bluuebunny/crossref_metadata_2025_split huggingface dataset:
518 Optimizing Inpatient Colonoscopy Preparation: A QI Project
Authors: Buaisha Haitam M. , Rao Sirish , Koppala Jahnavi , Vellanki Meghana , Abdussalam Abdullah , Machain Jose , Rangray Rajani 
Published: October 2019

INTRODUCTION:
Hospitalization is an independent risk factor of poor bowel preparation and it has a lower procedure completion rate as compared to outpatients. Ineffective inpatient colonoscopy preparation may lead to delayed or canceled procedures which subject the patient to additional bowel preparation and sedation. Subsequently it results in patient inconvenience, increased cardio-pulmonary complications, longer hospital stays, and increased hospital cost.

METHODS:
Defining the problem: Chart review of the inpatient colonoscopies performed between May and July 2017 revealed that 4 liters-single dose polyethylene glycol–electrolyte lavage solution [PEG-ELS] was used in more than 90% of the inpatient colonoscopies. The percentage of colonoscopies with a rating of fair or poor was 36%. On average, 15% of patients failed inpatient bowel preparation. Aim of the project: To reduce the percentage of failed inpatient colonoscopies to less than 10% by May 2018 and to reduce the percentage of inpatients colonoscopies with an inadequate bowel preparation by 5% by May 2019. Interventions: 1) Fellows education on the evidence based split-dose regimen. 2) Bowel prep quality deemed adequate if cecal intubation was successful and prep was satisfactory to identify the targeted lesions. 3) Nothing by mouth orders to be started at 4 am or later instead of traditional after midnight orders. 4) Notify MD orders if the patient has any problem with the bowel prep to enhance communication with nurses. 5) As needed orders for nasogastric tube placement for administration of the prep. 6) An order set was implemented in Epic to facilitate the process and make it uniform.

RESULTS:
After the first PDSA cycle (Sep 2017-May 2018), we were able to reduce the percentage of failed inpatient colonoscopies from an average of 15% to less than 5% and we reduced the percentage of inadequate bowel prep by 4% (Goal of 5%). In the second PDSA cycle (May 2018-May 2019), we maintained the percentage of failed inpatient bowel preparation under 10% (4.2-7.5%) and reduced the percentage of inadequate bowel prep 17% from the baseline.

CONCLUSION:
Implementing a split-dose regimen of 4 liter PEG-ELS for all inpatient colonoscopies, improving communication between nurses and ordering physicians, and executing a standard order set for bowel prep orders and instructions are successful strategies in optimizing inpatient bowel preparation. The reliability of the bowel preparation quality scales needs to be validated for use in inpatient colonoscopies.
606 Aggressive Approach Save Life in People Admitted for Both Upper GI Bleeding and Acute Coronary Syndrome
Authors: Al-Aboodi Yasir , Al-Chalabi Ahmed , Kobeissy Abdallah , Sodeman Thomas , Nawras Ali 
Published: October 2019

INTRODUCTION:
We occasionally encounter patients with upper gastrointestinal bleed (UGIB) who also happen to have coronary syndrome (ACS) during the same admission. In this study we tried to give a better insight about this target population demography and what's the best approach in terms of treatment options and its relationship with the inpatient mortality.

METHODS:
We did retrospective analysis using the National Inpatient Data base (NIS) for 2014. Its the largest available public all payer and it includes more than 7 millions inpatients admission. we examine the mortality difference among people who were admitted for UGIB and ACS and received different interventions approach including no interventions, endoscopy (Colonscopy/Endoscopy), Left heart Cath, or combination of left heart Cath and endoscopy. All diagnosis and procedures were captured using the the international code for disease version nine (ICD9).

RESULTS:
2830 ACS and UGIB related admission were extracted from the data. Mean age is 68 yr. 62% (1750) male and 38% (1075) female. 73% (2070) white; 14% (400) black; 7.1% (200) Hispanic; 65 (2.3%) Asian; 25 (0.9%) Native; % Others 2.5%. 195 out of the 2830 died. Of the 195 dead, 130 (66.7%) received no interventions, 50 (25.6%) received scopes only, 10 (5.1%) received left hearth catheterization only and 5 (2.6%) received both scopes and left hearth catheter. Considering no intervention as a reference, the likelihood of surviving are 3.3, 3.1, and 1.5 among combined therapy, Left heart Cath only and scopes only respectively (P < 0.005, CI 95% 1.3-2.5).

CONCLUSION:
Combined approach of endoscopy (colonoscopy/EGD) and left hearth catheterization for people with (UGIB and ACS) related admission have 3 times more likelihood to survive compared to patients who received no intervention.
610 The Comparative Effectiveness of Endoscopy versus Angiography in Patients With Recurrent Non-Variceal Upper Gastrointestinal Bleeding
Authors: Sanghi Vedha , Garber Ari , Lopez Rocio , Rizk Maged , Vargo John , Jang Sunguk 
Published: October 2019

INTRODUCTION:
Patients with recurrent non-variceal upper gastrointestinal bleed (NVUGIB) undergo repeat EGD, and for any further bleeding episode, consideration of angiography or interventional radiology (IR) with arterial embolization is employed. However, there is minimal evidence to support these recommendations promulgated by the national societies (refer to guideline). We sought to compare the effectiveness of repeat EGD with IR in achieving hemostasis in patients with recurrent NVUGIB after initial endoscopy.

METHODS:
This is a single-center retrospective cohort study. Between 2008-2018 consecutive ICU patients who underwent an EGD for diagnosis of NVUGIB (melena, hematochezia, hematemesis, coffee-ground emesis) were included. Continuous bleeding was defined by no hemostasis achieved, while recurrent bleeding was defined as re-bleeding within 30 days of hemostasis after index EGD. When hemostasis was not achieved, patients were stratified into treatment modalities of repeat EGD, IR without embolization, empiric embolization or lesion embolization. Generalized linear mixed models were used to evaluate if treatment effects re-bleeding when all bleeding episodes were analyzed.

RESULTS:
A total of 1067 patients were eligible for analysis. Mean age was 63 years and 44% were female. Following initial EGD, 90% (n = 960) of patients achieved hemostasis, 16% (n = 157) had recurrent bleeding and 10% (n = 107) had continuous bleeding without initial hemostasis. When compared to patients who underwent EGD and IR, patients with repeat EGD only had significantly higher Charlson Comorbidity Index (4.8 ± 3.2 vs. 3.4 ± 2.4; P < 0.001) and fewer re-bleeding episodes (P < 0.001). When all episodes of recurrent and continuous bleeding were analyzed, EGD had a three times higher likelihood of hemostasis when compared to IR without embolization (OR 2.9, 95%CI 1.05-7.7; P = 0.039). There is no significant difference between EGD and IR with empiric or lesion embolization or when all forms of IR were combined.

CONCLUSION:
Repeat EGD is three times more likely than IR without embolization in achieving hemostasis for all episodes of recurrent or continued NVUGIB after an initial endoscopy. However, EGD and IR with embolization appear equally effective modalities in achieving hemostasis after recurrent or continuous NVUGIB. The study is the first to directly compare EGD with IR and validates consensus recommendations of repeating upper endoscopy when hemostasis is not initially achieved as well as utilizing IR when necessary.
611 Finding the Ideal BUN to Creatinine Ratio in an Upper GI Bleed
Authors: Patel Sneha , Peraza Jellyana , Hasani Aliaskar , Luther Sanjana , Chugh Rishika , Tokayer Aaron 
Published: October 2019

INTRODUCTION:
The ratio of blood urea nitrogen (BUN) to creatinine can be used as a surrogate for identifying sources of upper gastrointestinal bleed (UGIB). The proposed mechanism of this “accelerated azotemia” is brisk bleeding above the ligament of Treitz, followed by blood protein breakdown and absorption in the upper GI tract in the setting of hypovolemia and subsequent kidney hypoperfusion. Several ratios have been described in the literature, with variable sensitivities and specificities, but there is no consensus on the ideal ratio for recognizing an UGIB. Our study seeks to expand upon a prior research study done at our institution to determine the sensitivity, specificity, and positive predictive value (PPV) of gradated BUN/creatinine ratios (20:1 to 100:1) in identifying an UGIB.

METHODS:
1,194 patients were identified between 2008 and 2016 using “Looking Glass Clinical Analytics”TM. Inclusion criteria were patients admitted with hematochezia, melena, or hematemesis, with a decrease in hemoglobin (Hb) of >1 g/dL from baseline. Patients with chronic kidney disease stage 3 or greater were excluded. Demographic data and source of bleeding were collected. Hb, BUN, and creatinine values were collected at baseline, day 1, and day 2 of admission. Sensitivity, specificity, and PPV were calculated for each ratio. A receiver operating characteristic (ROC) curve was created for day 1 and 2 of admission.

RESULTS:
604 patients had GI bleeding confirmed by endoscopy. Average age was 67 years, 50% (n = 302) were female, and 76% (n = 459) were Black or Hispanic. 62% (n = 375) had a confirmed UGIB source. Median change in Hb from baseline was 3.0 g/dL. For a BUN/creatinine ratio of ≥20:1 on day 1, specificity was 66.67%, sensitivity was 73.32%, and PPV was 78.16%. Values for day 1 and 2 of hospital admission are listed in Tables 1 and 2. ROC curve on day 1 (Figure 1) had an area of under the curve of 0.68 (CI = 0.64-0.73).

CONCLUSION:
A BUN/creatinine ratio of ≥30:1 has a PPV of 84% and may be ideal for identifying an UGIB. Interestingly, as the ratio increases above 30:1, the PPV plateaus and the likelihood of UGIB does not increase further. The specificity of UGIB at 30:1 is high at 85%. The ROC curve shows that the BUN/creatinine ratio is an accurate test for predicting an UGIB. This indicates that in clinical practice, a patient presenting with GI bleeding and a drop in hemoglobin ≥1 g/dL associated with an “accelerated azotemia” of ≥30:1 should first undergo upper endoscopy to localize a bleeding source.
629 Point-of-Care Ultrasound Improves Aspiration Risk Assessment for Anesthesia in Upper GI Bleeding: A Prospective Study
Authors: Jen Henry , Beg Tazeen , Ahmad Sahar , Buscaglia Jonathan M. , Bucobo Juan Carlos 
Published: October 2019

INTRODUCTION:
Gastric contents can be identified using point-of-care ultrasound prior to administration of anesthesia as part of a risk assessment tool to prevent aspiration however its clinical use is still being explored. We investigated the utility of US immediately prior to EGD in patients with suspected upper GI bleeding and its effect on anesthesia management.

METHODS:
We performed a prospective observational study of 30 patients undergoing EGD for upper GI bleeding at a large tertiary care center. All patients underwent a 2-5 minute US assessing antral contents in the endoscopy suite. EGD was then performed and actual gastric contents was assessed. A decision to proactively intubate was made prior to US findings and adjusted accordingly at the discretion of the anesthesiologist depending on US results. Outcomes included the confirmation of US results with EGD findings, aspiration events, intubation decisions, need for escalation of care, successful EGD intervention, and mortality.

RESULTS:
All 30 patients had US results that correlated directly with EGD findings. A total of 26 of the 30 patients (86.7%) were found to have negative US findings and all were found to have empty stomachs on EGD. 7 of these 26 (26.9%) presented initially with hematemesis. A total of 4 of the 30 patients (13.3%) had positive US findings and all were confirmed to have old or fresh blood seen immediately upon entering the stomach on EGD. Additionally, 5 of the 30 patients had US findings that altered anesthesia management preprocedure. Of these, 4 patients had empty stomach findings on US and thus were not intubated. All 4 had successful endoscopic interventions without aspiration events. The other 1 patient was unexpectedly found to have a full stomach on US and thus was electively intubated. The patient was found to have significant blood and clot in the stomach due to an underlying ulcer which was treated successfully. The patient was extubated post procedure without any aspiration event.

CONCLUSION:
In a prospective observational study, point-of-care US use prior to EGD was found to be accurate and effective in determining gastric contents and aided in preprocedural decision-making to help prevent aspiration events. To our knowledge, this is the first prospective study assessing this question and is a proof of concept that US is a viable risk assessment tool for patients with upper GI bleeding undergoing EGD.
662 Inflammatory Bowel Disease Patients With Type 2 Diabetes and Obesity Have a Higher Annual Burden and Costs of Hospitalizations: A Call for Action
Authors: Butnariu Madalina , Porter Kyle , Husain Syed , Afzali Anita 
Published: October 2019

INTRODUCTION:
Morbid obesity (MO) is increasingly more common among patients with inflammatory bowel disease (IBD). Prior studies describe a complex interplay between the proinflammatory state associated with obesity and IBD. Type 2 diabetes (T2D) patients are also at risk for poorer outcomes and additional healthcare costs. The clinical implications of obese, diabetic IBD patients are not well described. We conducted a nationally representative cohort study to estimate and compare the burden, costs and causes for hospitalizations and readmissions among IBD patients with or without diabetes and obesity.

METHODS:
Using the Nationwide Readmissions Database (NRD) 2010-2014, IBD patients were categorized into 4 groups: T2D and MO; MO alone; T2D alone; no-T2D and no-MO. A 1:1 propensity score was performed for each group matching to patients with both T2D and MO. Linear regression was used to compare rates of hospital days, total costs, and number of hospital admissions among the 4 groups. Outcomes were log-transformed for analysis to better meet normality assumptions, as each was right-skewed. Calendar year mortality were compared between groups by logistic regression.

RESULTS:
There were 8,526 IBD patients with T2D and MO; MO alone (n = 12,512); T2D alone (75,269); and no-MO and no-T2D (466,508). After propensity score matching, the mean number of hospital days per year (13.9 days, 95% CI 13.2-14.7) and mean cost per year ($32,709, 95% CI 30,937-34,582) were higher in the T2D and MO group compared to other groups (P < .001). Mean number of admissions per year was higher in the T2D and MO group (2.88, 95% CI 2.77-2.99) compared to MO only group (2.70, 2.58-2.82) (P < .05). T2D and MO were more likely than other groups to have infection- and respiratory-related readmissions (P < .001); and more likely than no-T2D/no-MO to have IBD-specific (P = 0.01) or cerebrovascular readmissions (P = .004). T2D patients were more likely than MO only or no-T2D/no-MO for cardiac-related readmissions (P < .001). There were no differences in mortality among the four groups.

CONCLUSION:
Our NRD analysis demonstrates that diabetic, obese IBD patients have higher burden and costs of hospitalizations. Improved strategies and preventative care efforts for tighter glycemic control and weight loss are needed to target this high-risk group of patients with IBD.
680 Intestinal Resection and Clostridioides difficile Infection in Inflammatory Bowel Disease Patients: A Single Center Retrospective Cohort Study
Authors: Baray Merwise , Dickson Zachary , Hunold Thomas , Behm Brian , Hays R. Ann 
Published: October 2019

INTRODUCTION:
In inflammatory bowel disease patients (IBD), Crohn's disease carries a greater risk for surgical resection than ulcerative colitis (UC) through 10 years after diagnosis. Prior studies identify small bowel resection and colectomy as risk factors for the development of Clostridioides difficile infection (CDI). This study assessed the correlation between acquisition of CDI and timing of intestinal resection in IBD patients.

METHODS:
A retrospective cohort of patients age 18-75 with a history of IBD and a diagnosis of CDI from Jan 2012–Dec 31, 2016. Patient demographics, history of intestinal resection, and history of a single CDI or multiple CDI were reviewed. CDI index case was chosen as the infection with the closest timing to intestinal resection. Statistical analysis was performed with Chi-square testing.

RESULTS:
121 IBD patients with CDI were identified. 48 patients (39.7%) underwent surgical resection (25 UC and 23 Crohn's). Of these, 16 patients had a single episode of CDI and 32 patients had a history of multiple CDI. CDI occurred prior to intestinal resection in 84% of UC patients and only 47.8% of Crohn's patients (P = 0.008). This relationship was mirrored in those with history of multiple CDIs (P = 0.006), but not for patients with history of a single CDI (P = 0.38). Within 1 month of surgical resection, there was no difference in the development of CDI for Crohn's compared to UC patients. However, in Crohn's patients with a history of multiple CDI, 77.8% experienced a CDI after a partial or total colectomy.

CONCLUSION:
In this cohort of IBD patients, CDI prior to surgery is more common in UC patients as compared to Crohn's. This likely reflects CDI's predilection for the colonic mucosa, which is altered by the pro-inflammatory state of UC. A history of CDI is not as common in Crohn's patients undergoing surgery likely due to decreased colonic involvement. Further investigation into CDI in Crohn's patients after colonic resection is warranted. This information may be used to guide therapeutic discussions with IBD patients who are diagnosed with CDI.
690 Ustekinumab Maintained Clinically Meaningful Improvement in Health-Related Quality of Life in Patients With Moderate to Severe Crohn's Disease: Results From the IM-UNITI Long-Term Extension
Authors: Sands Bruce E. , Han Chenglong , Gasink Christopher , Bin Zou , Stephen Targan , Sandborn William J. , Feagan Brian G. 
Published: October 2019

INTRODUCTION:
The IM-UNITI study evaluated the safety and efficacy of subcutaneous (SC) ustekinumab (UST) maintenance therapy in patients with moderately to severely active Crohn's disease (CD) who completed induction treatment with UST. Previously, we reported the effects of UST on health-related quality of life (HRQoL) through Wk44. Here, we evaluated HRQoL through Wk140 in patients who entered the long-term extension of the IM-UNITI study.

METHODS:
Patients who completed the safety and efficacy evaluation at Wk 44 of the maintenance study were eligible to continue their regimen in the extension study (placebo [PBO], UST 90 mg q12w, or UST 90 mg q8w). All patients who were treated in the extension study were included in this analysis of Inflammatory Bowel Disease Questionnaire (IBDQ) and SF-36 data according to the treatment they received during the extension study. The IBDQ is a 32-item questionnaire with 4 dimensions: bowel symptoms, systemic symptoms, emotional function, and social function. The total score ranges from 32 to 224, higher scores indicate better quality of life, and a change ≥16 points was defined as clinically meaningful. For SF-36, a change ≥5 points was defined as clinically meaningful.

RESULTS:
For patients who entered the extension, mean total IBDQ scores and SF-36 scores at maintenance baseline were comparable across treatment groups (Table 1). Patients who received UST maintained the improvement in IBDQ and SF-36 that was achieved by maintenance baseline through Wk140, and those who received PBO generally worsened. Through Wk 140, 26.5% of patients receiving PBO, 61.5% of patients receiving UST 90 mg q12w, and 59.3% of patients receiving UST 90 mg q8w had ≥16-point improvements from induction baseline in IBDQ score. In addition, 10.9%, 51.6%, and 54.2%, respectively, had ≥5-point improvements in SF-36 physical component summary scores, and 8.7%, 43.8%, and 43.7%, respectively, had ≥5-point improvements in SF-36 mental component summary scores during the same period.

CONCLUSION:
In patients who entered the long-term extension of the IM-UNITI study, those who received SC UST maintenance generally maintained improvements in IBDQ and SF-36 scores that were achieved through IV induction, and those who received PBO gradually lost these improvements.
722 Racial Differences in the Experience of Inflammatory Bowel Disease
Authors: McGrath Brian , Zheng Ziduo , Huang Eugene , Iskandar Heba 
Published: October 2019

INTRODUCTION:
In patients with inflammatory bowel disease (IBD), disease-related worries and concerns can have a substantial impact on clinical outcomes. However, most of the existing literature addressing IBD, its treatment, and disease-related concerns is drawn from majority Caucasian populations. This study aims to compare IBD-related worries and concerns among African American (AA) and non-African American (non-AA) patients.

METHODS:
We performed a cross-sectional study of IBD patients receiving biologic infusion therapy at a large academic medical center using the Rating Form of IBD Patient Concerns (RFIPC, © 1991, Rome Foundation Inc). This validated tool contains 25 items that assess concerns falling within four sub-domains on a scale from 1-100: impact of disease (IOD), sexual intimacy (SI), complications of disease (CD), and body stigma (BS). Total score, sub-domain scores, and individual item scores were compared between AA and non-AA groups using linear regression analysis, adjusting for age and sex. RFIPC used with permission of Mapi Research Trust, Lyon, France: https://eprovide.mapi-trust.org.

RESULTS:
Of 53 patients included in this preliminary analysis, 17 were AA and 36 were non-AA. AA participants tended to be younger (35.8 vs 45.3) and more predominantly female (71% vs 42%) compared to non-AA participants. Although AA participants tended to report a greater total burden of concerns, the difference was not significant (mean difference 91.75, P 0.65). AA patients had significantly greater concern in BS (mean difference 28.09, P 0.02); while there was a trend toward higher scores in other sub-domains in the AA group, these were not significant. Type 3 fixed effects analysis revealed significant effect of age on sum score (P 0.01) and IOD (P 0.01) and of sex on SI (P 0.05) and BS (P 0.01).

CONCLUSION:
Our results suggest that AA patients may experience slightly more IBD-related concern than non-AA patients. Although only the difference in concerns related to body stigma was significant, there was a trend toward greater concern in all other subdomains as well as overall concern in the AA group. We predict more significant differences with continued patient enrollment. Our study highlights important issues to discuss with AA patients, particularly relating to hygiene and self-awareness. As the prevalence of IBD in African Americans continues to increase, further research in this area will facilitate delivery of optimal IBD care for this population.