bluuebunny/crossref_metadata_2025_split huggingface dataset:
586 Investigation of Gastrointestinal Bleeding Among Left Ventricular Assist Device Recipients
Authors: Kalinowski Michael , Kothari Shana , Kobeszko Matthew , Josephson Greta , Cotts William , Pauwaa Sunil , Tatooles Antone , Elkhatib Imad , Silva Rogelio 
Published: October 2019

INTRODUCTION:
Left ventricular assist device (LVAD) therapy is a form of mechanical support for patients with advanced heart failure as either a bridge to heart transplant or destination therapy. The association between gastrointestinal bleeding (GIB) and LVAD recipients is well established. There has been reported literature comparing demographics and clinical associations between patients with and without GIB. The aim of this study was to further investigate these characteristics, identify associations with GIB, and further understand endoscopic management of GIB among LVAD recipients.

METHODS:
This was a single-center retrospective study analyzing randomly selected patients from a population of 425 Heartmate (HMII) and 193 Heartware recipients from 2007 to 2018. Chart review was performed and data pertaining to demographics, LVAD therapy intention and settings, endoscopic reports, home medications, and echocardiogram reports was collected. Univariate analysis was performed.

RESULTS:
A total of 188 HMII and 134 Heartware patients were included in this study. Patients that developed GIB tended to be older (56.4 vs. 61.7 years; P = 0.0002). No differences were found in race and gender. Patients that developed a GIB had a higher baseline Cr (1.2 vs. 1.4; P = 0.0284) and lower baseline Hg (10 vs. 11; <0.001). A supratherapeutic INR was associated with GIB (14.7% vs. 26.7%; P = 0.0075). Patients prescribed angiotensin II receptor blockers had less occurrence of GIB (Table 1). Melena was the most common presenting sign. Bleeding lesions were most frequent in the small bowel (42.6%). Of all bleeding lesions identified, 73% were found with EGD and 80.4% were found with push enteroscopy. Arteriovenous malformations were the predominant etiology (Table 2).

CONCLUSION:
This is one of the largest single-center studies of GIB among patients with LVADs. Small bowel gastric arteriovenous malformations were the most common etiology. The majority of upper GI bleeds were within reach of a push enteroscope (proximal small bowel), which had an incremental diagnostic yield over EGD. There was a protective association with reduced occurrence of GIB among patients taking angiotensin II receptor blockers. The use of proton pump inhibitors showed no association in GIB occurrence and may be overused in this population. Further development of the association between angiotensin II receptor blockers and GIB effect in LVADs are warranted. Multivariate analyses to validate these associations are in progress.
590 Gastrointestinal Bleeding in Veterans on Oral Anticoagulants
Authors: Wayde Melinda , Hussain We'am , Loesch Erin B. , Markert Ronald , Agrawal Sangeeta 
Published: October 2019

INTRODUCTION:
Oral anticoagulants play an integral role in the prevention and treatment of cerebral and systemic thromboembolism. Traditionally, this has been managed with vitamin K antagonists, primarily warfarin. Over time, however, the use of direct oral anticoagulants (DOACs) have gained popularity. Unsurprisingly, the initiation of a medication that decreases the blood's ability to clot increases the risk of bleeding. The aim of this study was to examine the incidence of gastrointestinal bleeding (GIB) in patients enrolled in an anticoagulation clinic at a Veterans Affairs (VA) medical center.

METHODS:
The VA's Computerized Patient Record System was used to create a list of patients seen in the VA anticoagulation (AC) clinic from 10/2010 to 9/2016. A sample of 1997 patients was randomly selected using a web-based program. Based on the formulary at the VA, only warfarin, rivaroxaban, dabigatran, and apixaban were examined. Demographics, indications for anticoagulation, and relevant comorbidities and concomitant medications were recorded.

RESULTS:
Despite increasing use of DOACs since their introduction in 2011, results of the analysis indicate warfarin was still the most commonly prescribed anticoagulant in our population with 1270/1997 (64%). Rivaroxaban was taken by 28%, apixaban by 13%, and dabigatran by 10%. GIB was seen in 31/1270 patients (1.55%). In those taking warfarin, 28/1270 (2.3%) had GIB (P < 0.001). GIB was seen in 3/552 patients taking rivaroxaban (0.5%, P = 0.024). GIB was seen in 5/256 patients taking apixaban (2%), but this did not reach statistical significance. GIB was seen in 1/198 patients taking dabigatran (0.5%), but this did not reach statistical significance. Factors associated with increased risk of GI bleeding included chronic kidney disease and diabetes mellitus. Patients not on proton pump inhibitors, clopidogrel, and nonsteroidal anti-inflammatory medications had an increased risk of GIB.

CONCLUSION:
Given similar efficacy of DOACs to warfarin shown in prior studies, the choice of oral anticoagulant rests largely on the safety profile. In a population of patients seen in the VA AC clinic, the most commonly prescribed anticoagulant was warfarin. The risk of GI bleeding was highest in these patients, similar to findings in previous studies. The lowest risk was seen with dabigatran. A data set with more GIB patients would allow multiple logistic regression analysis of the medications and comorbidities identified as risk factors.
593 Impact of Computed Tomography Angiography-First Approach on Length of Stay and Time to Definitive Therapy in Patients Presenting for Lower GI Bleed
Authors: Ekekezie Chiazotam , Vecchio Eric , Argueta Erick , Jimoh Lanre , Carter Valerie , Reinert Steven E. , Monteiro Joao Filipe G. , Grand David , Rich Harlan 
Published: October 2019

INTRODUCTION:
The initial study of choice in patients who present to the emergency department (ED) for lower gastrointestinal bleeding (LGIB) is a topic of debate. It is unclear how patient outcomes are affected if computed tomography angiography (CTA) of the abdomen and pelvis is a preliminary study. A major teaching hospital implemented a CTA-first protocol in patients presenting for LGIB in December of 2014. Our goal was to determine how this policy impacted outcomes like hospital length of stay (LOS), time to definitive intervention, number of colonoscopies or embolizations performed, and yield or impression of colonoscopy.

METHODS:
Electronic medical records were queried for patients presenting for acute LGIB from January 2011 to December 2016. We gathered healthcare and demographic information in patients older than 18. SAS© software was used to perform student's t-tests, chi-square and multivariable linear regression analysis of the data.

RESULTS:
Five-hundred seventy-four encounters were analyzed, 297 before CTA-first policy (B-CTA) and 277 after CTA-first (A-CTA) policy implementation. The groups were without significant differences in sex, race, age, admission day of the week, hemoglobin or creatinine on presentation (Table 1). There were significant differences in heart rate and systolic blood pressure on presentation (Table 1). LOS in the B-CTA group was 5.8 days compared to 5.1 days in the A-CTA group (P > 0.05; Table 2). In those hospitalized for more than two weeks, interestingly, LOS did seem shorter overall A-CTA (P < 0.01; Figure 2). More CTAs were performed after policy implementation (Table 2). Multivariate analyses showed a 77% reduction in the number of colonoscopies (P < 0.0001) and a 47% decrease in early (those within 24h of admission) colonoscopies (P = 0.0082) (Table 3). Time to colonoscopy was not significantly reduced B-CTA versus A-CTA (Table 2). Colonoscopy impressions detailing the source of bleeding pre- and post-policy implementation were similar (Figure 1). There was no significant change in the number of or time to embolizations (Table 2).

CONCLUSION:
The CTA-first protocol was intended to facilitate effective triage of patients, targeted definitive therapy, and decreased overall LOS. Our findings suggest that for patients presenting for LGIB, this approach did not significantly improve LOS unless admitted for more than 2 weeks. Moreover, it is questionable that it facilitated more targeted intervention with embolization or colonoscopy.
595 The Glasgow-Blatchford Score: Pitfalls and Cost of Generalization
Authors: Contreras Alberto , Robles Alejandro , Mendoza-Ladd Antonio 
Published: October 2019

INTRODUCTION:
Non-variceal acute upper gastrointestinal bleeding (NVAUGIB) is one of the most common causes of hospitalization worldwide. The Glasgow-Blatchford Score (GBS) was developed to identify subjects who would benefit from hemostatic endoscopic intervention (HEI), in this and other types of GIB. According to the literature, a GBS score <2 identifies with up to 99% accuracy subjects who do not need emergent HEI. Experience at our center suggests that the average GBS of our patients with NVAUGIB is consistently >2 and yet our rate of HEI is low. Therefore, the primary aim of this study was to accurately determine the rate of significant HEI in subjects with NVAUGIB with GBS >2. The secondary aim was to determine the cost of esophagogastroduodenoscopy (EGD) in patients in whom no significant HEI was performed.

METHODS:
Medical records of subjects admitted for NVAUGIB who underwent EGD from January 2015 – December 2017 were reviewed. NVAUGIB was defined as the presence of any of the following: hematemesis, hematochezia, coffee ground emesis, + FOBT, melena, drop in Hgb >2 g/dl and absence of varices on EGD. The GBS was calculated on the day of EGD on all subjects. Data obtained was compared using a Kolmogorov-Smirnov Test of Normality first to ensure normal distribution, then an independent T-test was used to evaluate for significance. EGD cost was obtained from the hospital administration.

RESULTS:
A total of 586 subjects underwent EGD for the evaluation of NVAUGIB, and their demographic characteristics are listed in Table 1. The mean GBS for subjects with ≤2 and >2 were 1 and 8.8 respectively. Of those with a GBS >2 (503/586), only 16.9% (85/503) underwent a HEI. On the other hand, only 1% (1/83) of those with GBS ≤2 (83/586), underwent HEI. Overall, subjects who received HEI (86) had higher GBS compared to those who didn't (9.29, SD 3.51) vs. (7.42, SD 4.06) (P ≤ 0.05). A total of 418 EGDs without HEI were performed in subjects with GBS >2. The cost of a diagnostic EGD at our institution is approximately $2,866.00. Therefore, the cost of these procedures was approximately $1,200,000.00.

CONCLUSION:
In our population, a GBS cutoff of >2 did not identify patients requiring HEI accurately as previously reported in the literature. The cost of performing non-therapeutic endoscopic evaluation in these subjects is alarming. Further research regarding the generalizability of the GBS is needed at this time.
600 Impact of Anti Coagulation and Anti Platelet Treatment on 30-Days Readmission Rate of Patients With Gastrointestinal Bleeding in Tertiary Care Setting of Northern Pennsylvania
Authors: Kirshan Ravi Shri Jai , Yang Tsujung , Ravi Priyanika , Ahuja Satish Kumar , Makhejani Kailash , Ahuja Keerat Rai , Essrani Rajesh 
Published: October 2019

INTRODUCTION:
Gastrointestinal bleeding remains the major complication of blood thinners such as anti platelet agents and anticoagulants leading to frequent hospitalization. It requires involvement of multi disciplinary approach for its management. Despite the hard efforts, patient readmission remains a major concern. Our study aims to highlight the impact of these agents on 30 day readmission.

METHODS:
Patients admitted with Gastrointestinal bleeding were extracted using ICD 10 codes K 92.0, K 92.1, and K 92.2. Essential baseline characteristics including age, race, Primary Diagnosis, Readmission Diagnosis, Patients not on blood thinners, Patients on anti platelet, Patients on anti coagulants, Patients on combined medications, Atrial fibrillation, Deep Vein Thrombosis, Pulmonary embolism, Metallic Heart Valve, History of Stroke, 30-day mortality, causes of re admissions were identified by reviewing the electronic medical record of individual patients. Patients were stratified into 4 groups as Patients not on blood thinners (group A), taking Anti platelet (group B), Anticoagulant (group C) and combined anti platelet with anticoagulant (group D). Statistical analysis was performed using SPSS version 25.

RESULTS:
Total of 1296 patients was admitted in the last decade from 2009-2018 with the diagnosis of Gastrointestinal bleeding. Mean age of patients was 70.31± 15.38 (Mean ± SD), the majority were Males (50.2%) and Caucasians (97.1%). Patients had following associated comorbidities such as Deep venous thrombosis (9.0%), Pulmonary Embolism (5.8%), Atrial Fibrillation (33.4%), History of Stroke/TIA (16.4%) and Metallic Heart Valve(5.8%).Majority of Patients were not on any agent (41.7%) followed by Anti platelet (29.6%), Combined (16.5%) and Anti coagulation (12.2%). The 30-days Readmission rate was higher among patients on Combined agents followed by Anticoagulant group, No agent group and Anti platelet agent (29.0% vs. 19% vs. 17.7 vs. 16.4%, respectively, OR: 1.89 CI 1.20-2.73 P-value = 0.01, whereas 30-days mortality was not significantly different among patients in different agents P-value= 0.70.

CONCLUSION:
This study reveals a very significant finding that odds of 30-day readmission approximately double for patients who are on combined anti platelet and anticoagulant therapy when compared with other groups, whereas 30-day mortality remains unchanged.
602 Angiography Versus Colonoscopy in Diverticular Hemorrhage
Authors: Lipcsey Megan , Moore Matthew , Stein Daniel J. , Feuerstein Joseph 
Published: October 2019

INTRODUCTION:
Diverticular hemorrhage is the most common cause of lower gastrointestinal hemorrhage. Determining the source of bleeding is difficult and therapeutic intervention rates are variable. Many centers perform angiography for patients with more severe bleeding since it does not require bowel preparation and can be rapidly performed; however it has never been directly compared to colonoscopy and may not be available. Using the national inpatient sample, we compared outcomes for patients with diverticular bleeding undergoing angiography to colonoscopy.

METHODS:
This national inpatient sample (NIS) from 2016 was queried for cases of diverticular hemorrhage based on ICD-10. Outcomes were compared for colonoscopy alone to angiography including mortality and rate of post-procedure transfusion. Angiography use was compared by hospital type to deduce if there was an availability bias in usage pattern. Survey-adjusted logistic regression was used to examine mortality and predictors of angiography use. Adjustment was made for the Elixhauser mortality score (a validated measure of comorbidities) and other confounders as below.

RESULTS:
63,620 patients were admitted for diverticular hemorrhage in 2016. 2,795 (4.4%) underwent angiography and 40,380 (63.5%) underwent colonoscopy. 62.3% of angiography patients had a colonoscopy (98.6% prior to the angiogram). Angiography was more common in patients at academic (5.1%) and urban non-teaching (4.0%) compared with rural (0.5%) hospitals. Mortality was 2.3% in patients undergoing angiography versus 0.8% in patients undergoing colonoscopy alone. In the multivariable regression, requiring angiography was associated with a 3.2 times the odds of mortality (95% CI 1.7-6.0) adjusting for age, transfusion requirement and Elixhauser. Adjusting for age, Elixhauser and transfer status, freedom from transfusion (OR = 0.34, 95% CI 0.28-0.40) and rural hospital location (OR = 0.13, 95% CI 0.06-0.28 compared to urban teaching) were strongly associated with angiography.

CONCLUSION:
In a national cohort of patients managed for diverticular bleeding, angiography was performed in under 5% compared with nearly 64% who had colonoscopy. However, it was associated with a higher rate of mortality though not transfusion. This persisted after controlling for confounders. Far fewer patients underwent angiography at small community hospitals, raising concern about the availability of this resource in the community setting.
607 Underutilization of Digital Rectal Exam in the Evaluation of Patients With Gastrointestinal Bleed in the Ambulatory Setting: Analysis of the National Ambulatory Medical Care Survey
Authors: Mossad David , Wu Benita , Agrawal Sangeeta 
Published: October 2019

INTRODUCTION:
Digital rectal exam (DRE) is a critical component in evaluating gastrointestinal (GI) bleeds in the ambulatory setting. It is important in dictating medical management and decision making.1 Ideal patient outcomes, in such an acute setting, require selection of appropriate interventions and therapies. The purpose of this study was to evaluate the overall frequency in which this test is performed in patients presenting with GI bleed in the ambulatory setting.

METHODS:
The National Ambulatory Medical Care Survey (NAMCS) was searched using International Classification of Diseases - Ninth Revision (ICD-9) diagnosis codes for patients seen in the office for GI bleed for the years 2011-2015. Patients were separated into two groups: those who underwent DRE and those who did not. Data was analyzed based on ethnicity, gender, race, and age. 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:
A total of 265 ambulatory care patients with GI hemorrhage were identified. Only 38 patients (14%) underwent DRE. Between gender groups, there was no difference in DRE performed (13.3% of males vs 15.4% of females, P = 0.727). Race had no significant impact on DRE rates when Asians, Whites and African Americans were compared (P = 0.487). There was no difference in DRE rates in Hispanic versus Non- Hispanic ethnicity groups (P = 0.087). Age was also found to be noncontributory to DRE performance (mean age of 54.3 for DRE vs 50.4 for no DRE, P = 0.349).

CONCLUSION:
With 14% of patients undergoing appropriate examination for GI hemorrhage, this study shows underutilization of DRE in the ambulatory setting. In this study, factors such as age, race, ethnicity and gender had no impact on DRE performance rates. GI bleeds can pose significant implications in morbidity and mortality and appropriate decision making is crucial for good patient outcomes. Evaluation of potential bleeds via DRE can impact clinical decision making and medical management in the form of admissions, endoscopic procedures and medical therapies. Proper physical examination in the setting of GI bleed should be emphasized in the ambulatory setting.
612 Impact of a Pharmacist-Managed Protocol Limiting Continuous Infusion of Proton Pump Inhibitor Use in Patients With an Upper Gastrointestinal Bleed
Authors: Lauren Schwaner , Thomas Drew , Kaila Vishal , Faust Andrew , Feldman Mark 
Published: October 2019

INTRODUCTION:
In patients with an upper gastrointestinal bleed, previous reports have shown that there is no difference among clinically significant endpoints when prescribed a continuous infusion of pantoprazole versus intermittent bolus administration. Our study evaluates the impact of a pharmacist-managed protocol aimed at reducing continuous infusion proton pump inhibitor use in upper gastrointestinal bleeds.

METHODS:
We performed a retrospective analysis of patients receiving intravenous pantoprazole for suspected upper gastrointestinal bleeding before and after the implementation of a pharmacist managed protocol. Prior to implementation, patients were continued on pantoprazole continuous infusions (8 mg/hr) at the physician's discretion. After implementation, all hemodynamically stable patients were allowed one dose of pantoprazole as a continuous infusion (8 mg/hr for 10 hours) and then were transitioned by the pharmacist to intermittent 40 mg IV injections twice daily. The primary endpoint assessed was the incidence of upper gastrointestinal re-bleeding within 7 days of treatment. Secondary endpoints included the number of pantoprazole continuous infusions and IV push injections, number of blood transfusions, number of endoscopic interventions, length of hospital stay, and mortality.

RESULTS:
After screening 702 patients, 222 patients met inclusion criteria (115 in the pre-protocol group and 107 in the post-protocol group). The re-bleeding rate at day 7 was 7% in the pre-protocol group, compared to 4% in the post-protocol group (P = 0.17). As expected, use of the protocol reduced the median number of continuous infusions per patient [4 (IQR 2-4) vs 2 (IQR 1-3); P < 0.001] and increased the median number of IV push injections [2 (IQR 2-4) vs 4 (IQR 2-7); P < 0.001] in the pre- and post-protocol groups, respectively. There were no significant differences between the pre- and post-intervention groups regarding blood transfusions (65% vs. 63%; P = 0.78), endoscopic interventions (79% vs. 79%; P = 1.0), hospital length of stay [4 days (IQR 3-8) vs. 4 days (IQR 2-8); P = 0.521], or hospital mortality (5% vs. 2%; P = 0.28) (See Tables 1 and 2).

CONCLUSION:
Implementation of this pharmacy-managed protocol, allowing automatic transition from pantoprazole continuous infusions to intermittent injections in hemodynamically stable patients with an upper gastrointestinal bleed, had no detrimental effect on the incidence of re-bleeding within 7 days.
614 Bidirectional Endoscopy in Premenopausal Women With Asymptomatic-Iron Deficiency Anemia (A-IDA)
Authors: Schopis Michael , Guerson Gil Arcelia , Ziv Yonatan , Seu Rie , Yeat Nai Chien , Muench Samuel , Nair Singh , Aroniadis Olga , Brandt Lawrence 
Published: October 2019

INTRODUCTION:
GI investigation of premenopausal women with A-IDA is a controversial subject with some societal guidelines recommending initially only celiac or Helicobacter pylori (HP) screening instead of upper (U) and lower (L) GI endoscopy. The aim of this study was to determine the relative frequencies of associated GI sources of A-IDA in premenopausal women who underwent bidirectional endoscopy (BDE).

METHODS:
We performed a retrospective chart review noting clinical characteristics of asymptomatic premenopausal women who had BDE performed within 6 months of IDA diagnosis between the yrs 2014-2019. Pts were excluded if they had GI tract surgery within 10 yrs, active pregnancy, active GI bleeding, an obvious site of non-GI blood loss or ferritin >100. McNemar's test was used to compare frequency of UGI and LGI lesions. Bivariate analyses of characteristics associated with UGI and LGI lesions were performed using t-test, Chi-squared test, or Fisher's exact test. Multivariate logistic regression models estimated odds ratios.

RESULTS:
Records of 98 premenopausal female pts were available for analysis (mean age 44 yrs; Table 1). BDE revealed lesions associated with IDA in 61 pts (62.2%) comprising 41 (41.8%) UGI lesions, 10 (10.2%) LGI lesions, and 7 (7.1%) both UGI and LGI lesions. In our cohort, UGI lesions were more common than LGI lesions [48 (49%) vs 17 (17%); P < 0.001]. Predictors of an UGI lesion included NSAIDS use [OR 3.60 (95% CI 1.36-10.25); P = 0.01] and HP infection [OR 5.4 (2.20-14.24); P < 0.001]. No significant predictors of LGI lesions were identified (Table 1). The most common UGI lesions were HP -associated gastritis (35.6%) and peptic ulcer disease (15.3%) (Figure 1a). The most common LGI lesions were large polyps (45%) and hemorrhoids (35%) (Figure 1b).

CONCLUSION:
Our results indicate 1) premenopausal women often have a GI-associated source of A-IDA; 2) premenopausal women with A-IDA are more likely to have an UGI than LGI source for blood loss; thus starting with UGI endoscopy may be prudent 3) H. pyloriinfection and NSAID use predict UGI lesions associated with A-IDA in premenopausal women.