary analysis was performed. A total of 148 patients were reviewed with a mean age of 70 years old. 56% of patients were females. Hemoglobin <8 g/dl, melena and bright red blood per rectum were significantly associated with an increasing need for endoscopic evaluation (Table 1). No significant association between patient age, gender, Obesity, and abnormal systemic inflammatory response indicators and the need for endoscopic evaluation. History of CHF, history of blood thinner use (Aspirin, Plavix, Ticagrelor, Warfarin or NOACs), presentation of exertional dyspnea, weakness, hemoglobin <8 g/dl, PT >15 sec, WBC >12K, Albumin <3 g/dl, SBP <90 mmHg and CRP >1 mg/L were significantly associated with an increase in the length of stay and complicated course (Figure).

CONCLUSION:
A comprehensive triage is important in evaluating patients presenting with GI bleeding. Predictors of poor outcome in such patients can be extracted from history, physical examination, vital signs, and initial lab workup. This may help to give priority to high-risk patients and planning for safe discharge and follow up.
621 Utility of FIT Testing in an Inpatient Setting
Authors: Barsky Maria , Nguyen Amie , Leverone Nicholas , Seav Susan , Losli Mathew , Solanky Dipesh , Saymann Gregory 
Published: October 2019

INTRODUCTION:
Fecal immunochemical tests (FITs) measure the globin portion of human hemoglobin and have been validated for the use of colorectal cancer screening. FIT testing is associated with many false positive (type I errors) due to GI inflammation, certain medications and even some foods. Furthermore, studies show that FIT testing often has little to no impact on clinical decision making in the hospital setting. Many argue the test adds cost and risk without providing meaningful clinical value in the inpatient setting.

METHODS:
The Slicer-Dicer tool of the EPIC electronic medical record system was used to identify patients hospitalized at UC San Diego affiliated hospitals between January and July 2018 who had a FIT test ordered. The primary outcome was proportion of patients with positive FIT testing receiving endoscopy. Secondary outcomes included reason for ordering FIT testing, proportion of patients referred for endoscopy at discharge, proportion of patients completing endoscopy after outpatient referral, and proportion of patients diagnosed with colon cancer on outpatient colonoscopy. Patient excluded were those who died during admission.

RESULTS:
During the 6 month study period, 140 inpatient FIT tests were ordered and 76 (54.3%) were positive. The majority of tests were ordered by the internal medicine service (Figure 1). Anemia was the leading indication for ordering the test (60% of all cases). 21% of the tests were ordered despite documented melena/hematochezia, and 70% of these tests were positive. Among the 76 patients with positive tests, 27 (36%) underwent inpatient EGD, 21 (28%) underwent inpatient colonoscopy, and 14 (18%) had both. Most patients with positive FIT testing did not receive an inpatient colonoscopy (72%, n = 55), and 42 (55.3%) did not receive any endoscopic testing. Of those 55 patients with positive FIT testing that did not receive inpatient colonoscopy, 26 (47%) did receive an outpatient GI referral, but only 8 (15%) received a colonoscopy within 6 months of discharge. No colon cancer was diagnosed in this small cohort. Among the 76 patients with positive inpatient FIT tests, 29 (38%) had neither GI referral nor endoscopy performed.

CONCLUSION:
Inappropriate use of FIT testing was prevalent at our institution, with inadequate documented follow up of abnormal testing in over one third of patients. Inadequate follow up can potentially lead to missed diagnoses of colon cancer.
622 Economic Burden of Bleeding Gastrointestinal Angioectasias
Authors: Baumgartner William , Stibbe Jason R. , Raines Daniel , Jiang Wei 
Published: October 2019

INTRODUCTION:
Angioectasias are dilated, thin-walled blood vessels resulting from degenerative changes in capillary vascular structure. They can occur anywhere within the gastrointestinal tract and are the most common source of small intestinal bleeding in patients over age 50. Small bowel angioectasias have the highest re-bleeding rates when compared to other sources. It is assumed that angioectasias complicated by bleeding result in consumption of a large volume of medical resources but this consumption has not yet be quantified in the medical literature.

METHODS:
A retrospective cross-sectional study was performed using Medicare data base analysis of ICD-10-DM codes for patients diagnosed with anemia and/or gastrointestinal hemorrhage during 2016 and 2017. A Crosswalk analysis of ICD-10-DM codes pertaining to primary gastrointestinal bleeding and primary anemia from angioectasias converted these codes into corresponding DRG (inpatient) and CPT (outpatient) codes. These codes of interest were followed throughout 2016 and 2017 in order to determine the cost of medical care for symptomatic angioectasias.

RESULTS:
In 2016, 38,250 Medicare services were provided in the management of angioectasias at a total cost of roughly $240 million. Hospitalizations accounted for 48% of total service volume but 95% of total costs at an average expense of $12,391 per inpatient stay. Outpatient services accounted for 52% of all services provided but only 5% of total annual costs in this analysis. Average costs for individual outpatient services were broken down into categories of therapeutic endoscopy ($922), diagnostic endoscopy ($805), injections ($522), blood transfusions ($261), and outpatient clinic visits ($261). Therapeutic endoscopy was the most expensive outpatient service category, accounting for 64% of all outpatient costs. A separate analysis of 2017 Medicare data validated our findings from the previous year with a steady total cost and only slightly (5%) increase in volume of individual services.

CONCLUSION:
Angioectasias are a common source of gastrointestinal bleeding and are associated with high recurrence rates as well as substantial morbidity. This study confirms that a large volume of medical resources are consumed in that management of bleeding angioectasias. In recognition of these findings, additional research is justified to improve upon our understanding and management of this disease process.
625 Characteristics of Patients With Obscure Gastrointestinal Bleeding in an Urban Academic Center
Authors: Hengehold Tricia A. , Li Lezhi , Yacyshyn Bruce 
Published: October 2019

INTRODUCTION:
Gastrointestinal bleeding is a significant clinical problem accounting annually for over 500,000 hospital admissions and 840,000 emergency room visits (1). Intestinal angioectasia (AEC) are an important cause of this bleeding, however, there is a lack of knowledge about this population's demographics. Aortic valve disease (Heyde's syndrome) and hereditary hemorrhagic telangiectasia (HHT) have been the most established etiologies and do not account for the majority of cases or increasing incidence. We sought to identify characteristics of patients with AEC, a condition increasing in incidence.

METHODS:
One urban academic center's electronic medical record was searched using ICD 9 and 10 codes to identify patients with gastrointestinal AEC. Those with aortic valve disease and HHT were removed. The control group included only those ages 65 and older. Demographic information was collected (age, gender, race, insurance and body mass index (BMI)), and the groups were further broken down into BMI >30 and BMI <30. The presence of diabetes mellitus (DM), chronic kidney disease (CKD), and diverticular disease was found.

RESULTS:
There was a total of 835 patients in the AEC cohort (average age of 65) that were compared to a control population of 318,923. More patients had a BMI >30 when compared to control (37.89% v 33.57%, P = 0.009). Additionally, the AEC cohort had more patients with DM (42.99% v 9.04%, and 20.87%, P < 0.001), CKD (35.21% v 5.00% and 11.72%, P < 0.001), and diverticular disease (36.89% v 2.85% and 6.78%, P < 0.001) than the total control and the control group with known BMIs. Demographics were similar between groups in the categories of gender, types of insurance and race. However, the AEC cohort had more patients that identified as black (30.74% v 11.16%, P < 0.001).

CONCLUSION:
Clinically, the increasing incidence of obscure gastrointestinal bleeding due to AEC is due to the increasing prevalence of complex chronic diseases that contribute to this condition. Our results showed that CKD and older age are risk factors. Additionally, we found that a BMI > 30 and DM are associated with a higher incidence of AEC. Diverticular disease was found to be a co-existing condition. Recognizing these risks and associated diseases is necessary to decrease the risk of bleeding from AEC, which can be very difficult to manage clinically with risk of significant morbidity and economic impact to healthcare.
632 Hemospray Efficacy in Achieving Immediate Hemostasis in Monotherapy versus Salvage Therapy: A Meta-Analysis
Authors: Odah Tarek , Ghoz Hassan 
Published: October 2019

INTRODUCTION:
The U.S. Food and Drug Administration (FDA) has recently approved the Hemospray (Cook Medical, Winston-Salem, North Carolina, USA) for treatment of gastrointestinal bleeding. Hemospray can be used as a monotherapy in certain circumstances and as salvage therapy in others. In this analysis, we compare the immediate hemostasis effects of Hemospray in upper gastrointestinal bleeding when used as a monotherapy compared to when used as a salvage treatment after failure of conventional hemostatic measures.

METHODS:
An extensive search for available studies comparing hemostasis effects of Hemospray as monotherapy versus salvage therapy in the treatment of upper gastrointestinal bleeding was performed in MEDLINE and Google scholar engine. Twenty-two studies were included. Odds ratios were calculated. Pooled odds ratios (OR) with 95% confidence intervals (95% CI) were calculated using either the fixed-effects or random-effects model.

RESULTS:
A total of 489 patients were included and divided into two groups, monotherapy group (N = 267 patients) and salvage group (N = 222 patients). A pooled odds ratio of 0.72 (95% confidence interval CI 0.27-1.92, P = 0.86) was obtained between two groups. Moreover, immediate hemostasis was achieved in 94% and 96.8% for monotherapy and salvage therapy, respectively.

CONCLUSION:
Both monotherapy and salvage therapies were highly effective in achieving immediate hemostasis in upper gastrointestinal bleeding.
635 Peripartum Exposure to Biologic Therapy Does Not Impact Wound Healing After Cesarean Section in Women With Inflammatory Bowel Disease
Authors: Aboubakr Aiya , Riggs Alexa , Mella Maria , Dubinsky Marla C. 
Published: October 2019

INTRODUCTION:
Inflammatory bowel disease (IBD) commonly affects women during their childbearing years, and mode of delivery is a frequent topic of concern. Rates of Cesarean section (C-section) are increased in women with IBD. Biologics are commonly used during pregnancy and data on their effect on C-section outcomes are limited. We investigated whether exposure to biologic agents impacts wound healing after C-section in women with IBD.

METHODS:
Women with IBD seeking consultation at the Marie and Barry Lipman IBD Preconception and Pregnancy Planning (I-PrePP) Clinic between years 2015-2019 were eligible. Delivery data collected as part of the I-PrePP prospective registry were analyzed. Primary outcome was rate of surgical site infection prior to discharge and/or at follow-up visits 2 and 6 weeks after delivery. Timing of biologics were investigated as well as impact of steroids on wound healing. Descriptive statistics summarized patient level data using frequency for categorical variables and median [IQR] for continuous.

RESULTS:
Of the 84 women who presented or became pregnant after their I-PrePP consultation, delivery data was available from 64 (38 (59%) Crohn's disease, 24 (38%) ulcerative colitis, 2 IBD-U (3%)) pregnancies (median [IQR] age 33 [29-35] years). Indications for the 37 C-sections (58%) included: history of perianal disease (n = 12, 32%), severely active inflammation (n = 1, 3%), ileal pouch anal anastomosis or end ileostomy (n = 2, 5%), previous C-section (n = 7, 19%), other obstetrical indications (large for gestational age, arrest of labor, malpresentation) (n = 14, 38%), or other (n = 1, 3%). Twenty six of 37 (70%) women with C-sections were exposed to biologics during pregnancy: infliximab (n = 13, 35%), adalimumab (n = 5, 14%), ustekinumab (n = 3, 8%), vedolizumab (n = 4, 11%), and certolizumab (n = 1, 3%). Time from last dose to delivery was 6 [4-7] weeks, and 21 of 26 (81%) received therapy at the time of (n = 10) and/or within 2 weeks (n = 11) of delivery. Four (11%) were exposed to systemic steroid therapy, including 2 patients at the time of and/or within 2 weeks of delivery. There was no incidence of surgical site infection in the biologic exposed patients, 1 case of MRSA bacteremia with an intra-abdominal abscess in a patient on systemic steroids, and 1 superficial infection in a non-medicated patient.

CONCLUSION:
Our data suggests that biologics exposure in the peripartum period does not adversely affect wound healing after cesarean section in women with IBD.
640 Outcomes in Geriatric Patients Admitted for IBD Management: A National Study
Authors: Schwartz Jeffrey , Li Brian , Stein Daniel J. , Feuerstein Joseph 
Published: October 2019

INTRODUCTION:
The proportion of the population considered geriatric continues to rise in the United States, as well as in most of the developed world. Based on this trend, combined with increased prevalence of inflammatory bowel disease (IBD), the burden of caring for elderly patients with IBD will likely rise. Given the complications of hospitalization in this cohort, we set to examine if elderly patients age >75 were at higher risk of poor outcomes when admitted for their IBD.

METHODS:
This national inpatient sample (NIS) from 2016 (most recent available) was queried for all cases of Crohn's or ulcerative colitis (UC) where this was the principle cause for admission (first diagnosis code) based on ICD-10. Outcomes for patients age >75 were compared to those <75 using survey-adjusted logistic/linear regression to examine mortality, length of stay, and hospitalization costs. Adjustment was made for the Elixahauser mortality score (a validated measure of comorbidities), undergoing surgery during the admission, and the presence of C diff infection. Crohn's and UC were analyzed separately.

RESULTS:
In 2016, admissions for UC were 35,950 and for Crohn's were 71,040. In UC, 1.4% of geriatric vs 0.2% of non-geriatric patients died in the hospital (P < 0.001). Similar results were found in Crohn's at 1.0% versus 0.1% (P < 0.001). Average Elixhauser mortality index (a validated measure of comorbidities) was higher for geriatric patients for UC (8.4 vs 4.8, P < 0.001) and Crohn's (7.3 vs 3.3, P < 0.001). In the regression analysis for Crohn's, non-geriatric patients had a OR = 0.25 of death (P = 0.001) but no significant difference in length of stay (P = 0.119) or costs (P = 0.446). For the UC regression, similar findings of an OR = 0.19 of death (P < 0.001) but no change in LOS (P = 0.529) or costs (P = 0.927) were seen. For all admissions in NIS, an OR = 0.50 was seen for the same controlling variables.

CONCLUSION:
In this U.S. national cohort from 2016, age >75 was associated with a notably higher odds of death in both UC and Crohn's patients, with nearly four times the odds of inpatient mortality even after adjustment for comorbidities. This is more than double the mortality difference compared to non-IBD admissions. Further research is needed to customize care for this growing group of individuals to improve outcomes.
643 RHB-104, a Fixed-Dose, Oral Antibiotic Combination Against Mycobacterium Avium Paratuberculosis (MAP) Infection, Is Effective in Moderately to Severely Active Crohn's Disease
Authors: Graham David Y. , Naser Saleh A. , Offman Elliot , Kassir Nastya , Hardi Robert , Welton Thomas , Rydzewska Grazyna , Stepien Beata , Arlukowicz Tomasz , Wos Anna , Fehrmann Clara , Anderson Patricia , Bibliowicz Aida , McLean Patrick , Fathi Reza , Harris M. Scott , Kalfus Ira N. 
Published: October 2019

INTRODUCTION:
MAP US was a global multicenter randomized trial comparing the efficacy and safety of RHB-104, a fixed-dose oral combination of clarithromycin, rifabutin and clofazimine against MAP infection, in moderately to severely active Crohn's disease (CD). We report evaluations of efficacy, symptom improvement and exposure-response by individual RHB-104 components.

METHODS:
Patients with active CD (CDAI ≥220 and ≤450) and failure with conventional therapies were randomized 1:1 to RHB-104 or placebo for up to 52 Wks. Concomitant corticosteroids, immunosuppressives (IS) and anti-TNF agents were permitted. The primary endpoint was clinical remission (CDAI <150) at Wk 26. Secondary endpoints included clinical response at Wk 26 (CDAI decrease ≥100 points), early remission at Wk 16 and remission at Wk 52. A population pharmacokinetic (PK) and exposure-response analysis was performed based on PK assessments and remission at Wk 26; a subset of patients underwent colonoscopy at baseline and Wk 26.

RESULTS:
331 subjects were randomized at 92 sites. The proportion achieving remission at Wk 26 (36.7% vs 23%, P = .007), remission at Wk 16 (42.2% vs 29.1%, P = .015) and response at Wk 26 (44% vs 30.9%, P = .017) were significantly greater with RHB-104 vs placebo. The superiority of RHB-104 was more pronounced in patients receiving RHB-104 with concomitant anti-TNF or IS treatment. Despite the small numbers (n = 35), a greater proportion of RHB-104 patients achieved endoscopic response by SES-CD 50 (28.6% vs 4.8%, P = .11). Differences in fecal calprotectin (FCP) increased over time (Figure 1); improvements in PRO-2 symptoms appeared by Wk 4 and reached significance by Wk 16 (Figure 2). A significantly greater proportion of patients receiving RHB-104 achieved clinical remission with at least a 50% reduction from baseline in either FCP or CRP concentration at Wk 16 (25.9% vs 9.7%, P = .0002), Wk 26 (21.1% vs 9.1%, P = .0003) and Wk 52 (16.9% vs 7.9%, P = .02). Exposure-response modeling demonstrated the combination of the individual components of RHB-104 contributed to the higher rate of remission compared to placebo and that the probability of achieving remission was most sensitive to clofazimine.

CONCLUSION:
RHB-104 demonstrated meaningful improvement in efficacy and biomarkers of active inflammation, with exposure-response for each drug component, early onset of response and benefit in patients with and without concomitant anti-TNF or IS therapy.