bluuebunny/crossref_metadata_2025_split huggingface dataset:
1096 The Prevalence of Chronic Opioid and Benzodiazepine Use in Patients With Liver Cirrhosis: A Meta-Analysis and Systematic Review
Authors: Al Momani Laith , Alomari Mohammad , Sarmini Muhammad Talal , Nehme Fredy , Young Mark , Romero-Marrero Carlos 
Published: October 2019

INTRODUCTION:
Opioid and benzodiazepine use in cirrhotic patients is probably underestimated and results in a significant burden for both patients and the healthcare system. Recent epidemiologic studies reported an upward trend in the number of both prescriptions in this drug-sensitive patient population. This study therefore aimed to derive a robust prevalence estimate of chronic opioid and benzodiazepine use in patients with liver cirrhosis.

METHODS:
We performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through May, 2019 to identify all studies that evaluated the prevalence of either chronic opioid use or benzodiazepine use in patients diagnosed with cirrhosis. We included studies that presented event rates with a 95% confidence interval (CI) or presented the data sufficient to calculate the event rate with a 95% CI. Although the definition of chronic opioid use varied between the involved studies, more than 60 days of either opioid or benzodiazepine use per annum was considered ‘chronic’ in this meta-analysis. Statistical analysis was performed using the Comprehensive Meta-Analysis (CMA), Version 3 software.

RESULTS:
Seven studies with a total of 300472 patients with liver cirrhosis were included in the analysis of chronic opioid use with a pooled event rate of 34.7% (95% CI: 0.239 – 0.473) and a reported prevalence range of 22.3-64.7% among the included studies. (Figure 1) On the other hand, six studies with a total of 173127 patients with liver cirrhosis were included in the analysis of chronic benzodiazepine use with a pooled event rate of 15.9% (95% CI: 0.079 - 0.294) and a reported prevalence range of 7.9-37.1%. (Figure 2)

CONCLUSION:
Our results indicate that chronic opioid and benzodiazepine use are prevalent among patients with liver cirrhosis. This is clinically important as their use was shown to be associated with increased readmission rates, hepatic decompensation, and all-cause mortality. Physicians should be cognizant of the implications of prescribing these medications and consider pursuing other pharmacological and non-pharmacological forms of analgesia in this patient population.
1099 Epidemiology and Diagnostic Evaluation of Patients With Liver Abscesses at an Academic Hospital in Washington, DC
Authors: Cioffi Joseph H. , Siegel Marc 
Published: October 2019

INTRODUCTION:
Liver abscesses often requires a multidisciplinary approach involving infectious diseases (ID), radiology, gastroenterology (GI) and occasionally surgery. Since there are no clinical guidelines for liver abscess management, regional epidemiology is important to refine management of these infections. This study reviewed the epidemiology, source evaluation and management of patients with liver abscesses in Washington, DC.

METHODS:
We performed a retrospective review of patients diagnosed with liver abscesses at our institution from 2012 through 2018. We reviewed patient demographics, predisposing conditions, abscess microbiology, hospital care and post-discharge management.

RESULTS:
105 patients were identified (mean age 57.1 years old, 62.9% men). 57.1% were African American (AA), 22.9% Caucasian, 7.6% Hispanic, 7.6% Asian, and 4.7% other races. 42.9% of patients had underlying risk factors including diabetes (21.9%), inflammatory bowel disease (4.8%), human immunodeficiency virus (3.8%), intravenous drug use (3.8%) and trauma (8.6%). 18.1% had known intraabdominal cancers (7 colonic, 5 pancreatic, 3 duodenal, 3 cholangiocarcinoma, and 1 ovarian). All patients underwent computed tomography, 52.4% ultrasound, 18.1% magnetic resonance imaging, and 6.7% MRCP. Abscess intervention was performed in 73.3% of patients. 56.7% of abscesses were monomicrobial and 43.3% polymicrobial. Cultures grew primarily Gram negatives (43%), followed by Gram positives (36.8%), anaerobes (11.4%), yeast (6.1%), and parasites (2.6%) (Figure 1). Blood cultures were positive in 41.9% of cases. ID was consulted in 68.6% of cases, while GI in only 39%. 23 patients underwent an inpatient procedure (14 ERCPs, 9 colonoscopies) with AA patients having statistically more ERCPs (21.7% vs 2.2%, P < 0.01). A source was identified in 69.2% of cases, with 32.4% having a biliary source. Those >50 years old were significantly more likely to have biliary disease than those < 50 years old (38.9% vs 18.2%, P < 0.05). When no source was identified, only 21.9% (7/32 patients) had outpatient GI follow up for further evaluation.

CONCLUSION:
Liver abscesses remain relatively uncommon. GI is not consulted in the majority of cases. Of concern is that a significant number of patients have no etiology identified and the majority of these do not get an appropriate outpatient evaluation. More frequent inpatient GI consultation, particularly for patients with no identifiable source, should be considered.
1105 Tenofovir Disoproxil Fumarate (TDF) to Prevent Hepatitis B Transmission in Mothers With High Viral Load in a Real World U.S. Cohort
Authors: Gayam Vijay , Wang Dan , Chen Bryan , Pan Calvin Q. 
Published: October 2019

INTRODUCTION:
Maternal TDF treatment during the third trimester has been shown to reduce perinatal transmission of the hepatitis B virus (HBV) in highly viremic women in several RCTs. However, the data is limited on the effectiveness of TDF in the real-world setting. With this real-world study, we aimed to assess the efficacy and safety of TDF therapy for these mothers in a single center in the US.

METHODS:
All Hepatitis B e-antigen positive mothers with HBV DNA >6log10 copies/mL who received TDF in the third trimester and delivered from July 2010 to September 2018 were retrospectively analyzed. All infants received hepatitis B immunoglobulin and vaccination at birth and subsequently. Primary endpoints were the safety of TDF use and mother-to-child transmission rates. Secondary outcomes were maternal HBV DNA level suppression at delivery.

RESULTS:
Among the 75 patients enrolled, the mean (±SD) age of the patients was 30.47 ± 4.49 years, mean (±SD) gestational age was 37.87 ± 2.95 weeks, and the mean (±SD) treatment duration before delivery was 9.60 ± 3.36 weeks. A significantly lower level of the mean (±SD) serum HBV DNA was achieved at delivery vs. baseline (4.2 ± 1.2 vs. 7.6 ± 0.80 log10 copies/mL, respectively; P- < 0.01). Additionally, 80% (60/75) of mothers achieved HBV DNA < 6log10 copies/mL at delivery. The median (Interquartile range) alanine aminotransferase (ALT) level before treatment was 26 (20) IU/L, and at delivery was 27 (20) IU/L respectively. Vertical transmission rate among infants was 0%, and all infants were hepatitis B surface antigen negative between 28 -52 weeks after birth. Fatigue was the most common complaint reported by 52% (39/75) of mothers. No infants had a birth defect. On treatment, ALT flares were observed in 4.5% (6/75) of mothers.

CONCLUSION:
In this US cohort of real-world practice, TDF therapy for highly viremic mothers was well tolerated and reduced vertical transmission effectively. No severe adverse effects were reported in both mothers and infants. Our study supports the use of TDF treatment for highly viremic mothers in a real-world setting.
1135 What Causes Marginal Ulceration Following Gastric Bypass?
Authors: Duarte-Chavez Rodrigo , Martins Noel B. , Chaput Kimberly J. , Mehta Sagar V. , El Chaar Maher 
Published: October 2019

INTRODUCTION:
The obesity epidemic affects more than one-third of the USA adult population, and over 350 000 bariatric procedures are performed annually. While bariatric surgery results in long lasting weight loss and resolution of comorbidities, complications can occur after surgery. Marginal ulceration (MU) is the most common complication following Roux-en-Y gastric bypass (RYGB), with an incidence reported to be between 1-9%. The etiology of MU is largely unknown but is believed to be secondary to technical aspects of the surgery as well as local factors such as inflammation and underlying macro and microvascular damage.The objective of this study is to investigate non-surgical factors and comorbidities that may contribute to the incidence of MU based on a national database.

METHODS:
After Institutional Review Board exemption was granted, we retrospectively reviewed the National Inpatient Sample database from 2003 to 2011. ICD-9 codes were used to abstract data including RYGB for obesity, gastrojejunal (GJ) ulcer, Helicobacter pyloriinfection (HPI), use of NSAIDs, use of aspirin, diabetes, hypertension, obstructive sleep apnea (OSA) and smoking. We compared groups using chi-squared and unadjusted odds ratio (OR). Multivariate logistic regression analysis was performed to adjust for confounders

RESULTS:
34830 patients with GJ ulcer after RYGB for obesity were identified. In univariate analysis, OSA had the highest OR of all the variables (91.22), whereas aspirin use had the lowest (3.09). All the listed factors were associated with increased risk for MU (Table 1). During multivariate analysis, NSAID use had the highest OR (13.14) followed by HPI (5.08) and OSA (4.03). Aspirin use was not found to be associated with the development of MU in our multivariate analysis (Table 2).

CONCLUSION:
To our knowledge this is the largest study assessing the risk factors for MU after RYGB for obesity and the first to report that OSA strongly correlates with the presence of MU. Our analysis demonstrated that the most significant risk factors for development of MU were in decreasing order NSAID, HPI, OSA and Smoking. Studies using bariatric specific databases should examine the issue. Prospective studies are also required to determine if correction or optimization of these risk factors can prevent MU after RYGB.
1165 Improving the Accuracy of Health Maintenance Reminders in the Electronic Medical Record to Promote Adherence to Colonoscopy Surveillance Guidelines
Authors: Kishfy Louis , Dimino Jennifer , Borges Lawrence 
Published: October 2019

INTRODUCTION:
Health Maintenance (HM) reminders in the Epic electronic medical record (EMR) offer an opportunity to increase adherence to recommended colonoscopy surveillance intervals. However, HM reminders must be updated by providers with specific knowledge of surveillance guidelines, and providers must be comfortable using the HM functionality. This quality improvement initiative aimed to improve the rate at which gastroenterologists accurately update HM colonoscopy surveillance recommendations.

METHODS:
1,602 colonoscopies performed by 7 gastroenterologists at a single community hospital were tracked prospectively between April 2018–February 2019. For each colonoscopy, the gastroenterologist’s post-procedure surveillance recommendation was compared to the HM surveillance recommendation in the patient’s Epic EMR. Accuracy was defined as concordance between these two recommendations. After obtaining baseline data, group and individual performance rates were disseminated and the gastroenterologists underwent an educational intervention to improve familiarity with the HM functionality. Monthly HM accuracy rates were tracked for the subsequent 6 months. Accuracy rates in the post-intervention month and the last month of follow-up were compared to baseline using the student’s T-test.

RESULTS:
The baseline HM accuracy rate for the group was 69% overall and 56% for high-risk patients (defined as a recommended surveillance interval of ≤5 years). For the month immediately following the intervention, the overall accuracy rate rose significantly compared to baseline (86% vs 69% overall, P ≤ 0.001; 80% vs 56% for high-risk patients, P ≤ 0.001). However, for the last month of follow-up the overall accuracy rate had decreased back to baseline (70% vs 69%, P = 0.646). The high-risk accuracy rate in the last month remained significantly higher than baseline but had also declined (65% vs 56%, P = .008). Notably, 82% of discordant HM reminders recommended a longer surveillance interval than was clinically indicated.

CONCLUSION:
Sharing performance data and provider education can significantly improve the rate at which gastroenterologists accurately update colonoscopy HM surveillance intervals in the EMR. However, a single intervention is not sufficient to sustain this improvement over time. Repeated intervention is needed to ensure that HM surveillance intervals remain accurate, particularly since the majority of discordant HM reminders recommend a longer surveillance interval than is clinically indicated.
1171 National Burden of Gastrointestinal Tuberculosis: Insights From the Nationwide Inpatient Sample
Authors: Shah Ishani , Bhurwal Abhishek , Mehta Harsh , Kadkhodayan Kambiz 
Published: October 2019

INTRODUCTION:
Gastrointestinal tuberculosis (GI TB) is a rare and morbid extrapulmonary manifestation of TB. There is scant published data regarding the prevalence of GI TB. ThE aim of our study was to assess the overall burden of inpatient GI TB in the United States. We also looked at demographic characteristics, comorbidities and all-cause inpatient mortality among patients with GI TB.

METHODS:
All adults hospitalized with the diagnosis of either gastric TB or intestinal TB or both, during the years 2010 to 2014, were identified using the Nationwide Inpatient Sample (NIS). Patients with tuberculous associated peritonitis were also included. We studied racial, regional and gender-specific characteristics of these patients. Other demographic data such as risk factors and comorbidities were also identified. Outcomes of interest included inpatient mortality and length of stay.

RESULTS:
During the five-year study period, there were a total of 2,300 inpatient hospital admissions for GI TB. We observed a downward trend in the prevalence of GI TB in the US during this time (469 vs 340 vs 380 vs 329 vs 78; P = 0.56) (Figure 1). Patients affected were predominantly Hispanic (36.04% vs 53.99% vs 24.78% vs 30.17%; P = 0.002) in all four regions. Several other comorbidities and conditions were identified as enlisted in Table 1. The overall inpatient mortality (6.25% vs 1.20% vs 2.61% vs 3.24%; P = 0.206) and mean length of stay (18.11 vs 9.07 vs 10.56 vs 14.57 days; P = 0.001) were highest in the NE region as compared to MW, SO and WE regions. In addition, hospitalized patients with GI TB were less likely to be female in Northeastern (NE) states (30.91% vs 56.29% vs 51.64% vs 50.64%; P = 0.05) as compared to Midwest (MW), Southern (SO) and Western (WE) states.

CONCLUSION:
Since the introduction of antituberculous therapy, the global and national overall burden of GI TB has decreased significantly. It is, however, important to note that although rare, GI TB continue to affect high-risk patient populations such as immigrants, prisoners, HIV patients and patients who are immunocompromised from receiving various biologic agents for treatment of several autoimmune diseases. Our study shows that although prevalent, overall inpatient admissions associated with GI TB have been decreasing over the last few years; however they are associated with high mortality. Our study highlights continued prevalence of GI TB amongst inpatients in the US, and emphasizes the importance of clinical suspicion when evaluating high risk patients.
1174 Cases of Angiotensin Receptor Blocker (ARB) Related Sprue-Like Enteropathy (SE): A Review of the Food and Drug Administration Adverse Event Reporting System (FAERS)
Authors: Khattab Ahmed , Burroughs Sarah , Villines Dana , Ehrenpreis Eli 
Published: October 2019

INTRODUCTION:
In 2002, olmesartan, an ARB, was introduced to the market as Benicar. In 2012, Rubio-Tapia et al. reported 22 cases of SE related to olmesartan. In 2013, the Food and Drug Administration (FDA) issued a safety warning about SE related to olmesartan. In August 2017, Benicar’s manufacturer paid $300 million to settle claims from about 2,300 plaintiffs in SE cases. The FAERS is a publicly available database for voluntary reporting of adverse drug events to the FDA. No study has summarized the reports of ARB-related SE to the FAERS. Our aim is to establish the timeline of FAERS reports of SE from ARBs and to further characterize reports of olmesartan and another ARB-related SE to the FAERS.

METHODS:
A total of 9,144,290 FAERS reports from January 2013 to December 2018 were downloaded. Data was first queried for all patients using an ARB for hypertension. All drugs were limited to those defined as “Primary Suspect”. Gastrointestinal adverse events (GIAE), including SE and control reactions were then obtained for all ARBs and searched by both generic and trade names. Information regarding the timeline of reports and demographics of reporters was collected. Reporters are categorized as physicians, pharmacists, other health care professionals, consumers, and attorneys.

RESULTS:
A total of 77,245 FAERS reports of people for ARBs were analyzed. SE was identified in 5,290 (6.8%) cases. With the exception of 6 cases, all were related to olmesartan. All olmesartan cases were filed under its trade name Benicar. In addition to the SE cases reported, there were 7,402 (9.6%) cases of GIAE related to ARB. These included drugs other than olmesartan. The number of reports filed by each category each year is shown in Table 1 and Figure 1. Cases of SE were followed, and their outcomes identified (Table 2). Hospitalization was reported in 52.7% and death in 0.9%.

CONCLUSION:
The FDA reports for olmesartan-related SE and ARB-related GIAE have increased dramatically. Unlike some high-profile cases with dramatically increased lawyer reporting, these reports originate from physicians and consumers. All reports were for Benicar, none for generics and a few reports for combinations. This can be explained by the minimum of 2 years of ARB use prior symptoms onset suggested in the literature. Other explanations include Benicar’s large market share or potential problems with the Benicar formulation.
1181 Prevalence of Celiac Disease-Compatible Human Leukocyte Antigen Haplotypes Across Ethnicities and Regions in the United States
Authors: Kelly-Goss Molly R. , Lebwohl Benjamin , Zhan Jianan , Nhan Hoang , Koelsch Bertram , Kim Esther , Mountain Joanna , Green Peter H R 
Published: October 2019

INTRODUCTION:
The prevalence of celiac disease (CD) is widely variable throughout the United States (US), with a higher prevalence of disease in the Northeast. The reasons for this variability are unknown. In a prior study, we detected ethnic differences within the US, using a name-based algorithm, with prevalence in patients of Jewish ethnicity similar to the overall population, and lower in persons of East Asian ethnicity. CD etiology is dependent on human leukocyte antigen (HLA) haplotype. Typically, either HLA DQ2.5 or DQ8 is required (but not sufficient) for the development of CD, with DQ2.5 being the highest-risk haplotype. To date, no study has characterized regional or ethnic differences in the frequency of CD-compatible HLA haplotypes. Thus, we aimed to measure the frequencies of DQ2.5 and DQ8 across regions and ethnicities in the US.

METHODS:
We assessed the frequencies of HLA DQ2.5 (DQA1*05:DQB1*02) and DQ8 (DQA1*03:DQB1*03) in an unselected group of genotyped individuals who have used direct-to-consumer genetic testing between 2013 and 2017. Eligible participants were 23andMe customers who consented to participate in research. We assayed two SNPs to classify individuals as DQ2.5 homozygous, DQ2.5 heterozygous, DQ2.5/DQ8, DQ8 homozygous, DQ8 heterozygous, and 0 detected variants. We compared the frequency of each haplotype across four regions of the US. Additionally, we used genome-wide array data to cluster participants into 8 categories that correlate highly with self-reported race and ethnicity, and compared the frequencies of these haplotypes across these ethnic categories (Table 1).

RESULTS:
Of 1,290,668 individuals studied, at least one CD-compatible haplotype was present in 38.7% of individuals, and this frequency was similar across the four US regions. The frequencies of DQ2.5 homozygotes were also similar across the Northeast, Midwest, South, and West (1.25%, 1.43%, 1.38%, and 1.37%, respectively). In contrast, frequencies differ across ethnic groups: the highest DQ2.5 and DQ8 frequencies were observed in European (12.01%) and Ashkenazi Jewish (16.39%) participants, respectively.

CONCLUSION:
Previously reported regional variability in CD prevalence in the US may not be due to differences in HLA-based susceptibility; rather, other genetic or environmental factors likely play a role in disease pathogenesis. In addition, these differences carry great significance in view of the development of HLA haplotype-specific non-dietary therapies for CD.
1206 Gastric Emptying Scans: Adherence to National Guidelines
Authors: Wise Journey , Vazquez-Roque Maria , Crowell Michael D. , Lacy Brian E. 
Published: October 2019

INTRODUCTION:
Gastric-emptying scintigraphy (GES), routinely used to measure gastric emptying, is an essential tool to diagnose gastroparesis. An accurate diagnosis of gastroparesis relies upon the GES being performed according to a validated protocol. Jointly published protocol guidelines have been available for over a decade; however, the extent to which these guidelines are adhered to is unknown. This study aimed to assess national compliance with established GES protocol guidelines.

METHODS:
We developed a questionnaire addressing key protocol measures outlined in the published Procedure Guideline for Adult Solid-Meal Gastric Emptying Study 3.0. Survey questions addressed patient information collection (15), patient preparation and procedure protocol (16), meal content and preparation (7), imaging (3), interpretation (4), and reporting (7). Demographic data was also collected. The anonymous questionnaire was distributed electronically to members of the Society of Nuclear Medicine and Medical Imaging (SNMMI) and non-member recipients of the SNMMI daily email newsletter. One response per medical institution was permitted. Data were entered manually and statistically assessed using JMP®, Version 14.0. SAS Institute Inc., Cary, NC.

RESULTS:
121 medical institutions (MI) responded; 49 (40.4%) were academic/teaching medical centers. The mean number of annual GES procedures was 199.9 (range, 5 to 2000 GES/year). On average, MI performed 64% (33.5/52) of protocol measures according to guidelines while academic medical centers performed 61% (31.5/52) of protocol measures according to guidelines. Only 59% of MI use the validated meal. 42% of MI reported stopping imaging prior to the validated 4-hour interval. Only 16% of MI test blood glucose levels prior to GES while 71% cancel or reschedule GES if blood glucose levels are above the validated cut-off. 68% of MI ask patients if they take narcotic pain medications; only 49% require that patients stop taking narcotic pain medications at least two days prior to the GES. Only 4.5% of MI perform GES while adhering to 3 critical measures: validated study duration; controlling blood glucose levels; and properly restricting medication use.

CONCLUSION:
Low compliance with GES protocol guidelines, even among academic medical centers, raises the likely possibility of misdiagnosis and thus improper management of upper gastrointestinal symptoms. These results highlight a need for increased awareness of protocol guidelines.