bluuebunny/crossref_metadata_2025_split huggingface dataset:
566 Improving Bowel Preparation Quality for Inpatient Colonoscopies at a Tertiary Hospital
Authors: Mandark Gandhi , Townsend Cassandra , Almaghrabi Majed , Alotaibi Ammar , Khanna Nitin , Yan Brian , Brahmania Mayur 
Published: October 2019

INTRODUCTION:
Adequate bowel preparation quality is required for appropriate mucosal visualization during colonoscopy. Several factors impede quality including patient, environmental and process factors. When colonoscopies demonstrate poor-quality preparation, it often delays further management and discharge for patients as they often need to return for a second procedure in order to get adequate visualization. This also results in increased costs to the healthcare system. Our aim was to identify the rate of poor-quality bowel preparation at our tertiary care hospital for inpatient colonoscopies and implement interventions to decrease this rate.

METHODS:
The study was conducted at University Hospital in London, Ontario from March 2018 - March 2019. In the first PDSA cycle we improved an existing order-set such that split- dose bowel preparation would more reliably be ordered and administered. Our second PDSA cycle focused on teaching junior residents how to order bowel preparation for inpatient colonoscopies. PDSA cycle three involved making bowel preparation quality assessment more objective. Lastly, PDSA cycle four wasaimed at improving patient education surrounding the importance of completing bowel preparation.

RESULTS:
Poor-quality bowel preparation in the six months prior to intervention was 14.0%. After intervention this came down to 8.0%. Similarly our process measure of patients receiving split-dose bowel preparation administration increased from 81.2% to 94.6% during this period.

CONCLUSION:
Several factors are involved with poor-quality bowel preparation for inpatient colonoscopies. Simple and sustainable interventions can be implemented to improve quality. We are continuing to identify new factors and interventions to further improve this metric.
584 Apelin Association With Hepatic Fibrosis and Esophageal Varices in Chronic HCV Patients
Authors: Soliman Lamyaa , Zayed Rania , Omran Dalia , Said Fadwa , Darweesh Samar , Ghaith Doaa , Eletreby Rasha , Barakat Mahmoud , Bendary Mahmoud , Zaky Doaa , Amer Eman , Elmahgoub Iman 
Published: October 2019

INTRODUCTION:
Portal hypertension (PH) and esophageal varices complicating HCV-related chronic liver disease (CLD) are the most devastating sequelae. Angiogenesis is the hallmark of their pathogenesis. Apelin is one of the recently identified angiogenic and fibrogenic peptides. We studied apelin gene expression, apelin (rs3761581) SNP and serum apelin level in chronic HCV patients, and their association with hepatic fibrosis and esophageal varices.

METHODS:
112 patients with HCV related CLD (40 having liver cirrhosis (LC)/low grade varices, 33 with LC/high grade varices and 39 with fibrotic non-cirrhotic liver/no varices), and 80 healthy control subjects were included. Real time PCR was used for apelin gene expression assay and apelin rs3761581 SNP analysis in peripheral blood samples. Serum apelin level was measured by ELISA.

RESULTS:
Apelin gene expression was undetectable in studied samples. SNP analysis revealed higher frequency of the C-(mutant)-allele among patients compared to controls (P = 0.012, odds ratio 3.67). Serum Apelin level was significantly higher in patients with hepatic cirrhosis/ varices (median 31.6 ng/L) compared to non-cirrhotic patients/ no varices (median 2.9 ng/L) (P < 0.001). Serum apelin level at cut off value 16.55 ng/L predicted the presence of varices with AUROC 0.786. Positive correlation was found between serum apelin level and grade of liver fibrosis (r=0.346, P < 0.001) and PH (r=0.438, P < 0.001).

CONCLUSION:
Apelin rs3761581 C-allele may be associated with progression of HCV-related CLD and varices formation, and can be considered as a potential therapeutic target to control fibrosis progression. Serum apelin level provided accurate prediction of the presence of esophageal varices.
587 The Safety and Efficacy of Thalidomide for the Treatment of Gastrointestinal Bleeding Refractory to Endoscopic Intervention: A Meta-Analysis
Authors: Soin Sarthak , Ali Faisal , Saleem Nasir , Pandit Sarbagya 
Published: October 2019

INTRODUCTION:
Thalidomide's role in patients with gastrointestinal bleeding (GI) secondary to angiodysplasia, cirrhosis, Crohn's disease, portal hypertensive gastropathy, hereditary hemorrhagic telangiectasia and left ventricular assist device which are refractory to endoscopic interventions has not been extensively studied. We conducted a meta-analysis to evaluate the safety and efficacy of thalidomide in the current body of literature.

METHODS:
A systematic search of Medline was performed from 2000-present. Studies enrolling adults reporting on the use of thalidomide for the treatment of refractory GI bleeding were included. The primary endpoint was the response rate, defined by reduction in frequency or resolution of GI bleed among patients treated with thalidomide. A meta-analysis of proportions was carried out to calculate pooled response rates (with calculation of 95% confidence intervals (CI)). A logistic normal random effects model was employed to account for inter-study heterogeneity and for effect sizes close to 0 and 1. Descriptive statistics were employed to outline the characteristics of included studies.

RESULTS:
Screening of 182 studies yielded 8 studies, enrolling 171 patients, of whom 99 were females. The most common cause for refractory GI bleed was angiodysplasia followed by left ventricular assist devices. [Figure 1] All patients had GI bleeds refractory to endoscopic therapy and most of the patient population was transfusion dependent. Patients underwent treatment with thalidomide for a median of 4 months, with doses ranging from 50-300 mg daily. The pooled response rate to thalidomide therapy was 77% (95% CI 70-83%). The pooled adverse event rate was 61% (95% CI 42-77%). [Figure 2] Thalidomide was discontinued in 8% (95% CI 1-35%) of the patients due to adverse events. The most common adverse event was peripheral neuropathy, accounting for 12% (95% CI 4-31%) of the adverse events, followed by fatigue, which accounted for 8% (95% CI 1-61%) of adverse events. [Figure 3] No treatment associated mortality was reported.

CONCLUSION:
Thalidomide for GI bleeding refractory to endoscopic intervention is a potentially efficacious medical therapy which can be considered before any surgical intervention is planned. Most adverse events are mild and self-limiting, though close monitoring for development of neuropathy is advised. Randomized controlled trials to validate the safety and efficacy of thalidomide for the treatment of refractory GI bleeding are warranted.
588 Skipping the Drip: Intravenous Bolus Proton Pump Inhibitor Therapy Produces Similar Outcomes to Continuous Infusions With Less Healthcare Resource Utilization
Authors: Hadi Yousaf , Khan Raja Samir , Chima Noor , Kupec Justin T. 
Published: October 2019

INTRODUCTION:
Continuous proton pump inhibitor (PPI) infusions remain the most commonly employed therapeutic strategy for administration of PPIs in upper gastrointestinal (GI) bleeding. Recent data has pointed towards non-inferiority of intravenous (IV) bolus regimens, but real-world data is lacking. Cost effectiveness and resource utilization data is also unavailable and projections made by estimation have shown low potential for cost savings.

METHODS:
A retrospective cohort study to evaluate the impact of a shift in institutional practice from PPI infusions to bolus was conducted. As part of a quality improvement initiative, an electronic medical record-based order set was employed; this involved an IV PPI twice daily for 72 hours subsequently defaulting to an oral regimen. After obtaining institutional review board (IRB) approval, patients admitted with upper GI bleeding at our institution from January 2017 to December 2018 were identified with relevant ICD 10 codes. All patients with peptic ulcer disease as the cause of bleeding were included and divided into two groups on the basis of PPI administration strategy. Clinical and resource utilization outcomes were compared between the two groups. Univariate and multivariable analyses were performed to assess independent associations.

RESULTS:
Of the 368 patients included the mean age was 62.68 years (SD: 5.3 years) and 170 (46.1%) were male. On univariate analysis, age, gender, smoking status, use of anticoagulants, and PPI administration strategy were not associated with inpatient mortality, readmissions, re-bleeding at 3, 7 and 30 days, need for endoscopic hemostatic therapy and need for re-intervention or surgery (all P values > 0.05). Multivariable logistic regression revealed that smoking (OR 2.12 95% CI 1.13- 3.70), anticoagulation use (OR: 2.27 95% CI 1.17- 4.62) and age (OR: 1.03, 95% CI 1.01-1.04) were significantly associated with in-hospital packed red blood cell transfusions. Bolus PPI use was associated with less pharmacy cost of drug calculated per patient, earlier de-escalation to oral PPI, and shorter hospital stay (P < 0.05).

CONCLUSION:
Our real world, tertiary care experience ascertains non-inferiority of IV bolus PPI regimen compared to continuous infusion for acid suppression therapy in managing upper GI bleeds. The use of simpler bolus regimens can result in a decrease in healthcare resource utilization. A practice shift to such a regimen can therefore serve as a good quality improvement initiative in health care settings.
589 Diagnostic Value of FIT in Upper Gastrointestinal Malignancy
Authors: Al Yassin Altaib , Sapho Lidia , Kheder Joan , Alazzawi Yasir 
Published: October 2019

INTRODUCTION:
Cancers of the esophagus and stomach are among the most lethal of all malignancies. The majority of these neoplasms are detected at an advanced stage due to their similarity in early stages to benign causes of dysphagia and dyspepsia. It has been suggested that fecal immunochemical testing (FIT) could be used for population-based screening for occult bleeding caused by colorectal cancer. However, the diagnostic sensitivity of these tests has been difficult to estimate. A positive FIT might also come from the upper gastrointestinal (GI) tract, so perhaps we should consider esophagogastroduodenoscopy (EGD), or Video capsule endoscopy (VCE) to detect upper GI cancers. We aimed to determine how many individuals are found to have upper GI cancers (esophageal, gastric, or small bowel cancer) in EGD or VCE after a positive FIT, and to see whether using FIT can predict the risk of cancer in patients.

METHODS:
A retrospective chart review of patients who were referred to a GI clinic in an academic center between 2006 and 2016, had a positive FIT, and followed by EGD or/and VCE. Patients' data including age, race, gender, in addition to the indication of EGD and VCE, and endoscopic findings were reviewed and collected.

RESULTS:
A total of 206 patients who had positive FIT. Of whom, 181 patients had EGD and 25 and had VCE. The mean age of the patients was 62 years with 94% above 50 years old. The most common indication for the EGD and VCE was gastrointestinal bleeding followed by dyspepsia and positive FIT. Abnormal endoscopic findings were found in 143 EGD and 19 VCE representing collectively 78% of the studies. Of the 172 endoscopic evaluation of the upper gastrointestinal tract, 1 patient was found to have cancer and 142 patients to have benign findings. The most common benign conditions were gastritis/duodenitis (63%) followed by esophagitis (22%) and peptic ulcers disease (12%). Positive predictive value of FIT for non-malignant lesions was found to be 79%.

CONCLUSION:
There is a high diagnostic value of positive FIT especially for patients older than 50 years. EGD and VCE evaluations after a positive FIT had a high yield of non-malignant lesions.
596 Efficacy of Self Expanding Metal Stent (SEMS) in Refractory Bleeding Esophageal Varices, Is There a Mortality Benefit? An Indirect-Comparison Meta-Analysis to Trans-Jugular Intra-Hepatic Porto-Systemic Shunt (TIPS)
Authors: Mohan Babu P. , Chandan Saurabh , Khan Shahab R. , Kotagiri Rajesh , Olaiya Babatunde , Ofosu Andrew , Adler Douglas G. 
Published: October 2019

INTRODUCTION:
Acute esophageal variceal hemorrhage (eVH) is a life threatening complication of portal hypertension and current guidelines recommend endoscopy with variceal band ligation within 12 hours of presentation. Up to 20% of these episodes can be refractory to standard treatment and in these cases, a “bridge” therapy is often necessary to control hemorrhage. Self-expanding metal stents (SEMS) have been used in this setting, however their role in the treatment protocol is unknown due to paucity in data. Aim of this study was to evaluate the clinical performance of SEMS and indirectly compare it to transjugular intrahepatic portosystemic shunt (TIPS) in refractory eVH, by meta-analysis methods.

METHODS:
We searched multiple databases from inception to May2019 to identify studies that reported on the clinical outcomes of SEMS and TIPS in refractory eVH. Outcomes assessed were all-cause mortality, technical success, immediate bleeding control, rebleeding, and adverse events. I2 statistics was used to assess heterogeneity.

RESULTS:
574 patients from 21 studies were analyzed (SEMS: 12 studies, 176 patients; TIPS: 9 studies, 398 patients). The pooled rate of technical success with SEMS and TIPS were comparable (88.3%, 81.7-92.7 vs 91%, 86.2-94.2, P = 0.42). The pooled rate of immediate bleeding control with SEMS was 84.5% (74-91.2) and with TIPS was 97.9% (87.7-99.7), with statistical significance P = 0.03. The pooled rate of rebleeding with SEMS was 19.4% (11.9-30.4) and with TIPS was 8.8% (4.8-15.7), with statistical significance P = 0.04. The pooled rate of all adverse events were comparable (36.9%, 26-49.2 vs 41.4%, 26.5-58.1, P = 0.66). Pooled rate of stent migration in SEMS cohort was 31.8% (22-43.5). The pooled rate of all-cause mortality with SEMS was 43.6% (28.6-59.8) and with TIPS was 27.9% (16.3-43.6). There was no statistical significance (P = 0.16). I2 heterogeneity of 91% was observed in mortality with TIPS. All results are summarized in Table 1.

CONCLUSION:
SEMS did not demonstrate mortality benefit when compared to TIPS in the management of refractory eVH. The overall clinical outcomes with SEMS seemed to be inferior to TIPS with higher rebleeding rate and lesser immediate bleeding control rate. In addition, a stent migration rate of 32% was noted with SEMS despite the comparable overall adverse events between the modalities. Based on our analysis, an emergent TIPS should be the standard of care in refractory eVH.
597 Bidirectional Endoscopy in Asymptomatic-Iron Deficiency Anemia (A-IDA)
Authors: Schopis Michael , Gil Arcelia Guerson , Ziv Yonatan , Seu Rie , Yeat Nai Chien , Muench Samuel , Kim Mimi , Aroniadis Olga , Brandt Lawrence 
Published: October 2019

INTRODUCTION:
GI investigation of pts with A-IDA typically begins with both upper (U) and lower (L) GI endoscopy. Guidelines tend to recommend bidirectional endoscopy (BDE) sequencing based on age stratification, or starting with LGI endoscopy. The aim of this study was to determine the most efficient BDE sequence among patients with A-IDA by investigating the relative frequencies of identified associated sources of bleeding by UGI or LGI endoscopy.

METHODS:
We performed a retrospective chart review of clinical characteristics of pts ≥18 yrs who had BDE performed within 6 months of A-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 lesions identified across the general population and stratified for age < 50 and >50 yrs. 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 estimated odds ratios.

RESULTS:
497 pts were available for analysis (65% female, mean age 63 yrs; Table 1). BDE found IDA-associated lesions in 307 (61.8%) pts comprising 196 (39.4%) exclusively UGI lesions, 66 (13.3%) exclusively LGI lesions, and 45 (9.1%) both UGI and LGI lesions. In our cohort, UGI lesions were more common than LGI lesions [241 (48.5%) vs 111 (22.3%); P < 0.001], regardless of age (P < 0.001) (Table 1). Protective variables against an LGI lesion included female sex [OR 0.51 (0.32-0.86); P = 0.01], BMI [OR 0.96 (0.93-0.99) per unit inc.; P = 0.01] and Hgb [OR 0.88 (0.78-0.98) per unit inc.; P = 0.03]. CKD was associated with LGI lesions [OR 1.99 (1.12-3.48); P = 0.02]. Hgb was higher in pts with only UGI than only LGI lesions (9.4±1.6 vs 8.5±1.5; P = 0.001). PPI use predicted absence of identifiable lesions [OR 0.66 (0.45-0.96); P = 0.03]. The most common UGI lesions were H. pylori-associated (HP-A) gastritis (24.2%) and peptic ulcer disease (17.6%) (Figure 1a). The most common LGI lesions were large polyps (37.7%) and colon CA (16.2%) (Figure 1b).

CONCLUSION:
Our results indicate 1) pts with A-IDA are more likely to have an UGI than LGI source; thus starting with UGI endoscopy may be prudent; 2) women are less likely to have a LGI source of A-IDA than men; 3) low BMI, low Hgb and CKD predict a LGI source of A-IDA. 4) HP-A UGI lesions account for a significant portion of A-IDA; 5) PPI use predicts the absence of lesions.
601 Gastrointestinal Bleeding in Patients With Co-Morbid End-Stage Renal Disease
Authors: Brindise Elizabeth , Kobeszko Matthew , Kuruvilla Aneesh , Elkhatib Imad , Silva Rogelio 
Published: October 2019

INTRODUCTION:
End Stage Renal Disease (ESRD) is steadily increasing in prevalence in the United States with more than 2 million individuals affected in 2015. ESRD is believed to predispose individuals for gastrointestinal (GI) bleeding by increasing bleeding diatheses, use of heparin during dialysis and GI angiodysplastic lesions. We sought to evaluate outcomes of patients with ESRD and GI bleeding.

METHODS:
The study population was derived from the HCUP-National Inpatient Sampling (NIS) database for the years 2010 to the third quarter of 2015. ICD-9 codes were used to identify patients with GI bleeding and a history of ESRD. In-hospital all-cause mortality, total cost of hospitalization, mean length of stay and outcome rates were assessed. Propensity score matching was used to adjust for baseline confounders.

RESULTS:
Among 5,434,241 admissions with ESRD, 250,383 (4.6%) individuals developed GI bleeding during our study period. 44.2% were female. Patients with ESRD and GI bleeding were more likely to have CAD, coagulation/hemorrhagic disorders, hepatitis, liver and biliary disease and alcohol related disorder (Table 1). GI bleeding in the ESRD population was associated with significantly higher all-cause mortality (10.9% vs 4.7%, P < 0.0001), length of stay (10.5 ± 15.4 vs 6.7 ± 9.3, P < 0.0001), cost of hospitalization ($110,019 ± 207,049 vs $65,875 ± 110,995, P < 0.0001) and blood transfusion rates (16.8% vs 51.2%, P < 0.0001). Furthermore, the GI bleeding cohort required significantly more endoscopies, colonoscopies, and upper and lower GI surgical procedures (Table 2). Following propensity score matching, these statistically significant differences persisted.

CONCLUSION:
GI bleeding in patient with co-morbid ESRD is associated with significantly higher all-cause mortality, length of stay, total cost of hospitalization, blood transfusion rates as well as a number of procedures including: endoscopy, colonoscopy, and upper and lower GI surgery.
603 Incidence of Non-Variceal Upper Gastrointestinal Bleeding Worsens Outcomes With Acute Coronary Syndrome: Result of a National Cohort
Authors: Pioppo Lauren , Bhurwal Abhishek , Reja Debashis , Tawadros Augustine , Patel Anish V. 
Published: October 2019

INTRODUCTION:
Upper gastrointestinal bleeding (UGIB) is a feared complication of acute coronary syndromes (ACS) and has been shown to increase morbidity and mortality. UGIB may occur due to stress-related mucosal disease as well as from standard therapy with antiplatelet and anticoagulant medications. Our aim was to assess the incidence of non-variceal UGIB in patients with ACS in a national cohort and its impact on in-hospital mortality, length of stay (LOS), and cost of hospitalization.

METHODS:
This was a retrospective cohort study using the 2016 Nationwide Inpatient Sample (NIS) utilizing ICD 10 CM codes. Principal discharge diagnoses of ACS (STEMI, NSTEMI and UA) in patients over 18 years of age were included. Non-variceal UGIB with interventions including endoscopy, angiography and embolization were also evaluated using ICD 10 CM. Primary outcome was national incidence of concomitant non-variceal UGIB in the setting of ACS. Secondary outcomes included impact on in-hospital mortality, LOS and cost of stay. Proportions were compared using Fisher's exact test and continuous variables using Student t-test. Multivariable and Poisson regression were performed.

RESULTS:
A total of 661,324 discharges with principal discharge diagnosis of ACS in 2016 were included. Patient demographics are listed in Table 1. Of this cohort, 0.65% (n = 4289) were complicated with non-variceal UGIB with increased frequency in older patients (OR 1.04, 95% CI 1.04-1.05; P = 0.001). Despite endoscopic evaluation, 17.35% (n = 744) underwent angiography whereas embolization was required in 0.5% (n = 21) of these cases. After adjustment of confounders (see Table 2), inpatient mortality was significantly higher in patients with UGIB (OR 1.49, 95% CI 1.10-2.03; P = 0.01). Non-variceal UGIB also led to significantly longer LOS (10.21 days vs 4.38 days; P = 0.001) and total cost of stay ($177,000 vs $88,592, P < 0.0001) (Table 3 and Table 4).

CONCLUSION:
We performed a retrospective cohort study which showed that the national incidence of non-variceal UGIB complicating ACS is low (less than 1%). However, as expected, its occurrence in ACS patients resulted in significantly higher inpatient mortality, LOS, and hospitalization charges. Limitations of the study include lack of information on antiplatelet or anticoagulant therapy which could affect outcomes. Further studies are needed to determine the safety and efficacy of endoscopy in patients on dual antiplatelet agents or anticoagulation.