bluuebunny/crossref_metadata_2025_split huggingface dataset:
599 Assessing Adherence to ACG Guidelines on Restarting Low-Dose Aspirin After Upper Gastrointestinal Bleed Secondary to Ulcers
Authors: Wu Yi-Chia , Kim Urian , Chuang Philip , Rogers Steven 
Published: October 2019

INTRODUCTION:
American College of Gastroenterology (ACG) guidelines in 2012 recommend that if low-dose aspirin (LDA) is used as secondary prophylaxis then LDA should be restarted as soon as possible with daily proton pump inhibitor (PPI) therapy in patients who achieve hemostasis after an upper gastrointestinal bleed (UGIB) secondary to an ulcer. It is not recommended to restart LDA for primary prophylaxis.

METHODS:
Retrospective chart review was performed on patients at our hospital center, Mount Sinai Beth Israel, who required an esophagogastroduodenoscopy (EGD) for UGIB secondary to ulcers during a hospital stay from February 2012 to December 2018. Patients were included if they were on LDA prior to EGD intervention. The percentage of included patients who were on LDA for primary prophylaxis and discontinued on discharge was calculated. The percentage of patients who were on LDA for secondary prophylaxis and restarted on LDA at discharge was calculated to assess the level of adherence to the guidelines. Subgroups within the secondary prophylaxis LDA group were also evaluated for adherence with chi-square tests to determine significance.

RESULTS:
155 patients who met the inclusion criteria were reviewed. The mean age was 73 years. Females (67, 43%). Caucasian (52, 33.6%), African American (12, 7.7%), Hispanic (35, 22.6%), Asian (51, 32.9%). 40 patients were on LDA for primary prophylaxis and 115 for secondary prophylaxis. Of those on LDA for primary prophylaxis, 28 (70%) were not restarted on LDA at discharge. Of those on LDA for secondary prophylaxis, 59 (51.3%) were restarted on LDA at hospital discharge. There was no significant difference in the decision to restart secondary prophylaxis LDA on discharge based on gender (P = 0.36) or race (P = 0.69). Additionally, there was no significant difference based on whether patients were taking another anticoagulant (P = 0.78), needed a second EGD (P = 0.09), required endoscopic hemostasis intervention (P = 0.71), or were indicated to receive blood transfusions (P = 0.83).

CONCLUSION:
This study showed that only about half of ulcer-related UGIB subjects on LDA for secondary prophylaxis were restarted on LDA and 70% on LDA for primary prophylaxis were not restarted on LDA at discharge based on suggested ACG guidelines at our institution. The decision to restart secondary prophylaxis LDA was independent of age, gender, and severity of gastrointestinal bleed. Therefore, greater awareness and education among hospital physicians is needed to improve adherence rates.
604 Outcomes of Long-Term Follow-Up in Patients With Iron Deficiency Anemia and Initial Negative Upper Endoscopy, Colonoscopy, and Video Capsule Endoscopy
Authors: Likhtshteyn Michelle , Arroyo-Mercado Fray Martin M. , Noel Jude , Chokshi Tanuj , Gupta Nikita , Aytaman Yasemin , Khudyakov Aleksandr , Lerer Renata , Grossman Jennifer , Tabone Sabrina , Frank David M. , Martinez Manuel 
Published: October 2019

INTRODUCTION:
Iron Deficiency Anemia (IDA) occurs in 2-5% of adults and requires workup including upper esophagogastroduodenoscopy (EGD) and/or colonoscopy.1 However, in 10-41% of patients a source of bleeding is not identified,2–5 which requires investigation of the small bowel using video capsule endoscopy (VCE). This study aims to determine the long-term outcomes in patients with IDA and a pan endoscopy-negative IDA, which entails negative EGD, colonoscopy and VCE.

METHODS:
Medical records at the VA NY Harbor were queried for patients with IDA and having an EGD, colonoscopy, and VCE between 2005-2015. Anemia was defined as hemoglobin less than 13 g/dL in men and 12 g/dL in women; IDA was confirmed using serum ferritin less than 100 ng/mL. Exclusion criteria included underlying causes for IDA such as pre-menopausal women or history of ulcerative colitis. Biographical, laboratory and endoscopic data were obtained. Baseline hemoglobin and ferritin levels were recorded, and subsequently followed at 1, 3, and 6-year intervals.

RESULTS:
A total of 7,000 records were reviewed, 311 patients had EGD, colonoscopy and VCE; 67 of these patients were excluded. Of the remaining patients, 99 patients (13 females, 86 males) had a negative initial workup and were included in analysis. The mean age was 68.2 (±11.1). IDA resolved in 37 (37.4%) patients, 49 (49.5%) patients had persistent anemia, and 13 (13.1%) patients had recurrent anemia. Of the 99 patients with negative workup, 80 (80.8%) patients went on to have subsequent EGD, colonoscopy or VCE. 62 (62.6%) patients had subsequent EGD with 12 (19.4%) patients having positive findings such as gastric ulcers. 64 (64.7%) patients had subsequent colonoscopies, 7 (10.9%) of these patients had positive findings such as chronically bleeding hemorrhoids. 18 (18.2%) patients had subsequent VCEs, and 5 (27.8%) of these patients had findings such as angioectasias.

CONCLUSION:
Our findings are consistent with previous reports suggesting that the majority of elderly patients who have an initial negative workup for IDA tend to have favorable outcomes. 21 of 80 patients (26.25%) had some findings on subsequent workup to explain IDA, however those findings were benign. In addition to previous published data, our study highlights the significance of VCE as a tool for identifying a bleeding source. Our study also emphasizes the need for randomized control studies to determine the optimal workup strategy for patients with initially negative bidirectional endoscopy and VCE.
618 The Use of Antibiotics Prophylaxis in Cirrhotic Patients Presenting With Gastrointestinal Portal Hypertensive Bleeding in a Community Teaching Hospital
Authors: Al Yassin Sarmed , Fatakhova Karina , Al-Naqeeb Ghadah , Glazer Emily , Haggerty Gregory , Tofano Michael , Eckardt Sarah 
Published: October 2019

INTRODUCTION:
Background: Bacterial infections are common in cirrhotic patients with acute gastrointestinal portal hypertensive bleeding, occurring in 20% within 48 hours. Outcomes including early re-bleeding and failure to control bleeding are strongly associated with bacterial infection. The use of short-term prophylactic antibiotics in patients with cirrhosis and GI hemorrhage with or without ascites has been shown not only to decrease the rate of bacterial infections but also to increase survival. This improved survival is partly related to a decrease in the incidence of early re-bleeding in patients with GI hemorrhage who receive prophylactic antibiotics. Therefore, short-term antibiotic prophylaxis should be considered standard practice in all patients with cirrhosis and acute variceal hemorrhage. The antibiotic of choice in most centers is intravenous Ceftriaxone at a dose of 1 g daily. Duration of antibiotic prophylaxis is short term, for 5-7 days (to be discontinued when hemorrhage resolve and vasoactive drugs discontinued).

METHODS:
300 charts were reviewed in retrospective data analysis for patients presented during 2017 and 2018 with cirrhosis related diagnoses and gastrointestinal bleeding related diagnoses. 43% (171 patients) of the presented patients had active cirrhosis.

RESULTS:
Anatomy and EGJ opening determine outcome in achalasia. Of those 171 patients: 17% (30 of 171) patients that have cirrhosis presented in 2017 and 2018 with gastrointestinal bleeding, 36% (11 out of the 30) patients received empiric antibiotics, whether as prophylaxis or for other indications such as sepsis,64% (19 out of the 30) patients, antibiotics were not started on admission; therapy started on the second or third day by gastroenterology service, or other service/team.

CONCLUSION:
Our results showed that the majority of patients (64%) with cirrhosis presenting with GI bleed were not started on a proper prophylaxis antibiotic. The ideas and the actions that were proposed and implemented post this study: Increase awareness through nursing and pharmacy staff teaching sessions, as well as residents didactic lectures. Also, through periodic awareness/teaching emails to medical staff. Hospital protocols were reviewed. A questionnaire step, “Warning window,” were integrated into the EMR, that to pop up when a medical provider add “liver cirrhosis” or “variceal hemorrhage” to patient admitting/visit diagnosis list. This intervention was implemented recently. In the next phase, we plan to gather data obtained post intervention, and to be studied and compared.
623 Impact of Hospital Teaching Status on the Outcomes of GI Bleeding Hospitalizations in the U.S.: Insights From the National Database
Authors: Elkafrawy Ahmed A. , Othman Hasan F. , Zafar Yousaf , Hasan Badar , Nehme Fredy , Numan Laith 
Published: October 2019

INTRODUCTION:
GI bleeding is a life-threatening GI emergency with a major burden for the health care system in the US. The aim of this study is to evaluate the impact of teaching status of the hospital on the outcomes of hospitalized patients with GI bleeding.

METHODS:
Nationwide Inpatient Sample database (NIS) was queried to identify patients hospitalized between 2006 and 2015 with GI bleeding using (ICD9-CM) codes. Patients were classified into 2 groups according to the teaching status of the admission hospital to either teaching or non-teaching hospitals. Both groups were compared regarding age, gender, race, mortality, undergoing GI endoscopy (EGD, small intestinal endoscopy, flexible sigmoidoscopy or colonoscopy), outcomes and commonly associated comorbidities. Statistical analysis was performed using SPSS V.25.

RESULTS:
We identified 8,211,580 patients admitted with GI bleeding between 2006-2015. Out of them, 3,826,532 patients were admitted to teaching hospitals while 4,385,049 patients were admitted to non-teaching hospitals. Median (IQR) age in patients admitted to teaching hospitals was 67 (53-79) years compared to 71 (56-81) years in non-teaching hospitals. 53.1% of patients admitted to teaching hospitals were males compared to 49.9% in the non-teaching hospitals. GI endoscopy was performed in 46.6% of patients admitted to teaching hospitals compared to 46.1% in non-teaching hospitals (95% CI 1.01, 1.02) (P < 0.001). Patients admitted to teaching hospitals had higher mortality (7.3%) compared to (6.1%) in non-teaching hospitals (95% CI 1.21, 1.22) (P < 0.001). The median length of stay was 4 days in both groups. Shock was present in 7.7% of patients admitted to teaching hospitals compared to 5.3% in patients in non-teaching hospitals (95% CI-1.46-1.48) (P < 0.001). 9.8% of patients with GI bleeding admitted to teaching hospitals were mechanically ventilated compared to 6.5% in non-teaching hospitals (95% CI 1.55-1.57) (P < 0.001). Blood transfusions were administered to 38.5% of patients admitted to teaching hospital compared to 41.9% of patients in non-teaching hospitals (95% CI 0.86-0.87) (P < 0.001).

CONCLUSION:
46% of patients with GI bleeding between 2006-2015 were admitted to teaching hospitals. Admission to a teaching hospital was associated with higher mortality, higher number of endoscopies, higher likelihood of shock and mechanical ventilation but less blood transfusion. Results likely indicate higher level of acuity and complexity of patients admitted to teaching hospitals.
630 Inpatient Capsule Endoscopy Does Not Lead to Increased Hospital Interventions in Stable Small Bowel Bleeding
Authors: Jen Henry , Al Sayah Leona , Sosa Daniel , Taub Erin , Monzur Farah 
Published: October 2019

INTRODUCTION:
Wireless capsule endoscopy is an important tool to evaluate for small bowel sources of bleeding when upper and lower endoscopies have been unrevealing. However its use as an inpatient test is controversial with some studies suggesting increased capsule retention, prolonged length of stay, and increased costs. We aimed to assess the yield of inpatient capsule endoscopy when hemoglobin stability or resolution of overt bleeding is achieved prior to capsule deployment.

METHODS:
We performed a retrospective study of 161 patients with suspected small bowel bleeding over a 3 year period. Primary outcome was inpatient endoscopic interventions in patients with positive capsule findings but stable precapsule hemoglobin or resolved overt bleeding. Other outcomes included length of stay, success of intervention, outpatient follow-up, rehospitalization, and capsule complications.

RESULTS:
A total of 119 of the 161 patients (79.9%) had positive capsule findings. Only 70 patients underwent subsequent endoscopic intervention prior to discharge. Even in patients with active bleeding seen, 15% were discharged without endoscopic intervention. Hemoglobin stability and resolution of overt bleeding prior to capsule deployment were found to be significant predictors of whether patients underwent intervention. Those who had a stable hemoglobin for 8, 24, and up to 48 hours prior to capsule deployment had significantly less endoscopic interventions prior to discharge (P = 0.0026). Additionally, patients with a stable precapsule hemoglobin had a significantly decreased chance of having an identified lesion with successful treatment on enteroscopy (P = 0.0097). Those who had resolution of overt bleeding prior to capsule deployment also had significantly less endoscopic interventions prior to discharge (P = 0.0036). However, those with a stable hemoglobin with positive capsule findings had higher rehospitalization rates with only 14% having follow-up outpatient enteroscopies. Overall capsule retention rate was 19%. Capsules extended length of stay by an average of 1.7 days with 45% of patients discharged within 48 hours of capsule read.

CONCLUSION:
Inpatient capsule endoscopy extends length of stay with high retention rates without changing in-hospital endoscopic management of patients with small bowel bleeding who have achieved hemoglobin stability and resolution of overt bleeding prior to capsule deployment. These patients however tend to have higher rehospitalization rates and require close outpatient follow-up.
636 Hyperbaric Oxygen Therapy Is Effective in the Treatment of Inflammatory Disorders of the Ileal Pouch
Authors: Fahad Hamna , Shen Bo , Kochhar Gursimran 
Published: October 2019

INTRODUCTION:
Inflammatory disorders of ileal pouch-anal anastomosis (IPAA) including chronic pouchitis, Crohn's Disease (CD) of the pouch and cuffitis are common and their management can be challenging. Hyperbaric oxygen (HBO) has been used for the treatment of ulcerative colitis (UC) and CD; however, its use in pouchitis has not been systemically evaluated. The aim of our study was to assess the response to HBO therapy in patients with inflammatory diseases of the pouch.

METHODS:
In this retrospective case series, we included all patients above the age of 18, with history of IPAA and medically refractory pouchitis. HBO was executed with standard protocol with 2.4 to 3.0 PSI with a total of 30 sessions over 2 months. A modified Pouchitis Disease Activity Index (mPDAI) was used to quantify symptom and endoscopy sub-scores. The Wilcoxon Signed Rank test was used to compare the results. A P value of < 0.05 was taken to be significant.

RESULTS:
A total of 21 patients were included in the study, 52.4% (n = 11) of these were males. The mean age of our sample was 40.4 ± 12.3 years. The indications of HBO were pouchitis (n = 18), fistulae (n = 9), surgical site/anastomotic ulcers (n = 7), active cuffitis (n = 6), ischemic ulcers (n = 4); most patients had more than one indication (Table 1). Thirteen patients (61.9%), reported subjective symptomatic improvement in stool frequency, bleeding, urgency and fevers. Of these, six patients (28.5%) reported complete remission of symptoms (Figure 1). Seventeen patients (80.9%) had endoscopic improvement. Among these 2 (10%) showed endoscopic remission (Figures 1 and 2). Of the 9 patients who had fistulae, 7 (77.8%) showed healing of the fistula tract. Overall, 19 (90.5%) patients had improvement in their mPDAI. Mean mPDAI of our cohort prior to therapy was 8.71. Of those who showed response, the mPDAI improved by a median of 3 (IQR 2-3) points. No side effects were seen in our cohort. The mean mPDAI was significantly better after HBO therapy (P < 0.05).

CONCLUSION:
Hyperbaric oxygen therapy led to symptomatic and endoscopic improvement, as noted by the mPDAI, in majority of patients. Most patients with fistulae had significant endoscopic improvement.
646 Molecular Response to Ustekinumab in Moderate-to-Severe Ulcerative Colitis by Serum Protein and Colon Transcriptomic Analysis: Results From the UNIFI Phase 3 Maintenance Study
Authors: Li Katherine , Yang Feifei , Hayden Karen , Strawn David , Wadman Eric , Bhagat Sunita , Marano Colleen , Friedman Joshua R. 
Published: October 2019

INTRODUCTION:
The cytokines IL-12 and IL-23 are elevated in ulcerative colitis (UC), and genetic association suggests they play causative roles in the disease. Ustekinumab (UST), an anti-IL-12p40 monoclonal antibody that binds both cytokines, is an effective therapy for moderate-to-severe UC. We previously observed a partial normalization of UC disease signatures in colonic biopsy gene expression and serum protein levels following UST induction therapy. However, the molecular effects of maintenance UST therapy in UC pts are unknown.

METHODS:
We evaluated the molecular effects of UST in the UNIFI Phase 3 maintenance study of moderate-to-severe UC (n = 961). Pts in response to UST 8 wks after intravenous induction were randomized to maintenance treatment with subcutaneous placebo or UST 90 mg q12w or q8w. Colonic biopsy mRNA and serum samples from the first ∼60% of pts treated in the UNIFI phase 3 induction study were analyzed, with equal representation of pts with or without a history of biologic therapy failure (Table 1). Biopsy and serum samples from healthy pts were analyzed as controls.

RESULTS:
At Wk44 after the start of maintenance therapy, expression of colonic genes dysregulated in UC was altered towards normal levels in all treatment groups, with the greatest improvements among those receiving UST and those in clinical remission (P < 0.05 for Wk 44 versus start of maintenance). No dose effect was observed between q8w and q12w UST doses, and no significant improvements in disease signature occurred in non-responders to placebo or UST. UST maintenance therapy magnified the normalization of serum proteins following UST induction; among pts receiving q8w UST who were in remission at Wk44, the proteins IFNγ, IL-17A, MMP3, and SAA reached concentrations comparable to those seen in healthy controls. Similar trends occurred in pts in remission following q12w UST and to a lesser degree among UST-treated pts not in remission at Wk44. Among pts receiving placebo maintenance therapy who were in remission at Wk 44, the disease-associated serum proteins that decreased following UST induction were not further reduced during maintenance. As previously observed in the induction studies, UST maintenance did not reduce serum TNF levels.

CONCLUSION:
UST maintenance therapy suppressed IL-12 and IL-23-related serum proteins and promoted normalization of the UC disease transcriptomic profile. These results provide insight into the molecular mechanisms associated with the efficacy of UST maintenance therapy.
650 The Effects of HIV Status on Complications and Outcomes in Patients With Inflammatory Bowel Disease: An Analysis Using the Nationwide Inpatient Sample Database
Authors: Shaikh Amjad , Patel Preet , Huynh James , Patel Pavan , Ahlawat Sushil 
Published: October 2019

INTRODUCTION:
The effects of HIV status on inflammatory bowel disease (IBD) has been described in the literature but has been limited in cohort size. Here, we examine data from patients with IBD and HIV in the Nationwide Inpatient Sample database over a 7-year period.

METHODS:
Data between 2008 and 2014 from the Nationwide Inpatient Sample database was extracted. Inclusion criteria for both groups included patients with a primary diagnosis of either Crohn's disease or Ulcerative colitis using International Classification of Diseases, 9th Revision codes. Exclusion criteria included all patients less than 18 years of age. Test group consisted of patients with a primary diagnosis of Crohn's disease or Ulcerative colitis and a concurrent diagnosis of HIV. In hospital mortality and complications including anemia, malabsorption, malnutrition, stenosis, obstruction, fistulas, abscesses, ulcers, perforations, and hemorrhage were compared between the two groups. Univariate and multivariate analyses were used to generate odds ratios. Multivariate analysis included age, gender, race, and calculated Elixhauser scores. Elixhauser Comorbidity scores predicting mortality and readmission were calculated based on weighted scores from 29 different comorbidities. Scores were compared between the two groups using univariate analysis.

RESULTS:
There were a total of 121835 patients with IBD and no HIV and 475 patients with IBD and HIV for hospitals in the United States between 2008 and 2014. There was no significant difference in hospital mortality between the two groups on univariate analysis (OR 0.5161, P = 0.5092). Of the complications studied, there was a significant difference for obstruction (OR 0.3447, P < 0.0001), ulceration (OR 1.97, p = 0.0063), and hemorrhage (OR 1.75, P = 0.0001) on univariate analysis. For the multivariate analysis, HIV status has a significant effect on anemia (OR 0.291, P = <0.001), malnutrition (OR 0.3, P = <0.001), obstruction (OR 0.411, P = <0.001), and hemorrhage (OR 1.47, P = <0.001).

CONCLUSION:
HIV status does not seem to have a significant effect on mortality, but appears to be protective against obstruction, anemia, and malnutrition. We suspect the immunocompromised status of HIV patients may lead to fewer bouts of acute inflammation, reducing the rates of complications. It may also be of interest to compare rates of procedures and interventions between the two groups to further explore potential differences.