bluuebunny/crossref_metadata_2025_split huggingface dataset:
553 Exploring Methods to Reduce Colonoscopy Cancellations
Authors: Sheikh Akber , Chang Andrew , Godil Aslam , Foliente Roy , Hill Kevin , Brichler Benjamin 
Published: October 2019

INTRODUCTION:
Colonoscopy cancellation negatively impacts endoscopy center efficiency and physician productivity. According to previous studies, the rates of colonoscopy cancellations within 24 hours were reported to be 2-4% (1,2). Using an automated call system to make reminder calls and informing patients of a cancellation fee, may be methods to reduce cancellations. Our aim is to evaluate the effectiveness of these methods in reducing late cancellations.

METHODS:
A prospective and retrospective study done at Sierra Nevada Gastroenterology Medical Associates and Sierra Endoscopy Center in Grass Valley, CA from Nov 2, 2018 to May 2, 2019. All enrolled patients had colonoscopy issues addressed by a physician at an office visit prior to scheduling. A reminder phone call was made by an automated calling system 48 hours prior to the colonoscopy. Results were compared to previous studies where a nurse gave the reminder call. Another group of patients were informed of a policy that a cancellation fee may be charged for late cancellation. Data was compared from this current study group to similar groups in 2009-11 and 2016-17 (1,2) to see if there were any significant factors that influenced colonoscopy cancellation rates.

RESULTS:
138 from a total of 2310 pts (6%) cancelled their colonoscopy within 24 hours of their scheduled procedure time when receiving the automated reminder phone call. 2-4% of pts cancelled their colonoscopy when receiving a personal reminder call from a nurse (1,2).Knowledge of a cancellation fee did not reduce the amount of cancellations.

CONCLUSION:
Using an automated phone call system to make reminder phone calls led to a higher cancellation rate (6%) when compared to a personal reminder phone call from a nurse (2-4%). Potential reasons are that the patient may not pick up the phone thinking it was a robocall, wrong phone numbers, deleted messages, and difficulty understanding automated messages. Even though no late fees were actually charged, just the knowledge of a potential cancellation fee was not a deterrent for cancellation. Type of insurance was the most significant factor influencing colonoscopy cancellation, as the rate of cancellation was directly related to the increase in Medicaid insured patients and inversely related to the number of privately insured patients. Personal issues were the most frequent cause for last minute cancellations. Anticipating and addressing these issues at the time of scheduling may be the most effective way of reducing cancellation rates.
559 Patients' Descriptions of Their Last Bowel Movement Before Colonoscopy, Converted to a Standardized Score, Shows Strong Correlation With Their Boston Bowel Preparation Scale (BBPS) Score
Authors: Akman Olgun , Chande Nilesh , Gregor James 
Published: October 2019

INTRODUCTION:
Colorectal cancer is the third most common cancer worldwide. Early detection of adenomatous polyps and adenocarcinoma reduces mortality. The effectiveness of colonoscopy for colorectal cancer screening is reliant on the quality of bowel preparation. Patients with inadequate bowel preparation may require repeat colonoscopy; this exposes patients to further risks while placing financial stress on individuals and healthcare systems. The purpose of this study is to assess if a patient's description of their last bowel movement, converted to a standardized score, correlates to the quality of bowel cleansing.

METHODS:
This is a cross-sectional study performed at two hospitals with data collected over two months. On the day of the colonoscopy, prior to the procedure, outpatients were asked by a resident physician to describe their last bowel movement. The description was converted to a standardized score: “fully solid”, assigned a score of 0; “liquid with solid pieces”, assigned a score of 1; “brown liquid”, assigned a score of 2; and “clear / yellow liquid”, assigned a score of 3. Subsequently, each patient's total and segmental Boston Bowel Preparation Scale (BBPS) score was determined and recorded by the clinician performing the colonoscopy. The nurses and clinicians performing the procedure were blinded to the patient's last bowel movement description. Data analysis using bivariate Pearson's Correlation was used to assess the strength of correlation between the patients' descriptions and BBPS scores.

RESULTS:
Study population characteristics: N = 121, 66 F and 55 M; mean age 56.16 with Std. Dev. of 16.12; mean total BBPS 7.74 with Std. Dev. of 1.87. Bivariate Pearson's Correlation showed a strong correlation (r = 0.738; P < 0.001) between the patients' descriptions and total BBPS score. Patients' descriptions versus segmental BBPS scores showed: a strong correlation with Left Colon BBPS (r = 0.702; P < 0.001); a moderate correlation with Transverse Colon BBPS (r = 0.632; P < 0.001); and a moderate correlation with Right Colon BBPS (r = 0.667; P < 0.001).

CONCLUSION:
A patient's description of their last bowel movement, converted to a standardized score, shows a strong correlation with their BBPS score. One implication of identifying a patient with inadequate bowel preparation before a colonoscopy is potentially rescheduling the procedure. Alternatively, it may be possible to provide patients with extra time and medication for colon cleansing before the colonoscopy is attempted.
567 What's Taking so Long? Optimizing Efficiency in the Endoscopy Unit
Authors: Do Albert , Sayyar Mubarak , Macklin Jared , Lee Mindy , Pourmorady Jonathan , Masoud Amir 
Published: October 2019

INTRODUCTION:
With the ongoing focus on value-based care, there has been greater emphasis on efficiency and cost-effectiveness of health services, including gastrointestinal endoscopy. Endoscopy unit optimization requires coordination of many providers, staff, equipment, and resources. We aimed to develop a value-stream map for performance of endoscopic procedures performed at a tertiary academic medical center, identify processes associated with delays, and assess if workflow process improved after recent redesign efforts were initiated.

METHODS:
Data were extracted from 13,663 endoscopic procedures from January 1st, 2018 to April 1st, 2019, at the Center for Advanced Endoscopy (CAE), a 5-room gastrointestinal and pulmonary endoscopy unit. The endoscopy workflow process was mapped (Figure 1) and potential processes associated with delays (lags) identified. We isolated patient process times through the CAE and compared those before and after clinical redesign initiatives were instituted. We additionally extracted clinical characteristics and performed logistic regression to identify potential predictors of delay ≥30 minutes, defined as delay in processes associated with patient transportation (lag 1 or lag 3).

RESULTS:
Patient clinical characteristics (Table 1) did not differ after implementation of clinical redesign though the proportion of inpatient procedures increased (33.9% vs 37.1%, P = 0.001). The rate of 30-minute delays was high and unchanged after clinical redesign implementation (25.9% vs. 25.9%, P = 0.99). Delays were noted at all three potential processes: procedure room availability (19 minutes), scheduled versus actual start time (49 minutes), and awaiting transport for inpatients to return to medical ward (34 minutes). Multiple logistic regression (Table 3) revealed male gender (OR 1.09, 95% CI: 1.00-1.19, P = 0.04) and inpatient status (OR 5.03, 95% CI: 4.60-5.51, P < 0.001) as significant predictors of delay in CAE workflow process.

CONCLUSION:
Patient hospitalization status is a contributing factor to delays in the CAE and. though prolonged monitoring of these patients is a logical practice, establishing benefit is needed to justify this action. Optimization of patient transportation services to procedure room and from post-procedure areas is one potential recommendation based on this analysis. This area for improvement is the center of our next optimization efforts and will be evaluated as part of this ongoing project.
572 Multi-Lingual Video Consent for Upper Endoscopy and Colonoscopy
Authors: Lawrence Zoe , Castillo Gabriel , Jang Janice , Tzimas Demetrios , Dikman Andrew , Williams Renee 
Published: October 2019

INTRODUCTION:
Informed consent involves a thorough understanding of procedural risks, benefits, and alternatives. Among patients with Limited English Proficiency (LEP) it is difficult to ascertain comprehension even with the use of a certified medical interpreter. Prior studies have demonstrated that use of video during informed consent improves patient comprehension relative to traditional verbal consent. This quality improvement initiative aims to improve patient comprehension of endoscopy and colonoscopy though utilization of an educational video in the patient's primary language as a component of informed consent.

METHODS:
Short videos explaining the risks, benefits, and alternatives for endoscopy and colonoscopy were produced in English and Spanish. All patients underwent a traditional verbal consent process, with the use of a certified medical interpreter if indicated. A group also watched the educational video. Following either the video or the traditional verbal consent, the patients filled out a questionnaire in their preferred language to assess comprehension of the planned procedure and its risks, benefits, and alternatives.

RESULTS:
A total of 74 questionnaires were administered. Group 1 underwent traditional consent alone and group 2 watched the video prior to traditional consent. The colonoscopy cohort included 35 English-language and 11 Spanish-language patients; the endoscopy cohort included 21 English-language and 7 Spanish-language patients. The mean patient score on the colonoscopy questionnaire for group 2 was 77% compared with 54% for group 1 (P = 0.003). In the endoscopy cohort, group 2 also scored higher than group 1 (P = 0.0004). Among Spanish-speaking patients, group 2 had better comprehension scores than group 1 (86% vs 33%, P < 0.0005).

CONCLUSION:
Our results demonstrate a significant improvement in patient comprehension with the use of video education as part of the consent for colonoscopy and endoscopy. This difference was most notable for Spanish-speaking patients. Future directions include translation of the video into additional languages and incorporation into the standard pre-procedure consent at our institution in order to improve quality of care for patients who are both language concordant and language discordant with their providers.
574 Role of Prophylactic Endoscopic Clipping for Prevention of Delayed Post-Polypectomy Bleeding: Meta-Analysis of Randomized Controlled Trials
Authors: Gonzalez Zorisadday , Roy Neel P. , Kanth Rajan , Roy Praveen K. 
Published: October 2019

INTRODUCTION:
Post-polypectomy bleeding is a common complication of colonoscopy. Several endoscopic techniques including prophylactic endoscopic clip placement are used for prevention of post-polypectomy bleeding. However, several studies have reported mixed results on the efficacy of this approach. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the efficacy of prophylactic endoscopic clipping for prevention of delayed post-polypectomy bleeding.

METHODS:
Several databases (Embase, Pubmed, Cochrane database, Google Scholar) and abstracts of gastrointestinal and surgical meetings were searched extensively for relevant articles. Studies comparing prophylactic endoscopic clipping alone to standard colonoscopy with no endoscopic clipping were included. Studies that combined prophylactic clipping with other hemostatic techniques were excluded. Data was extracted using a standard form by two reviewers. Data regarding patient characteristics, types of polyps resected, post-polypectomy bleeding and other complications were extracted. Effect sizes were computed either using the fixed effects or random effects model using the Comprehensive Meta-analysis software. Publication bias, quality of studies and heterogeneity were analyzed.

RESULTS:
Nine RCTs were included in this study. The studies recruited subjects from USA, Japan, Canada and Spain. There were 3762 controls and 3658 patients in the treatment arm. Studies evaluated both small (<20mm) and large polyps (>20 mm), sessile and pedunculated polyps. The polyps were predominantly removed with standard polypectomy or endoscopic mucosal resection (for larger polyps). Delayed post-polypectomy bleeding occurred in 2.4% of controls and 1.6% in patients with endoscopic clipping. On analysis of all polyps, prophylactic endoscopic clipping decreased the risk of delayed post-polypectomy bleeding (RR = 0.71: 95% CI 0.51-0.99, P = 0.04, I2= 20%). The risk reduction was seen mainly with larger polyps(>20 mm), RR = 0.53 (95% CI : 0.32-.90, P = 0.02, NNT 28) and with sessile polyps (RR = 0.52, 95% CI: 0.32-0.83, P = 0.006, NNT 100). The protective effect was not seen for small polyps (<20 mm) (P = 0.91, P = 0.7) or pedunculated polyps (RR = 0.58, P = 0.29). All studies were of high quality. No publication bias or heterogeneity was present.

CONCLUSION:
Prophylactic clipping decreased the risk of delayed post-polypectomy bleeding. The benefit was mainly seen in patients with sessile polyps or large polyps (>20 mm).
579 The Efficacy and Safety of Andexanet Alfa in Patients With Acute Gastrointestinal Bleeding While Taking Factor Xa Inhibitors: An ANNEXA-4 Sub-Analysis
Authors: Siegal Deborah , Beyer-Westendorf Jan , Yue Patrick , Souza Sonia , Nakamya Juliet , Connolly Stuart J. , Crowther Mark 
Published: October 2019

INTRODUCTION:
Andexanet alfa is a recombinant modified human Factor Xa (FXa) decoy protein developed to reverse the anticoagulant effect of FXa inhibitors.

METHODS:
ANNEXA-4 was a prospective single-arm study of andexanet alfa in patients with acute major bleeding while taking a FXa inhibitor. Patients with major gastrointestinal (GI) bleeding were eligible if they had (1) signs/symptoms of hemodynamic compromise or (2) bleeding associated with a hemoglobin (Hb) drop ≥2 g/dL or baseline Hb ≤8 g/dL. Upon enrollment, patients were treated with one of two andexanet dosing regimens based on the type, timing, and dose of the most recent inhibitor intake. Efficacy was evaluated in all patients who met the bleeding criteria above and had a baseline anti-FXa activity ≥75 ng/mL (≥0.25 IU/mL for enoxaparin). Co-primary endpoints were the change in anti-FXa activity and the achievement of hemostasis, as adjudicated by an independent committee, at 12 hours after andexanet treatment. Hemostasis was defined as: excellent if the red blood cell transfusion-corrected Hb at 12 hours was ≤10% lower than baseline, good if Hb was 10-20% lower, and poor/none if Hb was >20% lower.

RESULTS:
Of 352 patients enrolled in the study, 90 had GI bleeding, of whom 62 were included in the efficacy analysis. Median age was 76 years (range 24-95); 51 (57%) were male. Patients were receiving rivaroxaban (n = 44), apixaban (n = 5), and edoxaban (n = 3) at study entry. Bleeding location was identified in 48 patients (upper n=27, lower n = 21) and unknown in 42 patients. 66 (73%) patients had some evidence of hemodynamic compromise, including 38 (42%) patients with hypotension. Mean Hb at the time of dosing was 4.9 ± 1.4 g/dL. In patients taking rivaroxaban, the baseline anti-FXa activity was 267 ± 168.5 ng/mL and the percent reduction with andexanet was 94% (95%CI 89-96). In apixaban patients, the baseline anti-FXa activity was 244 ± 215.0 ng/mL and the percent reduction with andexanet was 92% (95%CI 88-95). Excellent/good hemostasis was achieved in 85% of evaluable patients. 58 (94%) of 62 patients received red blood cell transfusions, 3 (5%) received platelet transfusion, and 2 (3%) received a coagulation factor product. 30-day rates of thrombosis and death were 6% and 13%, respectively.

CONCLUSION:
In patients with major GI bleeding treated with andexanet, a high rate of effective hemostasis was achieved. The thrombosis and mortality rates are consistent with prior studies in this patient population.
580 The Safety and Efficacy of Proton-Pump Inhibitors (PPI) Usage in Critical Care Patients for Stress Ulcer Prophylaxis: A Meta-Analysis of Randomized Controlled Trials
Authors: Abdel-Aziz Yousef , Ahmed Tamer , Renno Anas , Awad Mohammed , Assaly Ragheb , Ismail Mohammad , Howden Colin W. , Nawras Ali 
Published: October 2019

INTRODUCTION:
There is some debate in current literature about the safety and efficacy of proton pump inhibitor usage in critical care patients. In this systematic review and meta-analysis we assessed the the Safety and efficacy of proton-pump inhibitors (PPI) usage in critical care patients for stress ulcer prophylaxis

METHODS:
We searched PubMed, Embase, Web of Science and Cochrane Central Register of Controlled Trials following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement from inception until January 2019. We included randomized controlled trials (RCTs) that examined the efficacy and safety of proton pump inhibitors (PPIs) vs placebo regardless of publication source, status and language with participants older than 18 year old and of any gender who were admitted to medical, surgical or neuro intensive care unit (ICU). We excluded studies in which participants were admitted to ICUs primarily for the management of GI bleeding. Seven eligible studies were included and relevant data was extracted and statistical analysis was performed using Rev Man 5.3.

RESULTS:
Of 57 potentially eligible studies, we included 7 trials enrolling 4021 patients. The results showed that PPIs are probably more effective for preventing non clinically significant gastrointestinal bleed (GI bleed) [Odds ratio (OR) 0.47; 95% Confidence interval (95% CI) 0.37, 0.6] and clinically significant GI bleed -reported in 4 studies- (OR 0.59, 95% CI 0.40, 0.86). PPIs did not increase the risk of developing infection [including pneumonia and Clostridium difficile infection (c-diff) ] compared with placebo (OR 1.02, 95% CI 0.86, 1.22) even with sub analysis: pneumonia (OR 1.03, 95% CI 0.86, 1.23) and c-diff (OR .80, 95% CI 0.45, 1.44) . Estimates of baseline risks of bleeding varied significantly across studies, only 4 studies reported clinically significant GI bleed, 5 studies reported pneumonia (Definitions of pneumonia varied) and two studies reported on Clostridium difficile infection.

CONCLUSION:
PPI decreases the clinically significant and non-significant GI bleeding in critical care patients. PPI did not increase the risk of developing infection [including pneumonia and Clostridium difficile infection (c-diff) ] compared with placebo (OR 1.02, 95% CI 0.86, 1.22) even with sub analysis: pneumonia (OR 1.03, 95% CI 0.86, 1.23) and c-diff (OR .80, 95% CI 0.45, 1.44).
598 Physicians Fail to Utilize Iron Supplementation After Discharge in Gastrointestinal Intestinal Bleeding
Authors: Baskharoun Marina , Goff Sara , Friedenberg Frank 
Published: October 2019

INTRODUCTION:
A common cause of iron (Fe) deficiency anemia (IDA) is gastrointestinal bleeding (GIB). While treatment is aimed at the underlying cause of IDA, it is also targeted at replenishing Fe stores to reduce anemia progression and end organ damage. Our objective was to assess whether patients hospitalized with IDA secondary to GIB received appropriate Fe supplementation upon discharge and the effect of this therapy post-discharge.

METHODS:
Retrospective review of patients hospitalized with GIB between 1/2017 and 12/2017. Patients eligible for Fe on discharge had one or more of the following: ferritin ≤30, Fe saturation ≤10%, and/or ≥2-gram decrease from the patient's baseline hemoglobin (hgb) with a final hgb of <10.0 due to GIB. We excluded patients with active malignancy, prior abdominal surgery, hematologic disorders, hgb > 10 on discharge, or died during hospitalization. We recorded the hgb on admission, nadir, and discharge and whether blood transfusions and Fe supplementation were given. In addition, use of anticoagulants and antiplatelet agents prior to admission was recorded. A post-discharge period of 180 days was used to assess outpatient hgb levels and hospital readmission. A regression analysis was performed to identify significant variables associated with receiving appropriate Fe supplementation on discharge.

RESULTS:
From 992 records, 228 patients met inclusion criteria. There were 115 M, 113 F, with a mean age of 62.6y. Overall, 106 (46.5%) patients received Fe on discharge. In regression analysis, adjusted for multiple confounders, having received Fe (PO or IV) while inpatient was strongly predictive of receiving Fe on discharge aOR= 13.5 (CI 6.8-26.8). In addition, if admission hgb was <8.0, the aOR of receiving Fe on discharge was 2.21 (CI 1.10 – 4.45). Nadir and discharge hemoglobin were not associated with Fe supplementation. There was no statistical reduction in readmission rates for those discharged on Fe although a Type 2 error could not be excluded.

CONCLUSION:
Physicians fail to provide Fe supplementation on discharge to over 50% of patients eligible after a GIB. Fe supplementation during a patient's hospitalization is the strongest predictor of receiving Fe upon discharge. This may be due to the medication reconciliation performed by the EMR at time of discharge. The other predictor variable was admission hgb but not nadir or discharge hgb. Automated reminders built into the EMR may help reduce this widespread problem.