bluuebunny/crossref_metadata_2025_split huggingface dataset:
573 Safety of Esophagogastroduodenoscopy in Patients With Active Cocaine Use: A Pilot Study
Authors: Nguyen Alexander , Desai Parth M. , Yap John , Yu Jie , Kotwal Vikram , Attar Bashar M. 
Published: October 2019

INTRODUCTION:
The timing of when to perform endoscopy in patients with a positive cocaine urine drug screen (UDS+C) varies across institutions and is based on expert opinions and personal experience. There are no clear published guidelines or reported studies in the English literature examining the safety of endoscopy in active users of cocaine. This study aimed to describe the incidence of adverse events of esophagogastroduodenoscopy (EGD) in patients with active cocaine use in a single inner-city tertiary hospital in Chicago.

METHODS:
We examined consecutive records of patients who underwent an EGD at the John H. Stroger, Jr. Hospital of Cook County from October 2016 to October 2018 and identified those who had a UDS + C within 4 days. We examined the demographics and outcomes of these patients including pre- and post-procedure hemodynamics. Paired T-tests were used to analyze the periprocedural hemodynamics.

RESULTS:
A total of 2122 patients were identified during the study period of which 129 patients had a positive urine drug screen and 50 had a UDS + C. From these patients, we identified 20 who had a UDS + C within 4 days of an EGD. These active users were predominately male (n=16) and African-American (n = 14). The majority underwent urgent procedures (n=16) in an inpatient setting (n = 19). The average time since a UDS + C was 2.3 days (SD ± 1.26). 8 patients were ASA class II and 12 were ASA class III. 14 patients underwent monitored anesthesia care (MAC) sedation and 6 underwent general anesthesia. 12 patients had abnormal electrocardiograms. The most frequent comorbidity was concurrent drug or alcohol abuse (n = 14) followed by hypertension (n = 7). There were no adverse endoscopic or anesthesia events, but 3 patients had transient procedural events (1 with oxygen desaturation and 2 with hypotension). Pre- and post-procedure hemodynamics were within normal ranges and blood pressure showed a statistically but not clinically significant decrease from a mean of 136/79 mmHg to 129/77 mmHg (P < 0.05).

CONCLUSION:
No major adverse events occurred in the active cocaine users undergoing EGD in our retrospective single center study. The decrease in blood pressure in our study was statistically but not clinically significant. Our study suggests that EGD with anesthesia support appears to be safe in patients with active cocaine use. More studies with larger sample sizes are needed to confirm these findings and further guide the safety and timing of endoscopy in cocaine users.
652 Ustekinumab Intravenous Reinduction Therapy Is Effective at Recapturing Response in Patients With Crohn's Disease
Authors: Hudson Joshua , Barnes Edward L. , Herfarth Hans 
Published: October 2019

INTRODUCTION:
Ustekinumab is a monoclonal antibody used in the treatment of Crohn's Disease that acts as an antagonist to interleukin-12 and interleukin-23. It is administered as a single intravenous infusion followed by subcutaneous maintenance dosing. There is paucity of literature evaluating the efficacy of repeating an intravenous infusion to recapture response among patients experiencing secondary loss of response to ustekinumab. We report on a cohort of patients who received a second intravenous ustekinumab loading dose after secondary loss of response at a large, academic IBD center.

METHODS:
We performed a retrospective cohort study of patients, who lost response to ustekinumab after initial intravenous standard induction followed by subcutaneous maintenance therapy and received a second intravenous ustekinumab loading dose following the standard weight-based dosing recommendations. We analyzed clinical and demographic characteristics of this patient population, including phenotype, prior therapies, and the efficacy of ustekinumab after the second infusion, including the subsequent maintenance dose after the second infusion. Response was defined as resolution or improvement of clinical symptoms that led to a second intravenous infusion.

RESULTS:
Among 372 patients treated with ustekinumab between 2016 and 2019, 18 (5%) patients received a second intravenous loading dose after experiencing secondary loss of response to their initial standard intravenous regimen. These patients had all failed prior biologic therapy and were placed on ustekinumab as second line (22%), third line (27%), fourth line (33%), fifth line (6%), or sixth line therapy (11%). After the second intravenous re-induction clinical response was observed in 15 patients (83%), whereas 3 (17%) patients did not respond and ustekinumab was stopped. Clinical and demographic characteristics of patients receiving a second loading dose are shown in Table 1. Among the 15 patients remaining on ustekinumab, 5 (33%) continued every 8-week dosing, 6 (40%) utilized every 6-week dosing, and 4 (27%) required every 4-week dosing regimens.

CONCLUSION:
A second intravenous ustekinumab loading dose is an effective strategy to recapture the therapeutic efficacy of ustekinumab after secondary loss of response. In addition, our data suggests that escalation in dosing frequency of maintenance subcutaneous therapy after a second intravenous loading dose should be considered for an ongoing durable response to ustekinumab.
688 Probability of Vedolizumab Response as Defined by Clinical Decision Support Tool Is Associated With Lower Risk of Serious Infection in Patients With Inflammatory Bowel Disease
Authors: Dulai Parambir , Feng Ding , Lasch Karen 
Published: October 2019

INTRODUCTION:
Disease activity is an independent predictor of infection in patients receiving biologics; non-response to a therapy might therefore present a higher risk of serious infection due to persistence of disease activity. We hypothesized that a clinical decision support tool (CDST) predicting lower treatment response may be predictive of a higher risk of infection.

METHODS:
Two validated CDSTs predicting vedolizumab (VDZ) response in ulcerative colitis (UC) and Crohn's disease (CD) were used on GEMINI phase 3 clinical trial data. After stratification by baseline variables into low, intermediate, or high probability of response to VDZ, time-to-event with Cox proportional hazard models was used to compare the risk of infection across groups and to identify independent predictors of infections among subgroups.

RESULTS:
618 UC and 1023 CD patients were included. Those categorized as having low-intermediate probability of response (n = 479 UC, n = 814 CD) to VDZ were more likely to develop infectious complications while on therapy than those categorized as having high probability (n = 139 UC, n = 209 CD) response to VDZ (UC: hazard ratio [HR] 1.383, 95% confidence interval [CI] 1.024−1.868; CD: HR 1.458, 95% CI 1.124−1.893). Serious infections were observed in 1% of UC and 3% of CD patients in the high probability of response groups vs 2% of UC and 5% of CD patients in the low-intermediate groups. Among the low-intermediate probability of response UC group, independent predictors of developing infection were: baseline extraintestinal manifestations (no vs yes; HR 0.755, 95% CI 0.569−1.001); previous tumor necrosis factor antagonist exposure (no vs yes; HR 0.671, 95% CI 0.497−0.906); and baseline fecal calprotectin (log transformed; HR 1.135, 95% CI 1.016−1.268). Among the low-intermediate probability of response CD group, an independent predictor of developing infection was exposure to opioids during treatment (yes vs no; HR 1.829, 95% CI 1.469−2.277).

CONCLUSION:
This analysis confirms a pattern of inverse correlation between CDST-predicted efficacy and risk of infection. Data are consistent with the VDZ safety profile and suggest that infectious events seen were related to persistence of disease activity as opposed to drug-related mechanisms.
733 Leukocyte Ratios in Adults 20-70 Years Old With Inflammatory Bowel Disease in the United States Population: NHANES 2009-2010
Authors: Ndulue Chidozie , Obiajunwa Chiagoziem , Ndulue Jideofor 
Published: October 2019

INTRODUCTION:
To assess the association between neutrophil to lymphocyte ratio (NLR), lymphocyte to monocyte ratio (LMR) and neutrophil to monocyte ratio (NMR) in adults 20-70 years old with inflammatory bowel disease (IBD) using a nationally representative database of the United States population.

METHODS:
Analysis was performed on 4,739 persons aged 20-70 years from the 2009-2010 National Health and Nutrition Examination Survey (NHANES) who responded to the question “has a doctor or health professional ever told you that you have ulcerative colitis or crohns disease. Participants with a diagnosis of cancer were excluded in the analysis. Mean values of neutrophils (N), lymphocytes (L), monocytes (M) and their ratios were compared between groups of participants with and without inflammatory bowel disease.

RESULTS:
There was no significant difference in NLR and LMR between participants with and without inflammatory bowel disease. Compared with participants without IBD, participants with IBD had a higher NMR (7.95 95%CI: 7.80, 8.09 vs 8.84, 95% CI: 7.91, 9.76).

CONCLUSION:
A high NMR might be effective, readily available and low-cost biomarker for assessment of people with inflammatory bowel disease. Further studies are needed to clarify the difference in NMR between people with and without IBD.
835 Can Ustekinemab Relieve the Symptoms of IBD-Associated Arthropathy?
Authors: Vizuete John A. , Randall Charles W. , Martinez Nicholas 
Published: October 2019

INTRODUCTION:
Arthropathy is the most common extra intestinal manifestation observed in patients with Inflammatory Bowel Disease (IBD). Various studies have shown that up to 40% or more of patients with IBD may experience arthropathy. Ustekinemab is a relatively new drug approved for the management of moderate to severe Crohn’s disease (Oct 2016) and phase 3 trials for ulcerative colitis have now been completed. It is also FDA approved for management of psoriatic arthritis. The purpose of this study was to determine if a small cohort of patients with enteroarthropathy had symptom improvement while receiving ustekinemab in a longitudinal retrospective cohort.

METHODS:
Adult patients with IBD and arthropathy with who were treated with ustekinumab were included in the cohort. We followed the minimal disease activity index (MDA) which includes 7 broadly accepted parameters. We chose to collect data on 5 of those parameters including 1) joint tenderness, 2) swollen joint count, 3) tender points, 4) standardized graphic pain scales (VAS or GRS), and 5) a global assessment score from 0-5 (GAS). Two parameters (psoriatic area and severity index and health disability index) were not assessed. At each visit outcome measures were evaluated for changes in arthritic symptoms.

RESULTS:
15 patients were included for review. 11 had Crohn’s disease and 4 had ulcerative colitis. Patients were followed for an average of 12 months (range 9-16). Eleven of 15 patients had joint tenderness on palpation at the start of therapy with 1 to 3 affected joints per patient while the others had subjective tenderness. Five patients had visibly swollen joints and 1 had both. The mean GAS was 3 with a range of 2 to 4. The pain GRS had a mean score of four out of 10 with a range of 2 to 8. The mean number of tender points was 3. After ustekinumab therapy, 14 of 15 patients had a drop in the global assessment score and the pain GRS score. Fourteen patients had resolution of joint swelling and tenderness. At the conclusion of the study, 6 of 15 patients complete resolution of all five scales. Four patients had resolution in three of the five scales, while 4 patients had resolution of two of the five scales. 1 patient did not exhibit improvement in any area.

CONCLUSION:
In this small observational cohort, ustekinumab improved arthropathy in 14 of 15 patients. We hope this stimulates interest in trials observing larger number of patients with this debilitating extra international manifestation of IBD.
869 A Comparison of ERCP Outcomes Between High Volume and Low Volume Centers
Authors: Hudhud Dania , Al-Obaid Lolwa , Enezate Tariq 
Published: October 2019

INTRODUCTION:
Endoscopic Retrograde Cholangiopancreatography (ERCP) is a commonly performed procedure for simultaneous diagnosis and treatment of biliary disease, which has several potential post-procedural complications. Few studies have addressed the association between hospital ERCP volume and post procedural complications. This study aims to examine the difference in the rate of post ERCP complications between high and low volume centers.

METHODS:
The study population was extracted from the 2016 Nationwide Readmissions Database using International Classification of Diseases, Tenth Revision, and Clinical Modification/Procedure Coding System for ERCP and in-hospital outcomes. Centers that performed > 200 ERCPs during the year of 2016 were considered high-volume, whereas centers that performed < 200 ERCPs were considered low-volume. Study endpoints included in-hospital all-cause mortality, length of hospital stay (LOS), post ERCP pancreatitis, and infection rates.

RESULTS:
A total of 137,825 ERCPs were identified, of which 39.8% were diagnostic ERCPs while 60.2% were therapeutic ERCPs. The mean age of patients was 59.7 years. 56.9% of the study population were female. High-volume centers performed 54,640 procedures while low-volume centers performed 83,185 procedures. In regards to complications, high-volume centers compared to low-volume centers, had a significantly higher rate of all-cause mortality (1.9% vs 1.4%, P < 0.01), post-op pancreatitis (7.0% vs 6.2%, P < 0.01), post-procedural infection (0.7% vs 0.5%, P < 0.01), and LOS (6.7 days vs 5.9 days, P < 0.01). This pattern was consistent for ERCP procedures performed for both diagnostic and therapeutic purposes, with the exception of similar rates of post-procedural pancreatitis associated with ERCP performed for diagnostic purposes in both high and low volume centers.

CONCLUSION:
In this preliminary analysis of a large database, hospitals with high ERCP volume were associated with a higher rate of complications including post procedural in-hospital mortality, morbidity, and length of stay. While procedural technique and operators vary amongst centers, we hypothesize that the higher rate of complications seen in patients being treated at high volume centers may, in part be due to a higher complexity in patients been seen at high volume centers.
1128 Effect of Sleeve Gastrectomy on Ghrelin, GLP-1, PYY, and GIP Gut Hormones: A Systematic Review and Meta-Analysis
Authors: McCarty Thomas R. , Jirapinyo Pichamol , Thompson Christopher C. 
Published: October 2019

INTRODUCTION:
Despite sleeve gastrectomy becoming the most common surgical weight loss procedure, weight loss mechanisms remain less clear. The primary aim of this study was to perform a structured systematic review and meta-analysis of all eligible studies to evaluate changes in various gut hormone levels in patients following sleeve gastrectomy.

METHODS:
Searches of PubMed, EMBASE, Web of Science, and the Cochrane Library databases were performed through April 1, 2019 in accordance with PRISMA and MOOSE guidelines. Measured outcomes included pre- and post-operative hormones: fasting ghrelin, post-prandial glucagon-like peptide-1 (GLP-1), post-prandial peptide YY (PYY), and fasting gastric inhibitory peptide (GIP) levels. Hedge’s g was used to determine pooled effect size and corresponding 95% confidence intervals (CIs). Heterogeneity was assessed with Cochran Q test and I
2 statistics. Study quality was evaluated with the Newcastle-Ottawa Quality Assessment Scale (NOS) score for observational studies and JADAD score for randomized controlled trials. Publication bias was evaluated by funnel plot using Egger and Begg tests.

RESULTS:
A total of 28 studies (n = 653; 29.56% male) were included. Mean age was 42.00 ± 5.48 years with average follow-up of 11.70 ± 11.38 months. Pre-procedure BMI was 46.01 ± 4.07 kg/m2 with a post-sleeve gastrectomy BMI of 34.07 ± 3.73 kg/m2 (%EWL 57.48 ± 9.64). Ghrelin decreased [Hedge’s g of -1.486 (95% CI, -1.884 to -1.089); I
2 = 91.95%; Q-value of 310.57] while GLP-1 and PYY increased post-procedure [Hedge’s g of 1.095 (95% CI, 0.509 to 1.642); I
2 = 84.38%; Q-value of 70.43) and Hedge’s g of 1.396 (95% CI, 0.781 to 2.011); I
2 = 84.02%; Q-value of 62.59), respectively]. GIP did not significantly change [Hedge’s g of -0.213 (95% CI, -1.019 to 0.592; I
2 = 79.65%; Q-value of 4.92]. Baseline characteristics as stratified by individual gut hormone are shown in Table 1. Quality assessment revealed all studies to be of high quality (i.e., NOS score ≥4 or JADAD score of ≥3). Classic fail-safe determined it would take 2044, 244, and 248 non-significant studies to nullify the difference in gut hormone levels for ghrelin, GLP-1, and PYY, respectively.

CONCLUSION:
Ghrelin levels decrease while post-prandial GLP-1 and PYY increase after sleeve gastrectomy. GIP levels remain unchanged. Future studies are needed to assess the role of these gut hormones and relationship to weight loss and metabolic outcomes. These results may have the potential to optimize patient selection in an era personalized medicine.
1311 Acute Pancreatitis in a Patient Using Liraglutide for Weight Loss
Authors: Fatakhova Karina , Rahman Ali , Al-Naqeeb Ghadah , Al Yassin Sarmed , Alqaisi Sura , Ramdass Adesh 
Published: October 2019

INTRODUCTION:
Liraglutide is a GLP -1 agonist, a class of type two diabetes mellitus injectable treatments, which has shown benefits of controlling blood glucose levels with a minimal risk of hypoglycemia. Liraglutide delays the movement of food from the stomach into the small intestine which causes early satiety and a decrease in appetite.

CASE DESCRIPTION/METHODS:
A 40-year-old female presented to the emergency department with a two-day history of acute onset of sharp epigastric pain radiating to the back associated with nausea. The lipase level was elevated at 1,595 U/L and triglycerides were normal. Upon further evaluation, right upper quadrant ultrasound revealed cholelithiasis. CT abdomen and pelvis revealed cholelithiasis without evidence of cholecystitis. Magnetic Resonance Cholangiopancreatography (MRCP) showed gallstones and mild gallbladder wall thickening. There were no signs of pancreatic ductal dilatation or mass lesions. The patient's medical history was significant for obesity, hypertension and asthma. Liraglutide injections were started four weeks prior to her presentation for weight loss. She denied any history of pancreatic disease, alcohol use, tobacco use or herbal supplementations. The patient medications were significant for lisinopril and pantoprazole.

DISCUSSION:
In 2014 liiraglutide has been approved by the Food and Drug Administration (FDA) for weight loss at a higher dose. In the phase III trials Liraglutide Effect and Action in Diabetes (LEAD), liraglutide was shown to have a substantial decrease not only in hemoglobin A1C over a placebo, but in weight reduction as well. Since its use for weight loss, there have been concerns for acute pancreatitis. Acute pancreatitis is an inflammatory disease of the pancreas. Etiologies most commonly include gallstones or alcohol use. In cases where there is no history of alcohol use or obstructive gallstone disease it is imperative to search for alternative causes. In the case we presented, the patient underwent MRCP which did not reveal signs of pancreatic ductal obstructions. A careful review of her medical history and medications did not provide any risk factors for developing pancreatitis except for liraglutide injections for weight loss. The possibility of autoimmune or viral acute pancreatitis was ruled out. Liraglutide has been reported to cause acute pancreatitis. It has been suggested that it is more common to develop acute pancreatitis while on liraglutide in patients who have a history of pancreatitis or gall bladder disease.
1487 Vedolizumab-Induced Remission of Refractory Microscopic Colitis: A Single Institution Case Series
Authors: Perry Courtney , Pekez Marijeta , Kudaravalli Praneeth , Hashim Mahmoud , Akanbi Olalekan , Yarra Pradeep , Barrett Terrence 
Published: October 2019

INTRODUCTION:
Microscopic colitis (MC) is a chronic inflammatory disease of the colon that is responsible for up to 10-15% of chronic watery diarrhea (Cotter TG, Binder M, Loftus EV, et al. Gut 2018). While this disease is often self-limiting, some patients suffer from severe disease that can be refractory to standard medical therapies, such as Imodium and budesonide. These patients are often referred to tertiary care facilities for initiation of anti-tumor necrosis factor agents (anti-TNFs) as they have shown some benefit in refractory disease. However, a significant side effect profile does accompany these agents which can make their use less desirable. Vedolizumab, a monoclonal human antibody to α4β7-integrin that blocks lymphocyte trafficking to the gut, has an excellent safety profile (Battat R, Ma C, et al. Drug Safety 2019) and is an appealing option for patients with severe refractory MC.

CASE DESCRIPTION/METHODS:
Three patients presenting to the University of Kentucky with severe microscopic colitis refractory to maximum budesonide and Imodium therapy were treated with vedolizumab. Vedolizumab was given at standard induction dosing (300 mg IV at week 0, 2 and 6, and then every 8 weeks). Clinical remission was defined as <3 stools a day following induction of vedolizumab with ability to wean budesonide.

DISCUSSION:
All three patients had remission of their MC as evidenced by cessation of diarrhea and ability to wean budesonide and Imodium after induction vedolizumab, including one patient who had suffered from microscopic colitis for over 20 years. This case series supports the small number of case reports that have surfaced in publications over the past 18 months, the largest of which consisted of 11 patients. While the definitive mechanism of microscopic colitis remains unknown, one of the proposed mechanisms details activation of CD8 T suppressor cells in the IEC and NF-ƙβ pathway activation leading to tissue damage in epithelial cells and barrier dysfunction (Gentile N, Yen E. Gut Liver 2018). The efficacy of vedolizumab in inducing MC remission supports this proposed mechanism, given its mechanism of action to bind α4β7-integrin and prevent T-cell adhesion. Larger scale clinical trials are needed to support routine clinical use of vedolizumab in refractory microscopic colitis, but this drug presents a promising, low-side effect profile treatment option for MC suffers.