bluuebunny/crossref_metadata_2025_split huggingface dataset:
1226 Under-Utilization of Proton Pump Inhibitors in the Prevention of NSAID-Related Peptic Ulcer Disease in the Elderly
Authors: Al-Taee Ahmad M. , Ghoulam Elie , Lee Preston , Sbertoli Robert , Hachem Christine 
Published: October 2019

INTRODUCTION:
Peptic ulcer disease (PUD) develops in approximately 25% of chronic users of non-steroidal anti-inflammatory drugs (NSAIDs). The incidence of uncomplicated PUD has been declining over the past 3 decades unlike that of complicated PUD especially in the elderly. We aimed to evaluate physician compliance with the American College of Gastroenterology (ACG) guidelines on the prevention of NSAID-related PUD complications in a tertiary academic setting.

METHODS:
We examined the Saint Louis University Hospital medical record database for a 9-month period extending from April 2018 until December 2018. Using this database, we identified 2,064 adult elderly patients (>64 years old) who were chronic (>3 months) users of low dose aspirin (81 mg once daily). We performed a retrospective analysis of patients who were at least on aspirin and had an indication for PUD prophylaxis as per ACG guidelines. Data collected from patient charts included age, gender, relevant medications (including proton pump inhibitors (PPI), aspirin, P2Y12 inhibitors, direct oral anticoagulants (DOACs), warfarin, or oral steroids), and whether prophylaxis was provided as per the ACG guidelines.

RESULTS:
A total of 301 adult elderly patients who were at least on aspirin and had an indication for PUD prophylaxis were identified in this study. The mean age was 75 years old. Six percent of included patients had a history of peptic ulcer disease. In addition to aspirin, patients were using P2Y12 inhibitors (clopidogrel or ticagrelor, 50%), DOACs (24%), warfarin (11%), or steroids (9%). DOAC users were prescribed apixaban (16%), rivaroxaban (7%), or dabigatran (1%) (Table 1). All antiplatelets, anticoagulants, and steroids were prescribed by non-gastroenterologists. Only 35% of patients with an indication for PUD prophylaxis received a PPI. The prophylaxis rates were highest for patients with a history of peptic ulcer disease (62%) and were lowest for users of P2Y12 inhibitors (29%). There were no statistically significant age or gender related differences in the rates of compliance when independent sample t and chi square tests were performed (Table 1).

CONCLUSION:
Peptic ulcer disease prophylaxis with proton pump inhibitors may be underutilized in elderly patients. This finding, along with increasing rates of NSAID use and aging population, may help explain the increased incidence of complicated PUD in the elderly. Efforts are needed to raise physician awareness of PUD prophylaxis guidelines.
1232 Factors Associated With Treatment Failure in Biopsy Proven Helicobacter pylori Infection in the Rio Grande Valley: A Retrospective Review of 3 Years Data
Authors: Castano Juan J. , Rapoport Grigoriy , Rivera Arturo Suplee , Sraow Amrit , Garrison Keith , Lopez-Alvarenga Juan C. , Chacon Ingrid 
Published: October 2019

INTRODUCTION:
The 2017 American College of Gastroenterology Clinical guidelines advocate clarithromycin triple therapy (CTT) as first line H. Pylori (HP) treatment. CTT consists of a 14-day course of a proton pump inhibitor (PPI), clarithromycin, and amoxicillin or metronidazole. The national CTT eradication rate (ER) nears 80%. Many well-established factors affect treatment success including therapy duration, compliance, smoking, diabetes mellitus (DM), and local antibiotic resistance rates. Efficacy data on CTT in the Rio Grande Valley (RGV) has not been previously described. It is assumed that local resistance rates parallel those of our neighboring country due to proximity which may influence clinical practice. Aim is to determine the factors that affect biopsy-proven HP treatment failure.

METHODS:
A retrospective analysis of patients treated for HP in one RGV gastroenterology center between 2015 and 2018 was done. Eradication was defined by either a negative 13C Urea breath test or by a negative HP stool antigen test after treatment. ER was calculated for each regimen and compared against therapy duration, smoking, DM, health insurance status, and socioeconomic level; the latter determined by patient zip codes. We calculated raw ORs (95% CI) and adjusted with Cox and binary logistic regression.

RESULTS:
Of 544 patients, 71% (384) were females and 97% (526) were Hispanic. Nonsmokers were 79% (425) and diabetics were 32% (174). In total, 56% (305) received CTT and 44% (239) received quadruple therapy (QT) (ie., Tetracycline, metronidazole, bismuth, any PPI). ER was 66% for CTT and 62% for QT. Regarding both therapies, no treatment failure difference was found (P = 0.62) at 10 days, however, treatment failure decreased with 14-day therapy (P < 0.001). Regarding health insurance, 84% (452) had private, 13% (72) had government-issued, and 3% (16) were self-pay. Cox regression found no differences in treatment type. Logistic regression found that females OR 2.25 (95% CI 1.4, 3.5, P < 0.001), income <$40,000/year OR 1.78 (95% CI: 1.1, 2.8, P = 0.013), and smoking OR 1.6 (95% CI 1.03, 2.6, P = 0.034) negatively affected eradication.

CONCLUSION:
HP therapy efficacy was suboptimal, however, 14-day therapy improved treatment failure. More females were affected with HP. Factors negatively affecting eradication were female gender, smoking, and income <$40,000/year. Further studies are required to determine the role of patient education, HP local antibiotic resistance patterns, and physician practice on HP eradication.
1235 Risk Factors for Advanced Gastric Intestinal Metaplasia in a Multi-Ethnic United States Cohort
Authors: Huang Robert , Park Sungho , Chitre Tanvi , Shen Jeanne , Longacre Teri , Hwang Joo Ha 
Published: October 2019

INTRODUCTION:
Gastric intestinal metaplasia (GIM) is a precursor to gastric cancer (GC). The operative link for GIM (OLGIM) is a standardized histologic scoring system (ranging 0 to 4) used to evaluate severity of GIM; in prospective European studies, it has been shown to predict risk for progression onto GC. Use of OLGIM has not previously been described in North American populations. Risk factors for advanced GIM are poorly described in North America, and currently no screening recommendations exist for either GC or GIM.

METHODS:
We prospective enrolled patients between the ages of 30 and 84 scheduled to undergo outpatient endoscopy at Stanford University for the following indications 1) dyspepsia, 2) H. pylori assessment, 3) GC screening, or 4) GIM surveillance. At time of enrollment, all patients completed a standardized questionnaire inquiring about medical, family, dietary, and exposure history. Biopsies were performed from both antrum and body. Histologic scoring was performed according to a Standardized protocol, and OLGIM score assigned to each subject. We compared demographic, clinical, and environmental variables between subjects with GIM and subjects without GIM. We also compared subjects with advanced GIM (defined as OLGIM ≥ 2) with subjects without advanced GIM (OLGIM < 2). Continuous variables were analyzed using Student's T-test, and categorical variables were analyzed using the Chi-squared test.

RESULTS:
38 subjects with GIM, and 41 subjects without GIM were enrolled. Of the GIM group, 20 subjects demonstrated advanced GIM. Subjects with GIM were older (P = 0.001), more likely to have a history of H. pylori treatment (P = 0.002), and more likely to be first-generation immigrants (P = 0.008) compared to subjects without GIM (Figure 1). Subjects with advanced GIM were more likely to be older (P = 0.02), and more likely to be first-generation immigrants (P = 0.04) compared to subjects without advanced GIM (Figure 2). Gender, presence of symptoms, presence of medical comorbidity, family history, smoking status, and dietary preferences did not demonstrate significant differences between groups in this cohort.

CONCLUSION:
Age and immigration status, known risk factors for GC, may also be risk factors for advanced GIM. As advanced GIM significantly increases risk for GC, detection of advanced GIM may improve GC morbidity and mortality. Additional research should be focused on non-invasive testing to detect advanced GIM in North American populations.
1236 Hospitals With Low-Medium Safety-Net Burden Incur the Highest Costs for Hospitalizations of U.S. Adults With Gastric Cancer
Authors: Park Gavin , Hirode Grishma , Wong Robert 
Published: October 2019

INTRODUCTION:
Although gastric cancer is relatively rare in the U.S., diagnosis at an earlier stage is associated with improved treatment options and higher overall survival. Safety-net hospitals continue to bear the brunt of recent major healthcare coverage reforms. We aim to evaluate factors, including safety-net burden (SNB), associated with in-hospital mortality and inpatient costs among hospitalized adults with gastric cancer.

METHODS:
Using the 2012-2014 National Inpatient Sample, adult hospitalizations with gastric cancer were identified using ICD-9 codes. Hospital SNB was defined as percentage of hospitalizations with Medicaid or uninsured payer status per hospital, and categorized into three groups: none, low-medium, and high. Between-group comparisons used chi-squared testing. Adjusted logistic regression was used to analyze predictors of in-hospital mortality. Multivariate linear regression was performed after logarithmic transformation of the outcome to identify factors associated with mean hospitalization costs; inflation adjusted to 2014 US dollars. Coefficients were exponentiated to yield percentage change associated with each predictor.

RESULTS:
Among 26,417 adults with gastric cancer (mean age 65.7 ± 14 years, 36.3% female, 55.3% non-Hispanic White), 48.6% were low-medium burden, and 22.4% were hospitalized in high SNB hospitals. Overall in-hospital mortality was 7%, with no significant differences by hospital SNB. Compared to men with gastric cancer, women had significantly lower odds of in-hospital mortality (7.3% vs. 6.4%; OR 0.81, 95% CI 0.73-0.89, P < 0.001), and patients who received surgery (vs. no surgery) were less likely to experience in-hospital deaths (3.4% vs. 7.7%; OR 0.49, 95% CI 0.41-0.58, P < 0.001). Total estimated hospitalization costs were $2.5 billion. On regression, mean inpatient costs were significantly higher for hospitalizations at a low-medium SNB hospital (vs. no burden) (4.6% higher, 95% CI 0.6-8.7%, P = 0.02). Patients who underwent partial/total gastrectomy (vs. no surgery) incurred greater costs (183% higher, 95% CI 176-190%, P < 0.001).

CONCLUSION:
There were no significant differences in rates of in-hospital mortality by SNB, however, low-medium SNB hospitals bore majority of the economic burden. Men with gastric cancer were more likely to die during hospitalization. While those who received partial/total gastrectomy incurred higher costs, in-hospital mortality was lower compared to those who did not receive surgery.
1241 Are You Full? An Analysis of Online Patient Resources for Gastroparesis
Authors: Naik Katrina , Cioffi Joseph , Adhatamsoontra Praphopphat , Dave Jenny , Khan Ali , Borum Marie 
Published: October 2019

INTRODUCTION:
Gastroparesis, a syndrome of objectively delayed gastric emptying in the absence of obstruction, can be a frustrating motility disorder. Affected individuals often seek online information for self-education. Systematic analysis of internet-available information is important. This study evaluated the readability and quality of easily accessible online information on gastroparesis.

METHODS:
A Google search using the term “Gastroparesis” to obtain the first 100 websites was performed. Websites were excluded if they contained veterinarian or pediatric content, were duplicates or were inaccessible. Sites were categorized by intended audience: professional or consumer. The validated Flesch-Kincaid Grade Level Calculation determined readability. The validated DISCERN questionnaire determined quality, with scores rated as Excellent >55, Good 36-55 or Poor <36. Statistical analysis was performed using Fisher's Exact Test with a P-value set at <0.05.

RESULTS:
89 websites were analyzed. 58 (65.2%) were written for consumers and 31 (34.8%) for medical professionals. 49 (55%) were created by academic institutions. The average Flesch-Kincaid Grade Level was 11.4. 6 websites (6.75%) scored a Flesch-Kincaid Grade Level of 6 or below. The mean quality was Good (DISCERN score 52.6) with 39 Excellent (43.8%), 35 Good (39.3%) and 15 Poor (16.9%). Consumer sites included significantly more recommendations for diet modifications (86.2% vs 64.5%, P < 0.03) than medical professional sites, but excluded references (27.5% vs 80.6%, P < 0.0001). Regardless of consumer status, methods of diagnosis (63.3% vs 37.5%, P < 0.02), labs (63.3% vs 37.5%, P < 0.02) and gastric pacers (63.3% vs 37.5%, P < 0.02) were discussed significantly more on academic institution websites.

CONCLUSION:
This study revealed the variability in readability and quality of online resources for gastroparesis. The majority of websites targeted consumers, yet readability exceeded the NIH 6th grade reading level recommendation for medical information. In the era of widespread internet use for acquiring health information, it is important that quality online health information resources use patient-centered language to facilitate formed decision making.
1242 Targeting Inappropriate Stress Ulcer Prophylaxis: A Multidisciplinary Approach
Authors: Mahmood Asadullah , Saeed Naba , Seyedtabaei Roheila , Saad Ali Bani , Saeidifard Farzane , Niaz Azra , McConachie Sean , John Rajiv 
Published: October 2019

INTRODUCTION:
Use of stress ulcer prophylaxis (SUP), administration of acid suppressive therapies (AST) to prevent nosocomial gastrointestinal bleeding, is rampant outside of intensive care units despite a lack of data supporting its efficacy. Inappropriate use rates as high as 90% have been reported nationally. Following this, many times AST is inappropriately continued at discharge as well. Potential side effects include vitamin B12 deficiency, osteoporosis, Clostridium difficile infection, pneumonia and CKD. A multidisciplinary educational approach has been used to improve prescribing patterns in other disease states.

METHODS:
We aimed to decrease inappropriate stress ulcer prophylaxis using a multidisciplinary academic detailing team on an inpatient internal medicine teaching service (IIMTS). Using the quality improvement model plan-do-study-act (PDSA), we retrospectively collected baseline data on inappropriate SUP use on IIMTS over one month. We then implemented PDSA 1: academic detailing, whereby a multidisciplinary team (clinical pharmacist plus internist), gave teaching sessions on appropriate SUP indications to IM residents. With PDSA 2, we introduced a hard stop into IIMTS note templates. We collected prospective post-intervention data for one month after each intervention.

RESULTS:
Pre-intervention, 95 patients received AST, of which 68 (71%) were receiving AST prior to admission and 27 were prescribed AST upon admission. Overall rates of inpatient initiation of SUP decreased from 25.4% to 16.4% and then 5.4% from the pre-intervention phase to PDSA 1 and PDSA 2 respectively. Rates of inappropriate SUP use also decreased from 8.4% to 7.1% and then 4% respectively.

CONCLUSION:
Academic detailing as a means to change clinician practices through evidence-based medicine has been shown to have a risk difference of up to 16% in the literature. Furthermore, the addition of a hard stop has been shown to effectively make these changes more permanent. These strategies were successfully used in our inpatient setting to decrease inappropriate AST use, subsequently translating to a reduction in long term complications and cost accrual.
1243 The Association Between Gastroparesis and Slow Transit Constipation as Seen by Wireless Motility Capsule (WMC)
Authors: Radetic Mark , Kamal Afrin , Rouphael Carol , Cline Michael 
Published: October 2019

INTRODUCTION:
Gastroparesis refers to delayed gastric emptying in the absence of a gastric outlet obstruction, as diagnosed by >10% gastric retention at 4 hours on Gastric Emptying Scintigraphy (GES). It presents with nausea/vomiting, upper abdominal fullness/discomfort, and early satiety. Several conditions can predispose patients to developing the disease, but ∼50% of affected patients are found to have idiopathic gastroparesis. The gastrointestinal tract is well connected through a series of neuronal reflexes that act to stimulate/inhibit specific segments based on stimuli detected at other “upstream or downstream” locations. The existence of a “cologastric brake” has been postulated in the past – where stimuli in the colon activate ascending tracts that may modulate upper gastrointestinal function. Based on this premise, the aim of our study was to determine the relationship between constipation and gastroparesis.

METHODS:
We conducted a retrospective study of patients who had undergone both GES as well as Wireless Motility Capsule (WMC) testing at our institution. Patients were divided into two groups based on the results of the GES: normal gastric emptying or gastroparesis. Constipation was assessed via WMC and anorectal manometry (when available). Demographic data, co-morbidities, selected labs, and medications were analyzed.

RESULTS:
A total of 224 patients were reviewed (101 with normal gastric emptying and 123 with gastroparesis). Mean colonic transit time was 2,321 min (normal <3,540 min) for patients with normal gastric emptying and 2,665 min for patients with gastroparesis (P = 0.361). There were no significant differences between the groups in demographics, co-morbidities, labs, or medications with the exception of prokinetics (P = 0.004) which were more common in the gastroparesis group. Univariate logistical regression found no association between slow-transit constipation and mild/moderate gastroparesis (OR 1.13/0.92, P = 0.82/0.81) but did find a correlation with severe gastroparesis (OR 2.45, P = 0.01). This relationship was strengthened with the exclusion of diabetes mellitus (OR 3.5, P = 0.008). Dyssynergic defecation did not appear to be associated with gastroparesis regardless of severity.

CONCLUSION:
Severe gastroparesis appears to be associated with an increased prevalence of slow-transit constipation – even more so after eliminating confounders (diabetes mellitus). Conversely, dyssynergic defecation does not appear to have any impact on gastric emptying.
1244 Symptomatic Patients Suspected of Eosinophilic Gastritis and/or Enteritis Have Elevated Mucosal Mast Cell Counts Without Eosinophilia: A New Diagnostic Entity?
Authors: Murray Joseph A. , Dellon Evan S. , Peterson Kathryn A. , Falk Gary W. , Chehade Mirna , Genta Robert M. , Gonsalves Nirmala , Rothenberg Marc E. , Khoury Paneez , Leung John , Bledsoe Adam C. , Shaw Camilla , Rasmussen Henrik S. , Singh Bhupinder , Chang Alan T. , Youngblood Bradford A. , Kamboj Amol , Hirano Ikuo 
Published: October 2019

INTRODUCTION:
Eosinophilic gastrointestinal diseases (EGIDs) are a set of inflammatory diseases subclassified according to the site(s) of abnormal accumulation of eosinophils (eos) in the gastrointestinal (GI) tract such as eosinophilic esophagitis (EoE), gastroenteritis (EGE), and colitis. These conditions often decrease quality of life due to debilitating symptoms. While the pathogenesis of EGIDs is primarily thought to be driven by eos, there is increasing evidence for the involvement of mast cells (MCs). AIM: To characterize symptomatic patients (pts) with suspected EG/EGE who did not meet histopathologic entry criteria for mucosal eosinophilia for a Phase 2 randomized, double-blind, placebo-controlled study of AK002, an anti-Siglec-8 antibody.

METHODS:
To undergo screening endoscopy for this study, pts were required to report an average symptom score ≥3 (0 to 10 scale) for abdominal pain, nausea, and/or diarrhea on a daily patient-reported outcome questionnaire for ≥2 weeks and have no other known cause for GI symptoms. During the screening endoscopy, biopsies were systematically obtained from the stomach and duodenum, and read by a single pathologist. Eos counts (eos/hpf; hpf area = 0.237 mm2) were assessed on H&E slides. To quantify MCs, immunohistochemistry for tryptase was performed. We quantified eos and MCs in the stomach and duodenum. Histopathologic entry criteria for the randomized study was ≥30 eos/hpf in 5 hpfs in the stomach (EG) and/or ≥30 eos/hpf in 3 hpfs in the duodenum (EGE). A literature review was conducted to determine normal MC counts in the GI tract.

RESULTS:
Eighty-eight pts underwent screening endoscopy based upon suspected EG/EGE and active symptoms, and 72 pts met histopathologic eos criteria. All pts whose eos did not meet entry criteria (n = 16) were found to have elevated MC counts (Figure 1; reported normal range = 12-19 MCs/hpf). In these pts, the mean gastric eos count was 6 eos/hpf in 5 hpfs and mean duodenal eos count was 15 eos/hpf in 3 hpfs. In contrast, these pts exhibited a mean gastric MC count of 47 MC/hpf in 5 hpfs and a mean duodenal MC count of 49 MC/hpf in 3 hpfs. Almost all symptomatic pts screened (87/88; 99%) had elevated MC counts.

CONCLUSION:
Data from this large randomized EG/EGE study showed that symptomatic pts with suspected EG/EGE had increased mucosal MCs with or without mucosal eosinophilia. These data suggest that MCs may play a role in pts with suspected EG/EGE and raise the possibility of a unique clinical presentation driven by MCs.
1245 The Morphological Changes of Fundic Gland Polyps After PPI Therapy
Authors: Fukuda Masahide , Ishigaki Hirohito , Sugimoto Mitsushige , Mizukami Kazuhiro , Ueo Tetsuya , Abe Hisanori , Andoh Akira , Kushima Ryoji , Murakami Kazunari 
Published: October 2019

INTRODUCTION:
Recent studies showed that patients on proton pump inhibitors (PPIs) have larger in size and a higher incidence of fundic gland polyps (FGPs) than patients not on PPIs. However, the morphological changes of the enlargement of FGPs after PPIs treatment was not clarified. The aim of this study was to clarify the endoscopic features and the morphological changes of FGPs in patients treated with PPIs.

METHODS:
A total of 196 endoscopic images of FGPs consisting of 87 FGPs in patients treated with PPIs (PPI group) and 109 FGPs in patients treated without PPIs (non-PPI group), all of which were pathologically diagnosed as FGPs, were compared by two endoscopists. The evaluated findings were shapes (sessile, pedunculated, semi-pedunculated), colors (isochromatic, light red, red, with hemorrhage, with black spot), surface structure (smooth, uneven) and atrophic change in back ground mucosa. The correlation between each endoscopic finding was examined.

RESULTS:
The average of polyp size was significantly larger in PPI group than that in non-PPI group (7.90 ± 4.68 mm and 3.76 ± 2.12 mm, P < 0.001). The semi-pedunculated shape (Isp) of FGPs were significantly more often seen in PPI group (67.0%) than in non-PPI group (32.2%) (P < 0.001), while the sessile shape (Is) of FGPs were significantly more often seen in non-PPI group (33.9%) than in PPI group (62.1%) (P < 0.001). Red colored FGPs and FGPs with black spots were seen only in PPI group although the number of the polyp was few (n, (%). 6, (6.9) and 5(5.7), <0.05, respectively). The uneven surface structure was significantly more often seen in PPI group than non-PPI group (n (%), 54 (62.1) and 27 (24.8), P < 0.001). Pearson's correlation analysis shows a positive correlation between the “Polyp sizes “and “Uneven surface structure” (r = 0.607, P < 0.05).

CONCLUSION:
FGPs in patients treated with PPIs shows larger, semi-pedunculated (Isp), uneven surface structure, and occasionally with red colored and black spot, compared with FGPs in patients without PPIs therapy. When FGPs became bigger, the surface of FGPs became uneven. The endoscopic morphology of FGPs will change like “red potatoes” after PPI therapy and will be difficult to distinguish from other potentially harmful polyps such as foveolar hyperplasic polyps.