bluuebunny/crossref_metadata_2025_split huggingface dataset:
500 Assessing the Impact of a National Small-Group CME Activity on Management of Patients With IBS
Authors: Salinas Gregory D. , Saenz Thomas , Cash Brooks D. 
Published: October 2019

INTRODUCTION:
Rapid advances in understanding of and available therapies for IBS have created a significant educational need among practicing clinicians. Our aim was to determine the effectiveness of a CME activity discussing IBS on clinical performance.

METHODS:
In 2018, a national educational initiative focusing on the management of IBS was led by the Gi Health Foundation (GiHF) IBS Centers of Educational Expertise and complemented by educational resources on the GiHF's educational portal. The initiative consisted of 50 small group CME discussions and one on-line module. The target audience consisted of community-based gastroenterologists and healthcare professionals who provide care for patients with IBS. To assess the effectiveness of the initiative, a series of case vignette-based surveys were provided to a sample of learners at least 30 days after attending the education (Aug-Oct 18). Learner decisions were compared to a demographically similar nonlearner control group of clinicians collected in the same timeframe. Analyses were conducted to compare the two groups and to understand specific and overall educational effect.

RESULTS:
The education had a total of 401 learners; 236 of those were eligible for the outcomes study based on demographic criteria (MD/NP/PA role, currently managing patients with IBS). A sample of 52 learners were collected and matched to a control group of 52 nonlearners. Comparing their performance and decision-making choices, learners were 42% (effect size 0.68) more likely than nonlearners to provide evidence-based care. Performance improvements were seen in aspects of diagnosis and patient management, including confirming IBS-D diagnosis, selecting appropriate initial IBS-D management, and selecting appropriate management for recurrent IBS-D. A linear regression analysis was conducted to determine whether the effect was due to education participation or another confounding demographic variable. We found that when all demographic variables (clinician age, degree, specialty, patient load, etc.) are equal, participation in education is the primary driver of performance change in this sample.

CONCLUSION:
This educational series had significant impact on lasting physician performance and indicated areas of need for future education, such as treatment choice of for a patient with IBS-C, timing of colonoscopies, managing psychosocial aspects of care, determining next steps in a patient not responding to rifaximin, and strategies to promote patient adherence.
502 Translumbosacral Anorectal Magnetic Stimulation (TAMS): Novel Anorectal Neurophysiology Test, Normative Values, and Effects of Gender
Authors: Yan Yun , Xiang Xuelian , Sharma Amol , Herekar Anam , Parr Rachael , Rao Satish 
Published: October 2019

INTRODUCTION:
Although anal electromyography and pudental nerve latency have been used for assessment of anal neuropathy, neither test is used routinely in clinical practice, because of significant deficiencies with each test and were not endorsed by AGA. Also neither test comprehensively assesses the entire nerves from their origin in spinal cord to anal innervation. Truslumbosacral Anorectal Magnetic Stimulation (TAMS) is a novel, non-invasive test for identifying anorectal neuropathy. It evaluates the neuronal integrity of lumbar and sacral plexus nerves from their origin in spinal cord to their innervation in the rectum and anus by measuring the latencies of motor evoked potentials (MEPs). Our aim was to determine the normal values for TAMS in healthy subjects and evaluate the effects of gender.

METHODS:
Healthy subjects underwent bilateral translumbar and transacral magnetic stimulation using a 90 mm magnetic coil (Magstim, UK). Motor evoked potentials (MEPs) were recorded simultaneously from the rectum and anus using two pairs of bipolar ring electrodes. The 8 MEP latencies from each healthy subject were measured (mean ± SEM) and gender differences compared.

RESULTS:
Forth-eight healthy subjects (18-59) years, F/M = 32/16) were evaluated. The mean latency of all 8 MEPs, and in men and women are summarized in Table 1. Although there are small differences in MEP latencies between individual sites, overall there were no differences between the lumbar and sacral nerve latencies or between the right or left side or between the anal and rectal sites (Table 1). Also there were no differences in MEP latencies between men and women for any of the 8 sites. Age is not significantly associated with the anal or rectal MEP latencies (r = 0.09 to 0.326), except weak association for right sacro-rectal MEP (r = 0.386), P = 0.009).

CONCLUSION:
This study provides normative values for the bilateral lumbar and sacral-anorectal MEPs in healthy subjects. Neither gender nor age appear to influence the rectal and anal MEP latencies. These data will provide the basis for comparing the novel TAMS test findings in patients with those from suspected anorectal or pelvic neuropathy.
503 Small Intestinal Bacterial Overgrowth (SIBO) in Functional Dyspepsia (FD): Does Dyspeptic Symptom Pattern Make a Difference?
Authors: Nojkov Borko , Baker Jason , Watts Lydia , Lee Allen , Chey William D. , Saad Richard 
Published: October 2019

INTRODUCTION:
FD is a common gastrointestinal disorder with poorly understood pathophysiology. Patients with FD and SIBO frequently overlap symptomatically. The prevalence of SIBO in patients with FD is not well studied, particularly in relation to the predominant FD symptom profile. We aimed to evaluate the prevalence of SIBO diagnosed by glucose breath test (GBT) in patients with FD and compare the SIBO prevalence in FD subtypes - Postprandial Distress Syndrome (PDS), Epigastric Pain Syndrome (EPS) or both (PDS+EPS).

METHODS:
Retrospective, tertiary center, study of patients fulfilling Rome criteria for FD, who completed GBT (2018-2019). Demographics, history, medications, and GBT findings were reviewed. Patients with documented structural disease (eg. neoplasm) were excluded. GI symptoms (including mid upper abdominal pain or burning, early satiety and postprandial fullness) were prospectively collected from all patients at the time of their GBT. Based on these responses, patients were classified into: 1. FD-PDS, 2. FD-EPS and 3. FD-PDS+EPS. A priori variables associated with SIBO were analyzed including: presence of diabetes, GERD, and gastroparesis; history of small bowel surgery or gastric bypass; use of opioids or proton pump inhibitors. Prior to GBT, patients had low carbohydrate diet (2 days), no antibiotics (30 days) and no tobacco (12 hrs). Positive GBT for SIBO was defined by ≥20 ppm H2 increase over basal within 90 min and/or ≥10 ppm CH4 increase at any time. Statistical methods included chi-square and t test.

RESULTS:
737 consecutive patients were studied (mean age=51.6±17.6 years, 70% female, 88% Caucasian, mean BMI=28.4±7.1). No differences in demographic or a priori SIBO-associated variables were found between the 3 subgroups of FD patients (P = NS). 31.4% of patients fulfilling criteria for FD had a GBT positive for SIBO. Individual gas (H2, CH4, or both) excretion responsible for a positive glucose HBT in each of the FD subgroups is shown on Table 1. There was no statistically significant difference in the prevalence of SIBO (by either H2, CH4 or both) between the three FD patient subtypes. There was borderline significant difference for slower H2 peak depicting a positive GBT in FD-PDS compared to FD-EPS and FD-EPS+PDS (83.8 vs. 70.7 vs. 65.7 minutes, P = 0.05).

CONCLUSION:
SIBO diagnosed by GBT is common in patients with FD regardless of the predominant symptomatic pattern. The prevalence of SIBO was similar in the three FD subtypes.
509 Burden of IBS-Diarrhea Symptoms Tracked With Daily Journals for 12 Weeks in a Randomized, Double-Blind, Placebo-Controlled Study of Lactobacillus AcidophilusCL1285, L. Casei LBC80R and L. Rhamnosus CLR2
Authors: Ship Noam , Mallais Cynthia , Carrière Serge 
Published: October 2019

INTRODUCTION:
The burden of symptoms in Irritable Bowel Syndrome is chronic and fluctuates from day to day, yet most research studies rely on scheduled clinical interviews. Daily symptom journals may provide better precision of the burden of illness. The diarrhea-predominant presentation of IBS (IBS-D) is particularly disruptive to Quality of Life.

METHODS:
Subjects with a history of IBS were randomized, double-blind, to oral capsules of a probiotic comprised of Lactobacillus acidophilus CL1285, L. casei LBC80R and L. rhamnosusCLR2, 100 billion CFU daily, or placebo in a 2:1 ratio (Preston 2018). In addition to the clinical interviews, subjects kept daily records of each stool with the Bristol Stool Scale (BSS), and, scored their abdominal pain on a 10-point visual analog scale (VAS). Scores were pooled for weeks 1 through 6 and weeks 7-12. Liquid stools had BSS ratings of 6 or 7. Missing journal entries were imputed with the Last Observation Carried Forward. A regression was performed for IBS-related Quality of Life scores at clinical interviews and journal data for abdominal pain and the proportion of liquid stools.

RESULTS:
Daily journals were available for 38 subjects with IBS-D (N = 26, active, N = 12, placebo). The active treatment group had significantly more liquid stools at baseline relative to placebo, RR = 1.2, P < 0.001. Both groups decreased vs. baseline for weeks 1-6 but the ratio remained the same, RR = 1.2, P < 0.001. For weeks 7-12 the number of liquid stools for placebo plateaued but the active group continued to improve, RR = 0.7, P < 0.001. The number of days of abdominal pain, 6 or greater on the VAS, in each arm was similar at baseline, RR = 0.9, but there were significantly fewer days of pain with probiotic treatment vs. placebo for weeks 1-6 and 7-12, RR = 0.6, 0.5, respectively, P < 0.001. For weeks 7-12, the probiotic group experienced fewer weeks with any pain rating of 6 or greater, RR = 0.6, P = 0.02. Better Quality of Life was correlated with fewer days of abdominal pain, 3 or greater on the VAS, and, a lower proportion of liquid stools (R2 = 0.16, P < 0.001).

CONCLUSION:
There was an important decrease in the burden of IBS-D symptoms in both treatment arms. Compared to placebo, subjects taking the probiotic capsules had fewer liquid stools and fewer days of abdominal pain. Despite variability among the subjects with IBS-D, fewer days of pain and a lower proportion of liquid stools correlated with improved IBS-related Quality of Life. Preston K, et al. Beneficial Microbes, 2018, 9(5):697-706.
510 Ginger, Paullinia Cupana, Muira Puama, and L-citrulline (COMP-4) as a Novel Natural Treatment for Severe Constipation
Authors: Gisi Catherine , Reicher Sofiya , Hou Linda A. , Fleischman Wayne , Eysselein Viktor E. 
Published: October 2019

INTRODUCTION:
Epidemiologic studies report that about 15% of adults and 30% of people older than 60 years suffer from constipation in the United States. The actual prevalence is likely greater as many people believe their bowel habits are normal and underreport symptoms of constipation. Moreover, most recent surveys assessing current medical management of constipation show that patients are dissatisfied and believe that conventional treatments, like laxatives and colonic stimulants, are suboptimal since they can cause explosive bowel movements which are difficult to control. COMP-4, a combination of ginger, Paullinia cupana, muira puama, and L-citrulline is a novel nutraceutical that has been shown to stimulate the production of nitric oxide and cGMP in smooth muscle cells resulting in smooth muscle relaxation and possibly increases intestinal secretion. In this study, we aim to demonstrate that treatment with COMP-4 is an effective treatment for severe constipation.

METHODS:
Seventeen patients with constipation were treated COMP-4 (2-4 capsules per day) for 2-4 weeks. Constipation was defined as two or more of the following: the sensation of incomplete evacuation, Bristol stool score 1-2 (hard, lumpy nut or sausage-shaped bowel movements), and straining during the majority of defecations. Patients were surveyed before and after the treatment regarding their approximate number of bowel movements per week, their typical Bristol stool score, the presence of abdominal pain, and the feeling of incomplete evacuation. Statistical analysis was performed using the Wilcoxon rank test with a P < 0.05 considered significant.

RESULTS:
Following treatment with COMP-4, the average weekly number of stools significantly (P < 0.0001) increased from 2.7+/-0.68 to 7.3+/- 1.11 (Figure 1). Prior to COMP-4, 16/17 patients reported incomplete bowel evacuation during bowel movements. After COMP-4, 10/17 patients reported complete bowel evacuation. The mean Bristol Stool Score significantly (P < 0.0001) increased from 1.5+/- 0.15 to 3.4+/-0.29 with softer and more formed stools (Figure 2). Patients also experienced a significant (P < 0.0001) decrease in abdominal pain (Figure 3).

CONCLUSION:
The combination of ginger, Paulinia cupana, muira puama, and L-citrulline improves the frequency and consistency of stools and helps relieve symptoms of constipation. The nutraceutical may be a novel agent used to treat severe constipation not responding well to other conventional treatments.
515 Are All Endoscopic-Related Musculoskeletal Injuries Created Equal?: Results of a National Gender-Based Survey
Authors: Pawa Swati , Banerjee Promilla , Kothari Shivangi , D'Souza Sharlene , Martindale Sarah L. , Gaidos Jill , Oxentenko Amy S. , Burke Carol A. 
Published: October 2019

INTRODUCTION:
Endoscopy- related injury (ERI) is common in gastroenterologists. This study aimed to evaluate the prevalence of self-reported ERI, patterns of injury and knowledge of ergonomic strategies in endoscopists who are ACG physician members.

METHODS:
A 38-item survey was developed and initially piloted at three academic medical centers. Through the ACG Women in GI Committee and ACG Governing Board sponsorship, the survey was administered to ACG physician members. Statistical analysis was performed using SAS Enterprise Guide 7.0 (SAS Institute Inc., Cary, NC); chi-square tests and descriptive analysis evaluating associations between multiple variables and ERI.

RESULTS:
Of the 14759 total surveys sent, 5940 were opened, and only completed surveys were included (n = 1133). ERI was reported by 71% of the respondents including 49% of trainees. More than half of the respondents reported pain in the thumbs (64%), hand/fingers (59%), neck (57%), and lower back (54 %). The most common causes of ERI reported were torqueing with the right hand (64%), adjusting tip angulation with left hand (53%), standing for prolonged periods of time (59%), and standing in awkward positions while supporting an endoscope (58 %). While no differences were noted in characteristics associated with overall ERI, including sex (P = 0.77), performance of interventional endoscopy or a focus in another GI domain (P = 0.55) women were more likely to have upper extremity pain and upper back pain (see Table 2). There were statistically significant differences between genders in the mechanisms of ERI (see Table 3). Most respondents did not receive training during fellowship (68%), or discuss ergonomic strategies in their current practice (63%). Those without training in ergonomics were more likely to report ERI (P = 0.02). 81 % of respondents noted a desire for more training in ergonomic strategies to reduce ERI.

CONCLUSION:
The results of this study show an overwhelming occurrence of ERI in all GI physicians and in nearly half of the trainee respondents. Preliminary analysis shows a significant difference between men and women with regards to specific areas of ERI and contributing mechanisms. Results strongly support training and a desire for continued education in ergonomic strategies as a preventative strategy. Education and prevention of ERI represent rich opportunities for improving key aspects of clinical practice, reducing burden on physicians, and decreasing interruptions to clinical care.
516 The Impact of In-Hospital Palliative Unit on Percutaneous Gastrostomy Practice, Volume, and Outcomes
Authors: Patel Harish , Makker Jasbir , Tariq Hassan , Ahmed Rafeeq , Kumar Kishore , Chime Chukwunonso U. , Ravi Madhavi , Abbas Hafsa , Baiomi Ahmed , Shaikh Danial , Mehershahi Shehriyar , Balar Bhavna , Chilimuri Sridhar 
Published: October 2019

INTRODUCTION:
Per-cutaneous gastrostomy (PEG) is often preferred for enteral feeding of patients with terminal and critical illness. Implementation of the palliative care often avoids the futile procedures in patients with short life expectancy. Inpatient palliative units have the potential to reduce placement of PEG in terminally ill patients.

METHODS:
In retrospective review, we analyzed all patients who underwent PEG from 2006 to 2015. The research protocol was approved by Institutional Review Board at our institution. The study population was divided into two groups based on the establishment of in-hospital palliative care unit at our institution in August of 2010. The demographic data including age, gender and ethnicity were reviewed. Endoscopy reports and patient charts were reviewed for the indication of PEG and post-procedural complications. The categorical variables were analyzed with chi-square and continues variable with student t-test. The annual procedural number were extrapolated from our endoscopy EMR.

RESULTS:
There were 780 PEGS placed on 721 unique patients from 2006 to 2015. Majority of them (62% n = 483) were placed before establishment of in-hospital palliative care unit (August 2010) and the remaining (38% n = 297) were done after Aug 2010. There was no significant difference in total number of hospitalizations or discharges during the study period. After implementation of palliative unit, number of PEGS decreased from 97/year to 52/year (Figure 2). The mean age of patient undergoing PEG was 69 years in both group. There was slight females preponderance (53% vs 50%). African American patients were predominant in both groups. Establishment of in-house palliative care unit led to statically significant decrease (34% to 7%) in number of Hispanic patients and an increase in white Caucasian (from 9% to 42%) undergoing PEGs (Figure 1). There was substantial change noted in the indication of the PEG (Figure 3) after inpatient palliative care unit services, with the predominant decrease for the PEG requirement in patients with dementia (from 42.9% to 24%, P-value < 0.001). There was a statistically significant decrease in the overall mortality (23.3% to 7.4%) and 30-day mortality (9.7% to 4%) for patients undergoing PEGS after the initiation of the palliative unit. However, overall PEG related complications were unaltered.

CONCLUSION:
The in-house palliative care units impact practice of PEG placement by decreasing procedural volume, lower overall and 30-day mortality after PEG placement.
517 A Survey of Peri-Colonoscopy Management of Anti-Diabetic Medications
Authors: Lee Byeori , Jain Deepanshu , Rajala Michael 
Published: October 2019

INTRODUCTION:
Currently, no standardized recommendations exist for management of antidiabetic medications in diabetes mellitus type II (DMII) patients undergoing bowel cleansing for colonoscopy. This study aims to find real-world practices of gastroenterology providers in the management of anti-diabetic medications in peri-colonoscopy period for DMII patients.

METHODS:
An online survey was created using Google Survey and sent to thirty-three providers who are routinely involved in planning colonoscopy for patients at our tertiary medical center. Survey questions were designed to know provider practices regarding the management of anti-diabetic medications on the day before and morning of colonoscopy in DMII patients. Questions specific to six non-insulin medications and four insulins (short, intermediate, long-acting, and mixed) for each meal were framed. Two expert endocrinologists were consulted to give best practice recommendations regarding management of same anti-diabetic medications in the peri-colonoscopy period. The answers from each provider were collected and summarized.

RESULTS:
Among 33 providers, 24 providers (72.7%) answered the survey. Of them, 12/24 were attending physicians, 6/24 were fellow in training, 6/24 were nurse practitioners/physician assistants). Table 1–3 summarize the cumulative numbers (and percentages) for each response specific to each anti-diabetic medication and time of day.

CONCLUSION:
Our survey shows marked disparity amongst gastroenterology providers (attendings, fellows, and nurse practitioners/physician assistants) and with regards to endocrinologist recommendations. Lack of consensus leads to confusion at the patient level, often leading to mismanagement and sometimes even clinically significant hypoglycemic and hyperglycemic events. Gastroenterologists should team up with endocrinologists to come up with practice guidelines to standardize peri-colonoscopy management of anti-diabetic medications among DMII patients.
521 Developing and Validating a Prediction Model to Identify Patients at High Risk for Failing Standard Sedation for Routine GI Endoscopy
Authors: Adams Megan A. , Saini Sameer D. , Gao Yuqing , Wiitala Wyndy , Rubenstein Joel 
Published: October 2019

INTRODUCTION:
In recent years, use of anesthesia-assisted (AA) sedation for routine GI endoscopy has increased markedly. One factor contributing to this increased use is clinical uncertainty about which patients are most likely to benefit from AA. We aimed to develop a prediction model to help providers identify patients who require AA due to high-risk of failing standard sedation (SS).

METHODS:
This was an IRB-approved retrospective longitudinal study of national Veterans Affairs (VA) data of all patients who underwent an EGD and/or colonoscopy in 2009-13 (during which AA was used for 4.1% of routine GI endoscopy in VA). Using step-wise logistic regression, we developed a model to predict the primary outcome of failed sedation using potentially predictive patient and procedure-level variables (Table 1). Failed sedation cases were identified electronically as patients who had a routine procedure (without polypectomy, dilation, or injection) with AA within 3-months of a prior similar SS procedure. All cases were manually validated by chart review (index endoscopy report or other records) documenting patient discomfort/agitation and/or medical instability resulting in either an incomplete procedure or specific mention of need for AA for future procedures. 10-fold cross validation was used to validate the final model.

RESULTS:
Of 710,252 SS procedures, there were 398 cases of failed sedation (173 EGD, 225 colonoscopy; prevalence = 0.06%). None of the factors found to be significant predictors of failed sedation (e.g., high-dose opioid use, younger age) had an odds ratio > 3; factors NOT associated with failed sedation included body mass index, obstructive sleep apnea, functional GI disorders, and others (Table 1). 10-fold cross-validation yielded a mean area under the curve (AUC) of 0.67 (range 0.63-0.71). The model was well-calibrated, but patients in the top decile of risk had a failed sedation prevalence of only 0.16% (Table 2).

CONCLUSION:
Failed sedation among patients undergoing routine outpatient GI endoscopy with SS is very rare, even among patients in the highest decile of risk. This suggests that concerns regarding failed sedation due to commonly cited factors such as chronic opioid use, obesity, or increased comorbidity do not justify forgoing SS in favor of AA in most patients. It also suggests that use of AA is generally unnecessary, since failed sedation is very uncommon even in VA where overall use of AA is much lower than in the private sector.