bluuebunny/crossref_metadata_2025_split huggingface dataset:
452 What Really Happens to Our Veterans With Achalasia?
Authors: Hasan Raza , Banerjee Promila , Sontag Stephen , Schnell Thomas , Leya Jack 
Published: October 2019

INTRODUCTION:
Few studies have reported the outcomes of veteran patients with achalasia over a period of decades, and the role of surgical versus non-surgical management remain uncertain.

METHODS:
This study identified 66 patients confirmed by manometry from 2000-2017. All patients were from a single site, Veterans Affairs Hospital in Hines, IL. Patients were followed up to 18 years overall. These outcomes were examined; natural progression of disease, complications from the disease and mortality. Additionally, type of treatment, responses to treatment (performed by 3 endoscopists) and complications of treatment were recorded. Sustained response was defined as a decrease to Eckhardt score <4 for one year.

RESULTS:
Of the 66 patients, 5 patients were found to have external compression from malignancy, and there were excluded. Of the remaining 61 patients, 100% were male, 70.5% were white, and 29.5% were African-American. Mean age at diagnosis was 67 years old. Average follow up was 5.3 years. Of the 48 patients that received treatment, 62.5% received pneumatic dilation (PD), 43.8% received Botox injections, and 25% received Heller Myotomy (HM). Sustained response rates were superior in the PD group compared to the botox, 63.3% vs 42.9% (P 0.07), and PD group compared to HM 63.3% vs 41.7%, (P 0.10). In this group, the average number sessions was 2.1 for PD, 1.9 for botox, and 1.1 for HM. Overall response rate for all three modalities was 75% (n = 36). Complications were highest in the HM group with a rate of 25%. Further analysis of subgroups showed that risk factors of GERD, obesity and OSA did not affect treatment response rate, with overall treatment response rates of 85.7% for GERD, 100% for obesity, and 100% for OSA. Of the 13 patients who did not receive any treatment for achalasia, 69.2% continued to have symptoms; however none of these patients developed complications of aspiration, infection, food impaction or death.

CONCLUSION:
PD was superior to botox and PD was superior to HM in sustained response and complication rate. There was no statistical significant difference between any type of interventions verses no intervention; but this may be due to the small number of patients receiving HM.
458 Implementation and Analysis of an Online Esophageal Motility Curriculum for Gastroenterology Fellows
Authors: Kraft Cary , Ko Myung S. , Sewell Justin , Kathpalia Priya 
Published: October 2019

INTRODUCTION:
Compared with endoscopic training, motility education of gastroenterology (GI) fellows is limited at many training centers. To better prepare fellows for treating patients with esophageal motility (EM) disorders, an understanding of EM is essential. Novel educational technology may facilitate dissemination of standardized curricula to train GI fellows at programs lacking strong motility presence.

METHODS:
A pretest survey assessing comfort level and baseline interpretation of EM studies was sent to UCSF GI fellows in July 2017. An online application called Qstream was then implemented which sent 1-2 questions per week out of a specially designed question bank. Questions, with detailed explanations, were repeated or retired depending on response accuracy. A post-curricular test was sent in June 2018 to gather quantitative and qualitative data. The Qstream software was also mined for data on correct responses across multiple attempts at answering questions. Analysis was performed using qualitative assessment of feedback from participants and comparative statistics using a paired- t test with unequal variance and Chi-square test.

RESULTS:
Nine trainees completed a pretest survey and 6 trainees completed the posttest. Initially, only 33.3% of fellows were comfortable in interpreting EM studies, whereas following the curriculum 83.3% felt comfortable in their abilities (P = 0.097). Trainees' accuracy in interpreting and answering clinical questions increased from 77.8% to 80% on the posttest (P = 0.43). However, when using data obtained directly from the Qstream software, there was relative improvement (26.9%) from fellows' first attempt at answering questions to their final attempt. Trainees found the following aspects of the curriculum to be valuable: the ease of usability of the online questions, the flexibility in pacing, and the real time explanations of questions.

CONCLUSION:
A technology based curriculum was effective and efficient in educating GI fellows on core concepts of EM. The online nature of the curriculum was critical in accommodating the busy clinical schedules of our trainees. Fellows reported increased comfort in interpreting EM studies after completing the curriculum; lack of improvement on the post-test likely reflects their high performance on the pre-test, which was not very complex. We plan to continue offering this curriculum with increasingly challenging questions to allow for further stratification of data and overall improved competency in EM among GI trainees.
460 High Rates of Loss to Follow-Up After Esophageal Food Impaction in Suspected Eosinophilic Esophagitis: Time to Standardize Care
Authors: Donohue Sarah , Hillman Luke , Lomeli Luis , Gaumnitz Eric 
Published: October 2019

INTRODUCTION:
Esophageal food impaction (EFI) is often the first presentation for patients with eosinophilic esophagitis (EoE). Management of EFI when EoE is suspected lacks evidence-based guidelines. The goals of this study are to evaluate the biopsy rates, medical management, follow-up and recurrence of EFI in patients with suspected EoE.

METHODS:
Adult patients presenting with EFI between 2007-2017 were identified by ICD-9 (935.1) and ICD-10 (T18.1) codes for foreign body in the esophagus. Inclusion criteria required endoscopic intervention with documentation of suspected EoE: defined as endoscopic features of rings, furrows, edema or exudate.

RESULTS:
We identified 471 cases of EFI requiring endoscopic intervention, with 171 suspected to have EoE. The biopsy rate at time of EFI for patients with suspected EoE was 46%. When patients were not biopsied at time of EFI (n = 93), the majority were initiated on empiric therapy without histologic diagnosis: PPI (90%) and topical steroids (1%). Follow-up endoscopy was recommended in 97% of patients not biopsied at time of EFI and 32% (n = 27) were lost to follow-up. Empiric therapy after EFI did not impact the diagnostic yield at time of follow-up endoscopy (median: 36 days) as rates of diagnostic biopsy (≥15 eos/hpf) were similar compared to those biopsied at time of EFI (66% vs 65%, P = 0.612). Time to follow-up endoscopy did not impact diagnostic yield (P = 0.21). While on therapy, 16% of patients (n = 9) had low level esophageal eosinophilia (5-14 per hpf) on follow-up EGD (median: 29 days). Over the 11 year period, recurrent EFI occurred in 16 patients (3.4%) with a median time to recurrence of 1.65 years.

CONCLUSION:
EFI presents a unique opportunity to diagnose, treat and establish care for patients with EoE. Our study identified low rates of esophageal biopsy and high rates of loss to follow-up. Empiric therapy did not impact diagnostic yield on subsequent endoscopy with early follow-up. Low level eosinophilia while on therapy should be interpreted cautiously as this may represent partially treated disease. Although uncommon, EFI and recurrence are a disease defining event that create significant patient discomfort and require costly intervention. Our study highlights the need for standardize practice at the time of EFI when EoE is suspected including a structured system to streamline outpatient care, avoid loss to follow up and ultimately, prevent long term complications from this chronic disease.
462 A Retrospective Review of Effervescent Granules and Glucagon for the Management of Esophageal Food Impactions in a Community Hospital
Authors: Beattie Michael , Mansour Ramy , Minaudo Mark 
Published: October 2019

INTRODUCTION:
Esophageal food impaction is one of the more common GI emergencies. While endoscopy is the definitive therapy, pharmacologic therapy does have a role. Despite minimal success, because of the safety profile glucagon is currently recommended as the initial pharmacologic therapy.1–5 Effervescent agents have been limited due to previous concerns of perforation, but studies have been revisited recently with safety and success.5–7 Our aim is to measure EG and glucagon as a primary pharmacologic agent.

METHODS:
A retrospective study was performed on all patients over 18 between 6/2015-5/2018, with diagnosis of esophageal obstruction or foreign body. Exclusion was transfer to outside facility. Records were reviewed for administration of glucagon and/or effervescent granules, if relief of obstruction was achieved, patient's ability to tolerate secretions and food responsible. Etiology was determined from history, endoscopy report, imaging, and pathology. T-test was performed for statistical significance.

RESULTS:
Demographic data, along with food bolus types and diagnoses can be found in Table 1. EG was attempted as an initial modality in 20.2% of cases and glucagon in 16.8%. EG was more successful when compared to glucagon (51.2 % vs 14.7%) (P = 0.0216). EG was successful as secondary modality in 75% of cases after glucagon initially failed, as compared to glucagon in 0% (0/9) of cases when EG initially failed (P = 0.0094). Figure 1 highlights success of EG and Glucagon based on diagnosis. There were no major safety events.

CONCLUSION:
Overall, EG is safe; and appears to overall be more efficacious than glucagon as initial pharmacologic therapy for EFI. This is a worthwhile therapy for both those who are tolerating secretions and those who are not, while glucagon seems to be more effective for secretion tolerant patients. EG was highly successful in patients tolerating secretions, however with a success rate of over 50% with no complications, we suggest it is worth attempting even in those who are not.
468 Effects of Eluxadoline on a Range of Bowel and Abdominal Symptoms in Patients With Irritable Bowel Syndrome With Diarrhea who Report Inadequate Symptom Control With Loperamide
Authors: Brenner Darren M. , Sayuk Gregory S. , Elmes Steven J. R. , Saeed Mazen , Chey William D. 
Published: October 2019

INTRODUCTION:
The efficacy and safety of eluxadoline (ELX), a US Food and Drug Administration-approved mixed μ- and κ-opioid receptor agonist and δ-opioid receptor antagonist for treating adult patients with irritable bowel syndrome with diarrhea (IBS-D), were evaluated in patients who self-reported inadequate response to loperamide in the RELIEF trial. Radar plots were generated from these results to interpret improvements across a spectrum of efficacy measures in ELX-treated patients.

METHODS:
A Phase 4, multicenter, placebo (PBO)-controlled, double-blind study randomized patients with IBS-D (Rome III criteria) with intact gallbladders who reported overall inadequate IBS symptom control with loperamide in the preceding 12 months to oral ELX (100 mg twice daily) or PBO for 12 weeks (RELIEF; NCT02959983). Patients rated IBS symptoms including worst abdominal pain (WAP), abdominal bloating, abdominal discomfort, stool consistency, number of bowel movements (BMs), and urgency episodes daily. Adequate relief of IBS symptoms was assessed weekly. Response rates over Weeks 1–12 and change from baseline to Week 12 were graphed using radar plots for the following endpoints: primary efficacy composite response (simultaneous daily improvement of ≥40% in WAP score vs. baseline and Bristol Stool Form Scale score <5 [or no BM] on ≥50% of treatment days); stool consistency response as per the primary endpoint; urgency-free response calculated using criteria of ≥50% or ≥75% of days with no urgency episodes; adequate relief response defined as a weekly “yes” response for ≥50% of treatment weeks; WAP response calculated using criteria of ≥30%, ≥40%, or ≥50% improvement vs. baseline.

RESULTS:
In this study cohort, baseline symptom scores were similar between the treatment groups (Table 1). Significantly higher proportions of ELX-treated patients were composite, stool consistency, and ≥30%, ≥40%, and ≥50% WAP responders vs. PBO at Week 12 (Figure 1). A greater proportion of ELX- vs. PBO-treated patients were also urgency-free and adequate relief responders. ELX-treated patients experienced greater improvements from baseline in WAP, abdominal bloating and discomfort, BM frequency, and urgency episodes vs. PBO (Figure 2).

CONCLUSION:
Across 13 endpoints, ELX treatment led to improvements vs. PBO, indicating efficacy across a multitude of IBS-D symptoms among patients with prior inadequate symptom control with loperamide.
474 Activated Duodenal Eosinophils Are Associated With Early Satiety-Predominant Functional Dyspepsia: Results From a U.S. Veteran Cohort
Authors: Sparkman Jordan , Damron Alexander , Green Linda K. , Rosen Daniel , Graham David Y. , El-Serag Hashem B. , Jarbrink-Sehgal Maria 
Published: October 2019

INTRODUCTION:
Functional Dyspepsia (FD) is unexplained epigastric discomfort, early satiety or postprandial distress for three months. FD affects 50% of care-seeking Veterans in the United States. Diagnosis of FD is based on Rome consensus symptom criteria as no objective markers exist. There is interest in duodenal eosinophilia as a driver of FD symptoms, however heterogeneity among recent studies has produced divergent results. A “normal” range of duodenal eosinophil counts should be established. The influences of a personal history of atopy, medication use and seasonal variation effects on duodenal eosinophil counts and their relation to FD symptoms are poorly studied.

METHODS:
This is a cross-sectional study from the Michael E. DeBakey VA Medical Center in Houston, Texas utilizing a well described cohort. Exclusion criteria included malignancy, H. pylori, celiac disease, parasite infection, eosinophilic gastroesophagitis and others. FD was defined by survey-derived Rome II symptom criteria. Medication use was obtained through chart review. Histopathology was independently reviewed by two blinded observers.

RESULTS:
460 patients were included in the present study. There was good observer agreement on duodenal eosinophil counts. Duodenal eosinophilia was defined as ≥62 per 5 HPF. Patient characteristics grouped by presence or absence of duodenal eosinophilia are found in Table 1. Mean eosinophil counts grouped by various items are included in Table 2. 182 patients had FD (39.6%) and were younger (58 vs 60.2 years of age, P = 0.01) and more likely to be on a PPI and H2RA (P = 0.03, P = 0.02) compared to controls. Eosinophil degranulation was present in 101 (22.0%) patients and was associated with FD (OR 1.84, 95% CI 1.15-2.94, P = 0.01), specifically early satiety symptoms (OR 2.15, 95% CI 1.33-3.47, P = 0.002) but not epigastric pain (P = 0.62). Samples collected in the fall had significantly lower mean duodenal eosinophils per 5 HPF (55.1) than those collected in the spring (82), summer (73.2), or winter (76.2) months.

CONCLUSION:
In this large, adult, and diverse VA study, duodenal eosinophilia, defined as counts ≥62 per 5 HPF, was common (50.2%). While we could not confirm an association between duodenal eosinophilia and FD in our patient cohort, a positive association between the presence of activated duodenal eosinophils and FD, specifically early satiety-predominant FD, was found. This supports the inflammatory hypothesis of FD, albeit more proximally in the cascade.
485 Evaluation of Somatic Pain Distribution Using Body Maps for Patients With Chronic Abdominal Pain Syndromes
Authors: Aivaliotis Vasiliki I. , Hah Jennifer M. , Pirrotta Luke , Nguyen Linda A. 
Published: October 2019

INTRODUCTION:
Chronic abdominal pain (CAP) is a widespread condition with a large impact on the healthcare field. Understanding the characteristics of patients with CAP and identifying high risk patients remains an important issue, particularly in the opioid epidemic era. A body map is a validated tool shown to accurately depict pain locations across the body. Our aim was to use body map data to characterize the pain distribution patterns of patients referred for abdominal pain to the Stanford Pain Clinic and to assess whether patterns of pain distribution (e.g. localized abdominal pain vs. widespread pain) are associated with underlying diagnoses and differences in psychosocial functioning.

METHODS:
We evaluated patients with CAP who presented to the Stanford Pain Clinic between 2013-2018. Data was collected through the CHOIR registry - a platform that longitudinally collects data for patients seen at our pain clinic. Patients were divided into 3 groups by their body map response: Localized (abdominal pain), Intermediate (abdominal pain + pain at 1-3 additional sites), and Widespread (abdominal pain + pain at 4-8 additional sites). We evaluated demographics, ICD-codes, and psychosocial functioning with NIH PROMIS questionnaires. Analysis was performed using descriptive statistics, one-way ANOVA for the PROMIS scores, and the Kruskall-Wallis test for comparing measures across the 3 groups.

RESULTS:
A total of 258 patients with abdominal pain were identified through the CHOIR registry. The majority of the patients were female (91%) and had widespread pain patterns (61%). Patients with widespread pain patterns reported higher pain interference (P < 0.01), anxiety (P < 0.05), and sleep disturbances (P < 0.01) compared to the intermediate pain group. Patients with widespread pain were more likely to carry a diagnosis of 2 or more chronic overlapping pain conditions (P < 0.001). Opioid use remained high in all patients, regardless of somatic distribution pattern.

CONCLUSION:
Our study supports that a body map is an effective and quick screening tool to help characterize CAP patients and identify higher risk patients. Identifying patients with widespread pain patterns early may help guide therapeutic interventions towards factors more prominent in this group such as pain interference, anxiety and sleep disturbance. Patients with widespread pain patterns are more likely to also suffer from chronic overlapping pain syndromes and should be screened for these conditions.
486 Social Media Use in Irritable Bowel Syndrome Patient Education: A Content Analysis of YouTube Videos
Authors: Zheng Xin , Fan Xiaowen , Wright Andrew P. , Kim John , Zhao Yan 
Published: October 2019

INTRODUCTION:
Irritable bowel syndrome (IBS) affects around 11% of the population globally and often associated with lower quality of life. The diagnostic challenges and myths surrounding IBS further drive patients to seek additional information via social media platforms such as YouTube. This study performs a multi-dimensional analysis of the most viewed IBS videos on YouTube using the DISCERN scoring system. The goal of this study is to determine the overall validity, breadth and depth of IBS knowledge delivered to patients seeking IBS information on YouTube.

METHODS:
The multi-dimensional content analysis includes two parts. Part I consists of a general search using keyword “IBS”. The 30 most viewed videos were reviewed individually for their information on IBS diagnosis, symptoms, treatment and prognosis. Part II focuses on the 10 most viewed videos and 3 board certified gastroenterologists undergo a detailed content analysis using the validated DISCERN scoring system (1- low quality to 5 – high quality) and further validated the contents against the current practice guidelines and consensus.

RESULTS:
Of the 30 top viewed IBS videos, 60% (n = 18) were made by for-profit websites or companies (total 5.28 million views), 23.33% (n = 7) came from scientific and medical institutions (total 2.54 million views), and 16.67% (n = 5) were personal commentaries and experiences (total 1.14 million views). Videos made by scientific institutions have the highest average number of views per video. The average DISCERN score for overall quality of the top 10 videos was low-intermediate quality (2.38 out of 5). Low quality videos have a total views three times more than those of intermediate quality (3.67 million vs. 1.25 million). These videos score relatively high (>3) on items relating to the benefits of their proposed treatment but low on item relating to the risks of each treatment.

CONCLUSION:
In this study, the overall quality of YouTube's most viewed videos on IBS treatment have a collectively low-intermediate quality. They often avoid discussion on the risks of their proposed treatment option. The number of views also does not necessary correlate with quality. Videos made by for-profit organizations have total view counts much higher than videos made by reliable medical institutions, likely because they are more invested in advertising and have more videos. The medical community will need to collectively deliver better quality and more YouTube video for the purpose of IBS patient education.
494 The Fragility of Randomized Placebo-Controlled Trials for Irritable Bowel Syndrome Management
Authors: Williams Mary-Jane O. , Dennis Brittany , Dlamini Vanessa , Nwaiwu Obioma , Nguyen Linda A. , Okafor Philip N. 
Published: October 2019

INTRODUCTION:
Fragility indices (FI) are a novel method to measure the robustness of results in clinical trials. The FI represents the number of participants whose status in a clinical trial would have to change from a non-event (not experiencing the primary endpoint) to an event (experiencing the primary endpoint) to turn a statistically significant result into a non-significant result. The aim of this study was to evaluate the robustness of trials for irritable bowel syndrome (IBS) including IBS-mixed, IBS-constipation, and IBS-diarrhea.

METHODS:
Trials published in high impact journals comparing the efficacy of therapies for IBS were identified from Medline. Trials had to be in adults, randomized, parallel-armed, with at least one statistically significant (P < 0.05) binary outcome, and a positive result (i.e. primary endpoint met). Only primary endpoints of therapeutic efficacy were considered. Only trials comparing Rifaximin, Eluxadoline, fecal microbiota transplant (FMT), probiotics, Ramosetron, Alosetron, physical activity, Cimetropium and Pinaverium to placebo met the inclusion criteria. FI and correlation coefficients were calculated and regression modeling was also used to identify predictors of a high FI.

RESULTS:
Thirteen trials meeting the inclusion criteria were analyzed. The impact factor of the journals in which they were published ranged from 3.5-79. The median FI was 6 (range 1-38). The median sample size in all trials was 427 (range: 44-1280). The trial publication year (P = 0.60), journal impact factor (P = 0.16), time point in weeks when the primary outcome was assessed (P = 0.45), duration of the study (P = 0.89), and number needed to treat [NNT] (P = 0.06) were not predictive of a high FI. However, a larger sample size was predictive of a higher FI (P = 0.01). The highest FI was seen in a Ramosetron trial (FI = 38) for IBS-D published in Gastroenterology. No correlation was seen between FI and journal impact factor (R = 0.19, P = 0.55), trial publication year (R = 0.09, P = 0.77), duration of trial (R = -0.45, P = 0.12), time point at which the primary endpoint was assessed (R = -0.12, P = 0.70), NNT (R = -0.34, P = 0.26), and sample size (R = 0.22, P = 0.47)

CONCLUSION:
Our results suggest that a median of six participants is needed to nullify efficacy outcomes in the included IBS therapy trials. A larger sample size was predictive of a high FI. Some trials used in the formation of evidence-based guidelines are fragile suggesting how easily statistical significance based on a threshold P-value may be overturned.