bluuebunny/crossref_metadata_2025_split huggingface dataset:
191 Decreasing Hospital Clostridium difficile Infections: Impact of an Educational Module
Authors: Jarodiya Vijay , Singh Tejveer , Khan Zarak H. 
Published: October 2019

INTRODUCTION:
Clostridium difficile is a leading cause of healthcare associated infections in the United States accounting for approximately 12% of infections acquired in healthcare settings. Currently there is no primary prevention through immunization to prevent Clostridium difficile infections. Therefore hospital staff should be knowledgeable about evidence-based infection-control guidelines to decrease transmission of Clostridium difficile and decrease risk of infection in the hospital. We created an educational module that focused on Clostridium difficile education.

METHODS:
We developed an educational module that focuses on general information about Clostridium difficile including the pathogenesis of infection and ways to decrease or prevent transmission. A module was created which consisted of a pre-test to determine the level of knowledge prior to our intervention as well as an educational module which consisted of PowerPoint slides going over information about Clostridium difficile as well as strategies to decrease and prevent transmission and answering frequently asked questions. This is followed up with a post-test which was meant to test retained information provided during the module. Our initial study was conducted with physicians, nurses and nursing assistants. Our second cycle was conducted from January to June 2018 and expanded to include hospital staff that may not be involved with medical management but also would interact with patients, which included case managers, social workers, patient transportation staff, janitorial staff, food services and other staff.

RESULTS:
Our PDSA cycle revealed a pre-test score of 70.63% with an increase to 96.93% post-test (P < 0.001). The Standardized Infection Ratio in the months prior to the intervention was 1.967 (P = 0.0139) and post-intervention it was 0.746 (P = 0.4187).

CONCLUSION:
Our study shows that an educational module is an effective way to help combat Clostridium difficile infection rates. We had a statistically significant improvement in test scores which correlated with a decrease in Clostridium difficile infections. While the post-intervention SIR was not statistically significant, it was clinically significant and there was a statistically significant improvement from pre to post-intervention. Some concerns include the possibility of a decay effect from a passive intervention such as a module.
205 Benefit of the Polyp Size-Based Resect and Discard Strategy for Polyp Smaller Than 10 mm in Screening Colonoscopy
Authors: Vanduangden Kunvadee , Sritunyarat Yingluk , Kongtab Natanong , Aniwan Satimai , Rerknimitr Rungsun 
Published: October 2019

INTRODUCTION:
The routine histological assessment of all polyps is costly. A resect and discard small polyp has yet to be used widely in practice. Practically, a 10-year surveillance interval is recommended. Without histological confirmation for these polyps, the surveillance interval may be too long in those with a high-risk adenoma (HRA) since the guidelines recommend the 3-year interval for HRA whereas the 10-year interval for a low-risk adenoma (LRA) and no adenoma. Therefore, we aimed to determine the benefit of this strategy and the risk of hidden HRA and cancer based on only polyp size assessment.

METHODS:
The electronic database of 7612 screening colonoscopy between January 2007 and February 2019 was retrospectively reviewed. All polyps sized <10 mm were resected and enrolled. In our practice, all identified polyps were resected and sent to a pathologist except diminutive polyps (polyp size <6 mm) at the recto-sigmoid colon would have left. The size of each polyp was estimated by using opened biopsy forceps, which was 7-mm diameter. The location of polyp was classified as the proximal and distal colon. The proximal colon was defined as the region between cecum and the splenic flexure. A HRA was defined as adenoma with high-grade dysplasia, or villous adenoma. A LRA was defined as tubular adenoma. Stratification with polyp size of <6 mm and 6–9 mm, the NPV for diagnosis of a HRA, and number needed for histological assessment (NNH) to detect one HRA were calculated.

RESULTS:
A total of 5064 polyps <10 mm detected in 4419 subjects were included (Table 1). Of those, size <6 mm was 4211 (83%) and size 6–9 mm was 853 (17%). Histology showed LRA in 3492 (69%) polyps, and HRA in 102 (2%) polyps (Table 1). None had cancer. The prevalence of HRA between proximal polyps and distal polyps was not different (1.7% vs. 2.3%, P = 0.16). Using only polyp size of <6 mm and 6–9 mm, the NPV for diagnosis of HRA were 96.4% and 98.3%, respectively. The NNHs to detect one HRA were 60 in polyp size <6 mm and 28 in polyp size 6–9 mm (Table 2). At $50 per specimen, the polyp size-based resect and discard strategy could save $57,298 for each 1000 subjects with at least one polyp <10 mm.

CONCLUSION:
In a country with financial constrain, resecting polyp <10 mm without histological assessment is recommended because there was no risk for missing cancer and this strategy achieved the Preservation and Incorporation of Valuable Endoscopic Innovation (PIVI) threshold with NPV at 96% for the HRA.
206 Oral Vancomycin Prophylaxis for the Primary and Secondary Prevention of Clostridium difficile Infection: A Systematic Review and Meta-Analysis
Authors: El Kurdi Bara , El Iskandarani Mahmoud , Babar Sumbal , Haddad Ibrahim , Alomari Mohammad , Al Momani Laith , Young Mark 
Published: October 2019

INTRODUCTION:
Clostridium difficile infection (CDI) is the leading cause of infectious healthcare-associated diarrhea. It is a major cause of in-hospital morbidity and increased healthcare costs. Past research has identified populations at high risk of CDI. However, there is no current consensus on CDI prophylaxis. Oral vancomycin prophylaxis (OVP) has been suggested for the primary and secondary prevention of CDI. Therefore, we have conducted a comprehensive systematic review and meta-analysis to investigate the role of OVP in CDI prevention in published literature.

METHODS:
A computerized search of MEDLINE, EMBASE and Cochrane databases from inception to March 2019 for publications investigating OVP for CDI prevention. Results were screened for relevance and eligibility criteria. Relevant data was extracted and analyzed using Comprehensive Meta Analysis software. Publication bias was assessed for using Egger's test. P < 0.05 was considered significant.

RESULTS:
Six retrospective cohort studies with total of 1263 patients published between 2016–2019 were included. OVP use was associated with lower CDI (OR 0.175, CI 0.06–0.52) with considerable heterogeneity (I2 67%). OVP use was associated with lower CDI in immunocompromised (OR 0.072 CI 0.01–0.92) (I2 30.8%) as well as immunocompetent (OR 0.22, CI 0.07–0.69) (I2 71%) patients. The reduction in CDI was noted when OVP was used for primary (OR 0.04, CI 0.01–0.27) (I2 0%) as well as secondary (OR 0.27, CI 0.10–0.76) (I2 64%) prevention. Meta regression analysis showed that total daily dose of OVP was correlated to OR of CDI and was able to explain 100% of heterogeneity noted between studies. Only two studies evaluated the risk of VRE emergence in treated populations and found no significant increase. No publication bias was found using Egger's test.

CONCLUSION:
Our results suggest that the use of OVP was associated with lower CDI rates in at-risk populations. Higher daily doses of OVP were associated with higher rates of CDI suggesting that a lower OVP dose might be more effective for CDI prevention. While it might be prudent for physicians to prescribe OVP for high risk patients, the total daily dose, duration of treatment and long term side-effects are yet to be determined. These questions should be further evaluated with randomized controlled trials.
210 Clostridioides (Clostridium) difficile PCR Amplification Cycle Threshold: More Than Just a Number?
Authors: Tung William , Hunold Thomas , Poulter Melinda D. , Warren Cirle , Wu Martin , Hays R. Ann 
Published: October 2019

INTRODUCTION:
The optimal diagnostic approach for C. difficile infection (CDI) is controversial. Infectious Disease Society of America currently recommends a high sensitivity test such as a nucleic acid amplification test (NAAT) PCR, followed by a stool toxin enzyme immunoassay to confirm clinical suspicion of CDI. C. difficile PCR cycle threshold (Ct) is the number of cycles required for a signal to exceed background fluorescence with low numbers reflecting a larger C. difficile nucleic acid burden. Recent reports correlate Ct in symptomatic patients with disease severity and mortality. Data regarding the predictive value of PCR Ct in recurrence of CDI is preliminary. We aim to determine the association between Ct and recurrence of CDI.

METHODS:
This was an IRB approved, single-center retrospective chart review cohort of 76 randomly chosen patients ≥18 y.o., with completely unformed stools that were C.difficile NAAT positive. 10 patients were excluded due to lack of Ct values. Recurrence defined as any positive test for C. difficile within 3 months after treatment for CDI. Severe CDI defined as WBC >15,000 or creatinine ≥1.5 md/dL and fulminant disease as refractory hypotension, ileus or megacolon. Poor clinical outcome defined as severe or fulminant CDI, or death within 30 days of diagnosis. A t-test or Mann Whitney U test was performed on populations with or without a normal distribution, respectively. A scatterplot was generated with Ct values for patients with initial vs recurrent episodes of CDI.

RESULTS:
Of 66 patients, mean Ct values of 8 patients with recurrent CDI (12.1%) and 58 without recurrence were 25.71 and 26.15 respectively (P = 0.79). Recurrence rates after the initial episode of CDI (n = 4), 1st recurrence (n = 1), and 2nd/subsequent recurrence (n = 3) were 9.1%, 12.5% and 21.2%, respectively. Mean Ct values trended lower for patients with poor outcomes (25.40 vs 26.42, P = 0.37).

CONCLUSION:
In our single center study, Ct values did not associate with a recurrence of CDI. Our findings suggest that Ct cannot be used to predict which patients will be at risk for recurrent CDI. The trend of lower Ct values associating with worse outcomes is worth a prospective study. Interestingly, there was no association with Ct values and common risk factors for CDI such as prior antibiotic use, suggesting that Ct values may not clarify current controversies in testing for CDI.
223 Does “Prior Appendectomy” Affect the Outcomes of Clostridium difficile Infection in Hospitalized Patients? A Retrospective Review and Analysis
Authors: Shaikh Danial , Patel Harish , Mehershahi Shehriyar , Pirzada Usman , Alemam Ahmed , Sun Haozhe , Nawaz Iqra , Naher Kamrun , Islam M. Rizwanul , Hanumanthu Siddarth , Nayudu Suresh 
Published: October 2019

INTRODUCTION:
Clostridium difficile infection (CDI) is prevalent in hospitalized patients and accounts for significant morbidity and mortality. Management and outcomes of these patients depend on the severity of CDI. Current classification of severity of CDI includes parameters that depict its inflammatory response. We attempted to study the influence of prior appendectomy on severity and outcomes of CDI.

METHODS:
We conducted a retrospective chart review of 1248 patients admitted to our institute between 2008 and 2016, whose stool tested positive for Clostridium difficile toxin. Baseline characteristics, comorbidities, and lab values were extracted from the EMR. Information regarding prior appendectomy was obtained from medical documentation and abdominal imaging, whichever was available. Patients were grouped into those with prior appendectomy (group A) and those without (group B). In-hospital Mortality was defined as death during the same hospital admission as CDI. Severity was defined as per the Infectious Diseases Society of America guidelines. The primary outcomes were to 1) assess all-cause in-patient mortality and 2) severity of CDI, attributable to prior appendectomy.

RESULTS:
There were a total of 1248 patients of which 13.5% (n = 175) had a history of prior appendectomy. The mean age was similar in both groups (57 years), and baseline characteristics were comparable. There was a female preponderance (60.06%) in group A. The dominant patient race was African American (36.6% in group A and 39.8% in group B). All lab parameters were similar in both groups, except WBC counts, which were higher amongst patients with appendectomy (13 vs. 11, ±8) (P 0.013). Group A patients were more likely to have a severe presentation of CDI (40%, n = 68), whereas group B had mostly mild CDI (45.9%, n = 492). Prior appendectomy did affect the severity status, although statistical significance was not achieved (P 0.057). There was no statistical difference in mortality either, with 25 deaths in group A (14.3%) and 169 in group B (15.8%) (P 0.62). Regression analysis performed to ascertain independent predictors of all-cause mortality in CDI did not identify prior appendectomy as a risk factor.

CONCLUSION:
Prior appendectomy status may affect the severity of CDI and hence the need for colectomy. However, we did not observe a difference in mortality associated with prior appendectomy. Since the prevalence of prior appendectomy was low in our study, larger population studies are needed to establish significant outcomes.
229 Assessing Varying Techniques of Colonic Endoscopic Mucosal Resection and Subsequent Residual Adenoma at 6-Month Follow-Up
Authors: Groff Andrew , Lester Courtney , Levenick John M. 
Published: October 2019

INTRODUCTION:
Local recurrence at colonic endoscopic mucosal resection (EMR) sites of medium to large polyps is common at first follow-up (∼10–30%). Extended edge resection has not shown a benefit of reducing this rate; however, edge ablation with snare tip soft coagulation has shown reduced local recurrence. Hybrid argon plasma coagulation (APC) is a novel technique, which can be used to treat microscopic residual disease to prevent local recurrence at follow-up surveillance colonoscopy. This study aims to evaluate if treating both the edges and base of an EMR site with a novel technique, hybrid APC, can reduce the rate of local recurrence at 6-month follow-up versus standard EMR assessing a single endoscopist.

METHODS:
This is a single center retrospective case series of all colonic EMRs with 6-month surveillance performed by a single endoscopist at a tertiary care center using both standard EMR and hybrid APC assisted EMR from May 2018 to May 2019. The main outcome measure was recurrence of precancerous polyp at prior EMR site at 6-month surveillance colonoscopy. Secondary outcome measures were the rate of procedure associated complications, including post-polypectomy bleeding and post-polypectomy syndrome.

RESULTS:
A total of 84 EMRs, 38 utilized hAPC, were performed from in the study period. 25 patients (mean age: 65.4 years, 48% men) with 30 polyps were included who completed surveillance colonoscopy after 6 months to evaluate for recurrence (Table 1). The average resected polyp size was 32 mm. Residual polyp recurrence occurred at 4 prior EMR sites (13.3%), with all of the recurrences occurring in patients who underwent standard EMR (100%). There was no recurrence of residual polyps in patients treated with hAPC assisted EMR. Further, 4 patients (15.4%) experienced post-polypectomy bleeding complications within 6 months, with all complications associated with patients treated with standard EMR (Table 2). There was a statistically non-significant trend toward higher recurrence and complication rate in patients treated with standard EMR compared to hAPC assisted EMR.

CONCLUSION:
In this retrospective study of colonic EMRs, the use of hAPC at initial EMR was associated with decreased local recurrence rate of precancerous tissue at EMR sites and rate of early complications. The findings of this early retrospective study warrant further studies to determine the efficacy of hAPC in reducing the recurrence rate after 6 months and how it compares to standard EMR procedure with snare tip soft coagulation.
230 Dosing Strategy for Itacitinib, a Selective JAK1 Inhibitor, for the Treatment of Ulcerative Colitis
Authors: Barbour April , Zhang Yan , Punwani Naresh , Diamond Sharon , Chen Xuejun , Yeleswaram Swamy 
Published: October 2019

INTRODUCTION:
Itacitinib is a JAK1 inhibitor currently under development for oncologic and auto-immune diseases. Itacitinib is delivered as a sustained release formulation with 27.1% of the dose eliminated as unchanged itacitinib in the feces. A clinical and an ex vivo study were conducted to understand colonic disposition, important for ulcerative colitis (UC).

METHODS:
Clinical study: Itacitinib concentrations in plasma and feces (colonic surrogate) were determined following a single 25 mg oral dose. Itacitinib concentrations in plasma following a single 100 mg dose were also determined in a separate study. Ex vivo study: Colon tissue samples from healthy and UC subjects (2/group) were mounted on a vertical Ussing diffusion chamber. 14C-Itacitnib was applied to the apical side of the chamber at 100 and 1000 nM and incubated for 1 h. Samples were collected from the donor and receiver sides for determination of itacitinib concentration. The colonic tissue was snap frozen for quantitative autoradiography.

RESULTS:
Following a single 25 mg dose of itacitinib, 8/12 patients had fecal concentrations that exceeded the in vitro IC50 for JAK1 inhibition. Systemic concentrations were below the IC50 for JAK1 inhibition in whole blood at both doses evaluated, mean (SD) Cmax = 18.9 (7.46) nM for 25 mg and 84.4 (45.8) nM for 100 mg. Ex vivo, no itacitinib related radioactivity was detected from the receiver side. Itacitinib penetrated into the mucosal layer and, to a lesser extent, submucosal layer in a concentration dependent manner.

CONCLUSION:
A dose range of 25 mg BID to 100 mg QD is recommended for study in UC patients to maximize colonic exposure while minimizing the potential for systemic exposure.
232 Numerous Non-Advanced Adenomas Are Not Associated With Metachronous Advanced Neoplasia
Authors: Rouphael Carol , Lopez Rocio , McMichael John , Burke Carol A. 
Published: October 2019

INTRODUCTION:
Studies using standard definition colonoscopes in the early 2000s demonstrated the risk of metachronous advanced neoplasia (MAN) was doubled in patients with >3 vs 1–2 small tubular adenomas. In the last decade, attention to the importance of adenoma detection rate and the use of high definition (HD) colonoscopes, increases small adenoma detection. We analyzed the association between baseline adenoma features, particularly multiplicity of non-advanced adenomas, on the risk of MAN in patients undergoing HD colonoscopy.

METHODS:
Patients undergoing first colonoscopy at age ≥50 in the era of HD colonoscopes (≥2006) and follow-up colonoscopy >24 months from baseline exam were identified from the electronic medical record. Exclusions included inflammatory bowel disease, history of colorectal cancer or colon surgery, incomplete colonoscopy, and inadequate bowel preparation. High risk adenoma (HRA) patients included those with an advanced adenoma (≥10 mm in size, adenoma with villous features/high-grade dysplasia) or ≥3 adenomas. Low risk adenoma (LRA) patients included those with 1–2, <10 mm tubular adenomas. The risk of MAN was calculated according to baseline adenoma features. Multivariable analysis compared the risk of MAN between individuals with LRA vs HRA on baseline HD colonoscopy adjusted for interval between first and follow-up colonoscopies.

RESULTS:
159,273 patients underwent colonoscopy at age ≥50 in 2006 or later. After exclusions, 3,383 were included. Mean age was 60.5 ± 7.8 and 54.6% were females. The median time interval between the first and follow-up colonoscopy was 59.9 (42.5–66.7) months for the LRA group and 41.8 (36.3–52.2) months for the HRA group. The risk of MAN was 3.8% in individuals with no baseline adenomas; 4% with LRA; and 9.2% with HRA. The risk of MAN in individuals with >3 non-advanced adenomas was 6.3%; 6.1% with 3–4 and 7.4% with >5 non-advanced adenomas (Table 1). On multivariable analysis, the risk of MAN was not different between HRA and LRA based upon the number of non-advanced adenomas: >3 [OR 1.6, (0.7, 3.9)]; 3–4 [OR 1.6, (0.61, 4.0)] and >5 non-advanced adenomas [OR 2.2, (0.27, 17.0)] (Table 2).

CONCLUSION:
In the contemporary era of HD colonoscopy, compared to LRA patients, patients with ≥3 non-advanced adenomas are not at increased risk of MAN including patients with 3–4 and ≥5 non-advanced adenomas. These data support a longer colonoscopy interval (>5 years) in these individuals.
243  An Interim Analysis of a Patient Navigation Program (PNP) to Improve Colonoscopy Access After Abnormal FIT
Authors: Idos Gregory , Herman David , Haghighat Shida , Gainey Christina , Shen Stacy , Mulgaonkar Ashwini , Dea Stanley 
Published: October 2019

INTRODUCTION:
Colorectal cancer (CRC) is a leading cause of cancer mortality despite being largely preventable. The fecal immunochemical test (FIT) is a recommended screening method, but timely evaluation of abnormal results is critical to the effectiveness of CRC screening. Recent studies indicate low rates of follow up colonoscopy after abnormal FIT within safety net health systems. A patient navigator program (PNP) is an evidence based strategy that has been shown to improve colonoscopy completion. The aim of this study was to evaluate the effectiveness of a PNP to encourage follow up colonoscopy after abnormal FIT within a large safety net hospital system.

METHODS:
We established an enterprise-wide PNP at five tertiary care hospitals within the Los Angeles County Department of Health Services (LAC-DHS) system. Patients 50–75 years of age with an abnormal FIT result were assisted by the PNP to complete their follow up colonoscopy within 6 months. Here we perform an interim analysis of a prospective cohort of patients from June 1, 2018 to December 31, 2018 assisted by the PNP. We compare the effectiveness of the PNP intervention by comparing colonoscopy rates to a period prior to the intervention. We also summarize the endoscopic findings of patients undergoing colonoscopy.

RESULTS:
Among 1217 patients with abnormal FIT results, 43% (n = 546) were men with a mean age of 60.3 ± 6.2 years. From a previous baseline of 167 days (SD 118), the mean time from abnormal FIT to colonoscopy improved to 117 days (SD 53) with navigation. The frequency of colonoscopy completion increased in patients who received navigation (53%, n = 642) as compared to patients who did not receive navigation (40.5%, 492/1213). Among PNP patients undergoing colonoscopy (N = 642), 50.2% (n = 322) had adenomatous polyps, 24% (n = 156) had “high risk” adenomas, and 2% (n = 12) had CRC.

CONCLUSION:
After the introduction of a patient navigator program, there was an overall increase in patients undergoing follow-up colonoscopy after abnormal FIT within a shorter time interval. Over half of the patients undergoing colonoscopy were found to have clinically significant findings including high risk adenomas and CRC. In this interim analysis, we demonstrate that the integration of a patient navigator program for CRC screening may be instrumental in increasing adherence to recommended screening guidelines across a large safety net health system.