bluuebunny/crossref_metadata_2025_split huggingface dataset:
297 Increasing Colon Cancer Screening Rates at Myers Park Internal Medicine Clinic
Authors: Sang Jessica , Simmelink Andrew , Denmeade Travis , Ost Emily 
Published: October 2019

INTRODUCTION:
Colon cancer is the third most common cause of cancer and cancer-related deaths. After regular colon screening was implemented, there was a 40% decline in incidence and mortality of colon cancer. The US Preventative Services Task Force gives grade A evidence recommendation for screening individuals age 50 through 75 that are of average risk. A US multi-society task force on colon cancer screening gave colonoscopy and Fecal Immunochemistry Test (FIT) a tier-1 recommendation. We sought to increase our internal medicine's clinic colon cancer screening rates.

METHODS:
We utilized the PDSA model for quality improvement. Baseline colon cancer screening rate was 53% in September 2018. The aim of our project was to increase colon cancer screening (CRCS) rates by 16.4% by April 2019 to a target goal of 69.4%, and to determine barriers to screening. A target goal of 69.4% was selected based on the clinic's metric goal. Our two main interventions included an informational video about CRCS reasoning and methods combined with a questionnaire that addressed barriers to care and recreation of FIT card instructions which were deemed inadequate. Educational materials and questionnaire were available in English and Spanish. We tracked improvement through clinic CRCS rate data available to physicians.

RESULTS:
Colon cancer screening rates at Myers Park Internal Medicine Clinic were increased by 15% (goal: 16.4%) to 68%. Ninety-two percent found the informational video “extremely informative,” with 38% choosing colonoscopy, 46% FIT testing, and 8% Cologuard®.

CONCLUSION:
Our clinic showed simple interventions can increase CRCS rates. The increase in CRCS rates we have shown can potentially lead to more early diagnoses of colon cancer and lower health care costs for the health system. The workflow used in our study could also be used in other clinics throughout Atrium Health to assess for increased colon cancer screening rates in other populations. The format of a simple informational video rather than documents may be beneficial in educating patients on different health care topics. Next steps will include reasons for not completing either FIT testing or having colonoscopy performed.
325 Novel Multi-Target Stool DNA Marker Panel Yields Highly Accurate Detection of Colorectal Cancer and Premalignant Neoplasia
Authors: Domanico MIchael , Kisiel John , Gagrat Zubin , Bourne Bridget , Allawi Hatim T. , Taylor William , Leduc Christine , Matter Michael B. , Mahoney Douglas W. , Ahlquist David , Lidgard Graham , Limburg Paul , Johnson Scott 
Published: October 2019

INTRODUCTION:
Despite the demonstrated effectiveness of average-risk screening, colorectal cancer (CRC) remains the 2nd leading cause of cancer death in the US. For optimal prevention, CRC screening tools should be highly accurate, user-friendly, and broadly accessible. Patient and provider adoption of the FDA-approved, guideline-endorsed multi-target stool DNA (mt-sDNA) test has grown exponentially since its launch in 2014. Toward ongoing improvement in CRC screening effectiveness, we conducted a blinded case-control study to assess the detection accuracy of a mt-sDNA panel of novel, highly discriminant methylated DNA markers (MDMs).

METHODS:
We selected 12 candidate MDMs from prior whole methylome discovery and validation in tissue. Stool was obtained as part of previous large, multicenter studies and collected prior to or 7 days post-colonoscopy (prior to any clinically-indicated treatment). CRC, advanced adenoma (AA; size ≥1 cm, high-grade dysplasia, or ≥25% villous morphology), non-AA, or control (no neoplasia) status was defined by colonoscopy and histopathology. Samples were blinded to operators and randomized by characterization to balance the test sets prior to assessment. MDMs were quantified by target-specific DNA capture and Long-probe Quantitative Amplified Signal assay on bisulfite-converted DNA; fecal hemoglobin was quantified by immunoassay. Bootstrapping methods were used to select a panel of 3 MDMs, which was then 10-fold cross-validated; hemoglobin was also included, as was a colon epithelium-specific MDM to normalize stool MDM levels.

RESULTS:
Participant samples included 117 CRC, 120 AA, 161 non-AA, and 327 controls. Median age was 67 (IQR 61, 75) years; 51% were men. The AUC with best-fit was 0.97 for CRC and 0.84 for AA, and these high AUCs held up tightly on cross-validation (Figure 1). At 92% (95% CI 88-94%) specificity, sensitivity of the panel was 92% (95% CI 86-96%) for CRC. Neither CRC stage (Figure 2) nor CRC site significantly affected performance. At the same 92% specificity, sensitivity was 65% (95% CI 56-73%) for AAs overall, 67% (38-88%) for sessile serrated polyps ≥1 cm, and 71% (57-82%) for adenomas with villous features (Figure 3).

CONCLUSION:
These data support highly accurate performance of a novel panel of mt-sDNA markers for detecting both CRC (including early stage lesions) and AAs at greatest risk of progression. Prospective comparative studies are warranted to further establish the clinical potential of this novel screening tool.
332 Effect of Behavioral Interventions on the Uptake of Screening Colonoscopy: A Systematic Review and Meta-Analysis
Authors: Yakoubovitch Stephanie , Anand Sanya , Pecoriello Jillian M. , Zaki Timothy A. , Liang Peter S. 
Published: October 2019

INTRODUCTION:
Screening decreases colorectal cancer (CRC) incidence and mortality, but uptake in the United States remains suboptimal at 62%. Prior studies have investigated the effect of various interventions on overall CRC screening and stool-based testing, but the effect on colonoscopy—the predominant screening test in the US—has not been fully examined. We performed a systematic review and meta-analysis to assess the effect of behavioral interventions on screening colonoscopy uptake.

METHODS:
We searched PubMed, EMBASE, and Cochrane databases through June 2018 for controlled trials that assessed the effect of behavioral interventions on screening colonoscopy rates. Our search yielded a total of 6,952 titles. All abstracts and articles were screened by at least two independent reviewers and 54 manuscripts were selected for review. Relative risk estimates were extracted from the original article or calculated from the raw data. The primary outcome was the relative increase in screening colonoscopy completion with any behavioral intervention. Subgroup analysis by type of intervention was also performed. Random effects meta-analysis was performed using Stata.

RESULTS:
A total of 21 studies with 24 behavioral interventions were analyzed. The most common interventions were patient navigation (n = 8), a combination of multiple interventions (n = 7), and educational interventions (n = 4). Overall, behavioral interventions increased colonoscopy completion by 58% compared to controls (OR 1.58, 95% CI 1.33-1.88, Figure). Patient navigation (OR 1.80, 95% CI 1.22-2.67) and multiple interventions (OR 1.70, 95% CI 1.15-2.50) had the strongest effect on colonoscopy completion. Significant heterogeneity was observed both overall and by intervention type, which may be attributed to differences in study setting and control group selection.

CONCLUSION:
Behavioral interventions increase screening colonoscopy completion and should be considered in clinical practice. In particular, patient navigation and multiple interventions are the best-studied and most effective interventions.
344 Multi-Modality Endotherapy of Esophagopleural Fistula (EPF) Using a Novel External Stent Anchoring Mechanism
Authors: Crain Rebecca , Abdulla Hamza , Guturu Praveen , Parupudi Sreeram 
Published: October 2019

INTRODUCTION:
Esophagopleural fistula (EPF) is a condition associated with high morbidity and mortality. The management of patients with chronic, recurrent, nonmalignant EPF remains controversial and challenging.

CASE DESCRIPTION/METHODS:
A 61-year-old man with a history of esophagopleural fistula (EPF) in diagnosed in 2013 treated with covered esophageal stent and subsequent decortication with resolution of symptoms and esophageal leak who presented to the hospital with sepsis. Chest CT revealed a fistula between the distal esophagus and right pleural space with large right-sided hydro-pneumothorax with resulting near complete collapse of the right lower and middle lobes. Chest tube was placed with external wound suction by luminal vacuum sponge. GI were consulted for endoscopic management. Upper Endoscopy revealed a 20 mm fistula in the lower third of the esophagus. The decision was made to close the fistula with endoscopic suturing and placement of esophageal stent. Three days following the procedure the esophageal stent migrated distally. This was repositioned endoscopically and anchored with repeat Overstitch of endoscopic clips. This again was displaced after 4 days. Due to the patient poor conditional status and the absence of offers for nonsurgical options, an alternative method of anchoring of esophageal was explored in the form of an external anchoring. This was done by loading the stent and suturing the proximal end at 12 and 6 o’clock, the stent was loaded back and then deployed in the patient esophagus under flurouscopic guidance. Then, the previously placed anchoring suture material was located and brought out of the mouth using a forceps. The sutures then were rerouted into each nostril using a nasal gastric tube. Then these anchoring sutures were loosely tied at/around the nasal septum using a soft rubber tube to protect the nasal septum. The procedure was technically successful and the patients was discharged from the hospital three days later. After one month, the patient’s nutritional status improved, and he underwent definitive thoracic surgery at an outside facility.

DISCUSSION:
Self-expandable metal stents are increasingly used in the management of esophageal fistulas but their efficacy is limited by high migration rate. Previously described methods to prevent stent migration include the use of endoscopic clips and endoscopic suturing. We describe external anchoring technique to maintain the esophageal stent in position in a case when endoscopic suturing failed.
Watch the video: http://bit.ly/2YiObuS
349 A Natural Orifice Transluminal Endoscopic Surgical Approach to Cruroplasty for GERD Management: A Feasibility Study in an Acute Porcine Model
Authors: Manzo Carl , Mathew Abraham , Maranki Jennifer , Pauli Eric , Moyer Matthew , Izer Jennifer , Karaisz Fred 
Published: October 2019

INTRODUCTION:
Gastroesophageal reflux disease is a common condition that often requires long term medical management or elective surgery in the form of fundoplication. Advanced endoscopic techniques can potentially be able to supply a safer alternative for patients with reflux disease. We propose a natural orifice transluminal endoscopic surgical technique that uses a self-approximating submucosal tunnel approach to the mediastinum to perform an anti-reflux procedure.

CASE DESCRIPTION/METHODS:
An acute porcine model was used for this acute animal feasibility study. Female Yorkshire pigs were kept on a liquid diet for forty eight hours and nothing by mouth eight hours prior to endoscopy. All animals were anesthetized and monitored. A four to five centimeter long submucosal tunnel is created in the posterior esophagus, beginning about ten centimeters above the gastroesophageal junction. From inside the tunnel, the muscles are incised to gain entry into the mediastinum. The esophagus is then followed down to the diaphragmatic hiatus and the right and left crura are located. The aorta, the vagal nerves, and other surrounding structures are identified. Using an overstitch device fitted on a double channel scope, we then suture the crura posteriorly, effecting a cruroplasty. Following the procedure, the animals were euthanized and immediate necropsy was performed to assess for any complications as well as determine the success of the cruroplasty. Esophageal pressure was assessed endoscopically in one animal.

DISCUSSION:
A submucosal tunnel was successfully achieved in all three animals with safe entry into the mediastinum. Mediastinal and then peri hiatal anatomy was demonstrated in each animal with excellent view of the thoracic aorta, esophagus, right and left vagus nerves, lungs, and the diaphragmatic crura. Endosuturing was successful with effective cruroplasty in all three animals without complications. Necropsy showed that sutures were in correct anatomical location without signs of procedural complication. We conclude that it is entirely possible to access the diaphragmatic hiatus and perform endoscopic cruroplasty for the potential treatment of reflux disease. A survival study aimed at developing a full-fledged anti reflux procedure is currently underway. We speculate that a trans-esophageal approach can provide an easy and safe treatment option for selected patients suffering from reflux disease.
Watch the video: http://bit.ly/2JQiEaF
422 Positive Association Between CDX2 and MUC2 Intestinal Factors and Dysplasia in Barrett’s Esophagus Utilizing WATS3D Tissue Sampling and Analysis
Authors: Odze Robert , Goldblum John , Sharma Prateek , Lightdale Charles J. , Smith Michael S. , Shaheen Nicholas J. 
Published: October 2019

INTRODUCTION:
During the pathogenesis of Barrett’s esophagus (BE), the background columnar epithelium often shows evidence of intestinal differentiation, such as early expression of intestinal specific transcription factors (CDX2) and late expression of mucin proteins (MUC2), prior to the development of goblet cells. The clinical significance of these markers is unknown. The aim of this study was to evaluate the association between the expression of CDX2 and MUC2, and the presence and grade of dysplasia in a large cohort of patients with endoscopic evidence of esophageal columnar mucosa using wide area transepithelial samples (WATS3D, CDx Diagnostics, Suffern, NY).

METHODS:
Over a 2-year period, we collected data from 129,158 consecutive patients with endoscopic evidence of esophageal salmon colored mucosa who were evaluated with WATS: 125,749 no dysplasia (ND), 2,012 crypt dysplasia (CD), 745 low grade dysplasia (LGD), and 652 high grade dysplasia/adenocarcinoma (HGD/EAC). CDX2 and MUC2 immunostaining was performed, and then their extent was graded semi-quantitatively (on a 4-point scale) in the background non-dysplastic, non-goblet epithelium, from all patients. The CDX2 and MUC2 results were then correlated statistically with the presence and grade of dysplasia.

RESULTS:
Table 1 summarizes the data according to dysplasia grade. Overall, 33.3% of cases were CDx2- MUC2-, 30.6% were CDx2+ MUC2-, and 36.1% were CDX2+ MUC2+. A significant (P < 0.0001) increase in CDX2+ MUC2+ staining occurred in dysplasia cases (97.0%) compared to non- dysplasia cases (34.5%). Upon regression analysis, there was a highly significant (P < 0.0001) association between both the presence and grade of CDX2 and MUC2 staining and dysplasia, that increased progressively from CD to LGD to HGD/EAC. CDX2+ MUC2+ was present, uniformly, in more than 94% of all dysplasia categories. In a sub-analysis of either CDX2 or MUC2 staining in ND vs. HGD/EAC cases only, there was a significant increase (P < 0.0001) in the grade of CDX2, and in the grade of MUC2, staining, such that 3+ or 4+ CDX2 or MUC2 staining was noted in 8.8% and 9.1% of ND cases, respectively, compared to 54% and 41%, respectively, in HGD/EAC.

CONCLUSION:
CDX2 and/or MUC2 positivity is a highly significant risk factor for dysplasia/EAC in patients with endoscopic evidence of esophageal columnar mucosa. CDX2/MUC2 immunostaining may represent a more effective method of confirming Barrett’s esophagus, and the risk for dysplasia/cancer, than the identification of goblet cells.
435 Trends and Correlation Between Eckardt Scores and Timed Barium Esophagram Parameters After Per-Oral Endoscopic Myotomy in Achalasia
Authors: Sanaka Madhusudhan R. , Parikh Malav P. , Tang Andrew , Chadalavada Pravallika , Khoudari George , Gupta Niyati M. , Thota Prashanthi N. , Gabbard Scott , Murthy Sudish , Raja Siva 
Published: October 2019

INTRODUCTION:
Symptomatic relief by Eckardt scores is used to assess treatment success after per-oral endoscopic myotomy (POEM). However, it is unclear if symptomatic improvement correlates with objective esophageal emptying on timed barium esophagram (TBE). Hence, our study aims were to identify the trends and correlation between Eckardt scores and TBE parameters after POEM.

METHODS:
Medical records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients who underwent timed barium esophagram (TBE) and high-resolution esophageal manometry (HREM) prior to POEM along with two-month post-POEM, TBE and HREM were included. Demographics and procedural details, TBE, HREM and Eckardt scores were reviewed. Post-POEM Eckhardt score of ≤3 was considered as successful palliation of symptoms. Trends in Eckardt scores and TBE parameters were identified and their association was analyzed. Statistical tests were performed using linear mixed effects and longitudinal modeling.

RESULTS:
A total of 219 patients underwent POEM with a median follow up duration of 2.6 months [Q1-3: 2.2 to 13.7 months]. Baseline patient characteristics and outcomes are described in Table 1. Improvement in Eckardt scores was stable over 24 months, however symptoms were lowest at 3-6 months after POEM (Figure 1a). TBE width at 1 and 5 minutes were lowest at 6-9 months after POEM, however TBE width gradually returns to baseline around 18-21 months even becoming worse than baseline levels (Figure 1b,c). Lower esophageal sphincter-Integrated relaxation pressure (LES-IRP) improvement was stable over 15 months, however this parameter was limited by number of patients undergoing follow up testing (n = 62). BMI increases slightly but remains around baseline for 24 months (Figure 1d). Among the 4 TBE parameters assessed, Eckardt scores correlates the most with barium column width at 5 minutes and the degree of correlation is moderate (Figure 2).

CONCLUSION:
Although patients continue to have symptomatic relief after POEM, objective parameters of esophageal emptying on TBE return to pre-operative levels or even worsen around two years after POEM. Eckardt scores correlate the most with barium column width at 5-minutes on TBE. Our findings suggest that barium column width at 5 minutes on TBE might be a useful objective marker for treatment response in the mid to long-term follow up after POEM.
479 Length of Time Spent in the Outpatient Setting With Patients With Irritable Bowel Syndrome: Analysis of the National Ambulatory Medical Care Survey
Authors: Mossad David , Ellis Matthew , Agrawal Sangeeta 
Published: October 2019

INTRODUCTION:
Irritable bowel syndrome (IBS) is a chronic and debilitating functional gastrointestinal disorder that affects 9%-23% of the population across the world. Based on IBS association with psychological symptoms such as anxiety and depression, it is assumed that patients with this condition require more time during outpatient visits than the average patient. The purpose of this study was to evaluate differences in time spent by physicians in the outpatient setting with patients with IBS versus patients with other conditions.

METHODS:
The National Ambulatory Medical Care Survey was searched using International Classification of Diseases - Ninth Revision (ICD-9) diagnosis codes for patients seen in the outpatient setting for IBS for the years 2011-2015. Time spent during the outpatient visits was also gathered. Patients were separated into two groups, those with IBS and those with other conditions. Data was analyzed with regards to patient age, sex, and duration of outpatient visit. Statistical comparisons were made using Statistical Package for the Social Sciences (SPSS) with chi-square and student T tests with a significance level of 0.05.

RESULTS:
175,863 outpatient visits were identified, with 381 patients with IBS and 175,483 patients with other conditions. Patients with IBS were significantly older (mean age of 49.3 vs 46.1, P = 0.0129) and had a longer duration of visit with the physician (24.7 minutes vs 22.5 minutes, P = 0.0007). The IBS group had a significantly larger proportion of females compared to the other conditions group (80.05% vs 57.16%, P < 0.0001)

CONCLUSION:
In this study, it was found that IBS patients take a significantly longer clinic time compared to patients with other conditions. These patients were more likely to be older and female. Various comorbid factors such as fatigue, lack of sleep, anxiety, and depression are potential contributors to the extended amount of time needed for these patients. Physicians should expect to potentially spend more time with these patients during their clinic visits and adjust their schedules accordingly to provide the best quality of care for patients with IBS.
499 Plecanatide for Patients With Chronic Idiopathic Constipation and Irritable Bowel Syndrome-Constipation: Analysis of Abdominal Bloating From Four Randomized Phase 3 Clinical Trials
Authors: Franklin Howard , Sayuk Gregory S. 
Published: October 2019

INTRODUCTION:
Patients with chronic idiopathic constipation (CIC) or with irritable bowel syndrome with constipation (IBS-C) often report bloating. Plecanatide is an analogue of human uroguanylin, an intestinal peptide that induces fluid and ion secretion. Data from 4 large randomized, placebo-controlled trials in CIC (2 studies) or in IBS-C (2 studies) were analyzed to determine whether plecanatide improved bloating in patients with CIC or IBS-C.

METHODS:
Patients (N = 2683) who met modified Rome III criteria for CIC or patients (N = 2189) who met Rome III criteria for IBS-C were included in separate combined phase III intention-to-treat populations in CIC and IBS-C, respectively. Patients were randomized to placebo, plecanatide 3 mg QD, or plecanatide 6mg QD for 12 weeks. Baseline characteristics were comparable between groups within the CIC studies and within the IBS-C studies. The primary endpoint for the CIC trials was the percentage of durable overall complete spontaneous bowel movement (CSBM) responders (≥3 CSBMs plus increase of ≥1 CSBM over baseline in the same week) for ≥9 of the 12 treatment weeks, including ≥3 of the last 4 weeks. The IBS-C primary endpoint was the percentage of Overall Responders, defined as a patient who was a weekly responder (CSBM + ≥30% improvement in abdominal pain) for ≥6 of the 12 treatment weeks. Electronic diaries recorded daily symptoms of bloating (0 = none to 4 = very severe) and bowel movements.

RESULTS:
In patients with CIC, pooled efficacy demonstrated a significantly greater percentage of CSBM responders in each of the plecanatide groups when compared to the placebo group. Both plecanatide 3mg and 6mg resulted in a significantly greater percentage of Overall Responders than did placebo in the IBS-C studies (Table 1). In CIC or IBS-C, over the 12-week treatment period, both plecanatide treatment groups experienced a significantly greater reduction in weekly mean abdominal bloating scores compared with the placebo group (Table 2). The most common adverse event (AE) was diarrhea across all studies; discontinuation rates due to AEs including diarrhea were similar across studies (Table 3).

CONCLUSION:
Patients with CIC or IBS-C who received plecanatide 3 mg and 6 mg demonstrated a significantly greater percentage of responders compared to patients who received placebo. Bloating was significantly improved both in patients with CIC and IBS-C. Plecanatide treatment was associated with a low incidence of diarrhea and other AEs.