bluuebunny/crossref_metadata_2025_split huggingface dataset:
2988 Development of the Celiac-Provider Education Guideline Support (Celiac-PEGS) Website
Authors: Crozier Louise A. , Crowe Sheila E. 
Published: October 2019

INTRODUCTION:
Celiac disease is an autoimmune disease that affects about 1% of a genetically susceptible population. Approximately 3 million individuals in the United States have celiac disease (CD) and are required to eat a gluten-free diet (GFD) to prevent severe health issues. Poor dietary management and lack of comprehensive care can lead to increased significant co-morbid conditions. Current literature suggests a significant lack of provider knowledge and implementation of CD guidelines may negatively affect management and care of adult patients with CD. Poor dietary management of CD, in addition to the lack of comprehensive care, can lead to daily symptoms, significant co-morbid conditions and decreased quality-of-life in patients with CD. There is an increased need for improving awareness, knowledge, and accessible treatment guidelines for providers who manage the care of adult patients with CD.

METHODS:
The emphasis of this project has been on the development of a web-based program to assist providers in the implementation of the current complex CD guidelines for management of adult patients with CD. Grounding of this web-based program is with currently published guidelines including the American College of Gastroenterology “Diagnosis and Management of CD” guidelines (2013), the British Society of Gastroenterology “Diagnosis and Management of Adult Coeliac Disease: Guidelines” (2014), the American College of Physicians “In the Clinic” celiac guidelines (2011), and the World Gastroenterology Organization Global CD Guidelines (2016). This project translates current evidence-based practice guidelines into an organized system that will guide providers as well as increase their knowledge and confidence to successfully direct care and guide patients with CD.

RESULTS:
A usability study conducted in 2018 involving 15 GI providers from California and New Mexico evaluated ease of use of the new Celiac- Provider Education Guideline Supportweb-based program, which showed above average usability and this information, was previously presented at DDW 2019.

CONCLUSION:
We have developed a web-based program for providers of adult patients with CD, which is easy to use. The goals of this innovative website are to improve awareness, education, and management support that will result in comprehensive implementation of current adult CD guidelines. Ultimately, we believe that this web-based program once nationally disseminated, will especially support providers in primary care and in rural areas.
2989 To Determine the Frequency of Helicobacter pylori in Patients With Gastric Cancer
Authors: Adnan Muhammad , Adnan Nida 
Published: October 2019

INTRODUCTION:
Around the world, particularly in Asia and Eastern Europe, gastric disease remains a main source of malignant growth demise. A higher danger of advancement of gastric malignancy has been accounted for in patients with positive serologic tests for H pylori. This investigation is a push to demonstrate a relationship of H pylori as a cancer-causing agent and the seriousness of harm it is related with. H. pylori is perceived as a reason for constant gastritis, which might be viewed as the initial phase in a grouping of changes to the gastric mucosa perhaps bringing about malignancy. In this manner, the present examination investigated the presence of H. pylori disease in people with gastric malignant growth at tertiary consideration healing center.

METHODS:
The two year cross section study screened fifty cases of carcinoma stomach for H. pylori infection. The inclusion criteria were patients with carcinoma stomach confirmed by endoscopy and histopathology while the exclusion criteria patients received anti H pylori treatment within 6 months and the patients not willing/refuse to give consent for the study. All patients who presented with upper GI symptoms and suspected to have carcinoma stomach investigated in the form of complete blood count, ultrasound and upper gastrointestinal endoscopy. On endoscopy patient who had growth in the stomach biopsy was taken from and around the growth and subjected to Rapid urease test and histopathologic examination along with serology test for antibobies to H. pylori. The frequency/percentages (%) and means ± SD computed for study variables.

RESULTS:
During two year study period total fifty patients were explored for H. pylori infection. The frequency for male and female population was 32 (64%) and 18 (36%) with mean ± SD for age of male and female individuals was 55.83 ± 9.62 and 58.21 ± 8.72 respectively. The H. Pylori infection was positive in 30 (60%) patients while the growth exists in antrum 25 (50%), antrum and body 10 (20%), body 08 (16%), body and fundus 04 (8%), fundus 03 (6%) while regarding the histopathology well differentiated carcinoma 07 (14%), moderately differentiated carcinoma 10 (20%), poorly differentiated carcinoma 33 (66%).

CONCLUSION:
The existence of H. pylori observed in gastric carcinoma cases may lead to a spread of H. pylori in histologic sections and might describe the variation in H. pylori infection rates reported for patients with gastric cancer.
2990 Helicobacter pylori in Chronic Spontaneous Urticaria: An Interim Analysis of a Case-Control Study in Nepalese Population
Authors: Poudyal Yogesh , Paudel Mukesh , Pathak Nandu , Mandal Amrendra 
Published: October 2019

INTRODUCTION:
Chronic spontaneous urticaria (CSU) is defined as the spontaneous appearance of wheals, angioedema or both for more than six weeks due to known or unknown causes. Infections like helicobacter pylori have been implicated as causes of CSU. In this study, we aimed to determine an association of H. pylori infection with CSU.

METHODS:
This was a case-control study conducted in Lumbini city Hospital, Butwal, Nepal. Study duration was from March to May 2019. Sample size was calculated to be 83 participants in each group. Participants fulfilling the diagnosis of CSU were enrolled. They underwent 14C -Urea Breath Test (UBT) by a standard protocol, for noninvasive detection of H. pylori. HUBT-20P model of the analyzer from Shenzhen, China was used. A value of less than 150 DPM (disintegration per minute) was considered to be negative. We excluded the following from the study: pregnant individuals, participants with recently used of antibiotics and bismuth compounds (<4 weeks), participants with recent use of proton pump inhibitors (<2 weeks), less than two years age, those with previous gastric surgery and those suspected of having coexisting inducible urticaria. The results were compared with age and sex-matched controls.

RESULTS:
We included 29 patients with CSU and 29 controls in this study. The average age of participants was 25.8 ± 8.69 years. Sixteen (55.17%) patients with CSU were females and 13 (44.82%) were males. Twenty-six (89.65%) patients with CSU tested positive for H. pyloriwith UBT; only 10 (34.48%) participants from the control group tested positive. The distribution of H. pylori by 14-C urea breath test in cases and controls is shown in Table 1.

CONCLUSION:
In this interim analysis of 29 cases and controls, majority of participants were females with an average age of 25.8 years. In a study of 673 adults with CSU, majority (72%) were reported to be females. Chronic urticaria is sometimes associated with other autoimmune conditions and hence its increased prevalence in females may be indirect evidence of the autoimmune nature of this disease. Most of the participants with CSU tested positive for H. pylori with UBT as compared to the age and sex-matched controls and this difference was statistically significant (P < 0.0001).
2994 Hospital Outcomes of Gastric Cancer: A Nationwide Analysis
Authors: Rai Manoj P. , Bedi Prabhjot , Singh Tanveer , Kothari Shaili , Enofe Ikponmwosa 
Published: October 2019

INTRODUCTION:
Gastric cancer is the fifth most common cancer in the United States. It carries a poor prognosis since it tends to be discovered at advanced stages, limiting the role of curative surgery. Hospitalizations for gastric cancer occur for medical and surgical management of disease or complications related to cancer. In this study, we analyzed the frequency of hospital admissions, in-hospital treatment outcomes and resource utilization for hospitalizations with a diagnosis of gastric cancer.

METHODS:
This is a retrospective cohort study using the 2014 National Inpatient Sample. Hospitalizations were included if they had a principal or secondary diagnosis of gastric cancer. The primary outcome was the number of hospitalizations per year. Secondary outcomes included: 1) Their demographic characteristics 2) Five most common reasons for hospitalization, 3) In-hospital mortality and 4) In-hospital resource utilization (length of hospital stay (LOS) and total hospitalization charges).

RESULTS:
We identified 43,365 hospitalizations for the management of gastric cancer. The 5 most common principal diagnoses for admission were: gastric cancer, gastric cancer in the cardia, malignant neoplasm of contiguous or overlapping sites of the stomach, malignant neoplasm of the pyloric antrum and septicemia. The demographics and hospital characteristics are presented in Table 1. The mean age was 65. 6 years. The majority of hospitalizations were white males in the lower two income quartiles with Medicare or private insurance. Most of the hospitalizations occurred in large urban teaching hospitals located in the Southern USA. The inpatient mortality rate was 7.3% (6.6%-8.1%). The average length of stay was 7.6 (95% CI 7.4-7.8) days. The mean total hospitalization charges were $73,867 (95% CI $70,750–$76,985), with a cumulative healthcare burden of $3. 2 billion.

CONCLUSION:
The use of inpatient services for gastric cancer was significant with around 50,000 hospitalizations per year. Older age group, male gender, and white population comprised the majority of the hospitalizations. Cancer care and sepsis accounted for the majority of hospitalizations. Hospital admission is associated with substantial mortality, along with a staggering cumulative in-hospital healthcare burden of $3.2 billion per year. Interventions aimed at decreasing hospital admission for management of gastric cancer have the potential to decrease both mortality and healthcare resource utilization.
2996 Proton Pump Inhibitors: Do We Practice What We Preach? A Quality Improvement Intervention
Authors: Shahnazarian Vahe , Kolli Sree , Nagaraj Savitha , Ramai Daryl , Reddy Madhavi 
Published: October 2019

INTRODUCTION:
Timing in the administration of proton pump inhibitors (PPIs) plays an important role in their efficacy. Studies have demonstrated increased efficacy of PPIs when administered 30-60 minutes before the first meal of the day. Current default frequency for PPI orders at our urban community hospital is “daily,” which translates to a 10 am administration. This quality improvement study investigates the frequency with which PPIs are being ordered, and if they are being done in line with current recommendations.

METHODS:
The Plan-Do-Study-Act (PDSA) model was applied in order to determine whether there was a problem in PPI administration frequencies, and if so, how to address that problem. A retrospective and prospective electronic medical record (EMR) analysis was done. Data retrieved from that analysis included whether or not a PPI was ordered, which service it was ordered by, and the frequency at which it was ordered. Inclusion criteria included any inpatient in the hospital who had a PPI ordered. Exclusion criteria included any patient that was not an inpatient, did not have any PPI ordered, had a PPI ordered for more than once a day or had a PPI drip ordered. Statistical analysis was done with percentage change from baseline results.

RESULTS:
During a one month period (December 2018), every inpatient had a PPI frequency of daily. This meant the PPI would be given at 10 am. Based on the data, an EMR intervention was implemented where the default frequency for PPI administration was changed from “daily” to “before breakfast,” which meant it would be given at least 30 minutes before breakfast. A second report was run after the intervention for a one month period (March 2019), and it was noted that every single inpatient PPI ordered now had a frequency of “before breakfast.” This was a 100% improvement from the baseline.

CONCLUSION:
Quality improvement is not only important in improving healthcare systems but also in improving patient care. The PDSA model was applied here in order to correct an overlooked issue within our urban community hospital. Once the problem was identified, a simple EMR intervention was implemented. This change created 100% compliance with current recommendations, which led to improved patient care while not creating more work for the housestaff.
2997 Venous Thromboembolism Among Hospitalized Patients With Gastric Cancer: Insights From National Inpatient Sample 2004-2014
Authors: Gupta Kamesh , Handa Shivani , Goyal Hemant , Khan Ahmad , Sohail Abdullah , Desilets David 
Published: October 2019

INTRODUCTION:
Venous thromboembolism (VTE) is common in patients with malignancies and is associated with significant morbidity and mortality. The occurrence of VTE has been recognized as an independent predictor of mortality in patients with gastric cancer (GC) in smaller studies. However, no nationwide data is available about the VTE-related hospitalizations in patients with GC.

METHODS:
We used the US largest database National Inpatient Sample (NIS) from 2004 to 2014 to identify adults (≥18 yrs) with GC who were hospitalized with VTE using ICD-9 codes. These included patients with both deep vein thrombosis (DVT) and pulmonary embolism (PE) but superficial thrombosis was excluded. We adjusted for baseline demographic characteristics (age, sex, race, insurance, income quartile, history of chemotherapy, Charlson’s comorbidity index) and hospital characteristic (teaching vs. non-teaching, hospital size) to find out the in-hospital outcomes (mortality, length of stay and total hospitalization charges). Regression analysis was used to calculate odds for the association.

RESULTS:
Out of the total 445,719 hospitalizations with GC, 22,658 (5.08%) were identified to be associated with VTE. Out of these, 14,056 were associated with PE and 8602 presented with DVT. There was no significant difference in the mean age or sex. However, patients presenting with VTE were more likely to be and possess private insurance (Table 1). Total inpatient mortalities for these GC patients were 908 in the VTE group vs. 38,096 in the non-VTE (adjusted OR- 0.69, 95% CI 0.59-0.81). On univariate analysis, age, male sex, no history of chemotherapy and Charlson's comorbidity index were associated with increased in-hospital mortality. GC patients admitted with VTE had a significantly lower length of stay (5.6 ± 0.1 days) as compared to GC patients were admitted for other reasons or did not have VTE (6.4 ± 0.03 days) (P = 0.000). Similarly, total hospitalization charges were also significantly lower for GC patients with VTE ($38,052 ± 1008 vs. $43,696 ± 583; P = 0.001).

CONCLUSION:
In this large inpatient cohort retrospective study on GC patients, hospitalizations with VTE did not confer any change in the rates of mortality. However, length of stay and hospitalization charges were significantly lower in VTE patients than those admitted for other causes which could be due to a targeted treatment approach for VTE. Male sex and higher comorbidity index are associated with more mortality rate.
2999 Is There Truth to the Numbers?
Authors: Zackria Rasiq , Ling Joseph T. 
Published: October 2019

INTRODUCTION:
CA 19-9 is a tumor marker associated with pancreatic and biliary tumors that can be directly measured in the blood with a normal range of 0-37 units/mL. Other inflammatory conditions such as biliary obstruction can also cause an elevation, which can obfuscate the diagnostic and prognostic value of CA 19-9.

CASE DESCRIPTION/METHODS:
A 66-year-old male with no medical history presented with a 1-month history of abdominal pain, jaundice, and weight loss. He was febrile at 100.4 F. Bilateral conjunctival icterus, full upper body jaundice, hepatomegaly, and mild tenderness to deep palpation in the right upper quadrant and epigastric regions were noted on exam. Gallbladder ultrasound revealed significant common bile and intrahepatic duct dilation concerning for obstructive lesion with no gallstones and minimal sludge. Total bilirubin was 27 mg/dL. CA 19-9 was elevated at 9,272 units/mL. CT abdomen and pelvis with contrast confirmed severe common bile and intrahepatic duct dilation with CBD measuring up to 22 mm. MRCP revealed marked intrahepatic and extrahepatic biliary dilation with dilated CBD up to 24 mm and choledocholithiasis with the largest gallstone measuring 15 mm in the distal CBD. ERCP revealed CBD stricture and sphincterotomy was performed with temporary stent placement. Ceftriaxone and metronidazole were given for ascending cholangitis. Fine needle aspiration was done by EUS, which was negative for malignancy on pathology. Repeat MRCP showed improvement in dilation and CBD now at 14 mm. Repeat CA 19-9 was 193 units/mL. Of note, CT chest with contrast did not reveal any evidence of pulmonary metastasis, CEA level was normal, and hepatitis panel was negative.

DISCUSSION:
A CA 19-9 cutoff of greater or equal to 300 unit/mL have been reported to have a specificity of 87% for cancer in patients with cholangitis. However, an extremely elevated CA 19-9 level does not always equal cancer or correlate with tumor burden and should not be used as the sole criterion for a diagnosis of malignancy. Non-cancerous causes of elevated CA 19-9 include gallstones, cholangitis, bile duct obstruction, and pancreatitis. EUS was critical in obtaining tissue to exclude pancreatic and biliary cancer. CA 19-9 and total bilirubin levels dropped after CBD stent placement, supporting a diagnosis of cholangitis without tumor. This is a rare case of extreme tumor marker elevation caused by choledocholithiasis and cholangitis, which serve as a cautionary tale of not relying too heavily on numbers to treat the patient.
3000 A Diagnostic Dilemma: Ovarian Cancer or a Pancreatic Neuroendocrine Carcinoma
Authors: Abraham Fiyinfoluwa , Shiralkar Kaustubh , Younes Mamoun , Thosani Nirav , Dedania Bhavtosh 
Published: October 2019

INTRODUCTION:
Small cell pancreatic neuroendocrine carcinoma (P-NEC) is in a group of malignancies described as Gastroenteropancreatic (GEP) NEC, and is an extremely rare neoplasm. We present a case of P-NEC with confounding findings of multiple ovarian and pancreatic masses.

CASE DESCRIPTION/METHODS:
A 33-year-old European female with history of ovarian cysts (∼4 cm × 5 cm) presented with a ten-day history of lower abdominal/pelvic pain with new onset ascites and weight gain. No family history of GI or gynecologic malignancy. A CT (Figure 1a,b) of her abdomen and pelvis showed ascites, multiple pancreatic hypodense lesions and enlarged cystic ovaries (10 × 11 cm). Subsequent MRI pancreatic protocol (Figure 1c,d), and an endoscopic ultrasound (EUS-FNB) was performed. MRI showed diffusely abnormal pancreas with multiple focal solid masses with T2 hyper intense, T1 hypo intense, and hypo-enhancing lesions on early post contrast phases with no pancreatic ductal dilation or cystic component. EUS confirmed multiple hypodense pancreatic lesions but the findings were not consistent with primary pancreatic malignancy. Cytopathology of gastric nodules (Figure 2) and the pancreatic FNB (Figure 3) showed small cell NEC with a Ki-67 proliferative index (PI) of 43%. Pathology showed infiltrative process with small blue cells and scant cytoplasm. The IHC was positive for synaptophysin, chromogranin, CD56, weakly positive for CAM5.2 and AE1/AE3, negative for TTF-1, PAX8, CD45, CDX2, ER, and inhibin. The diagnosis was pancreatic small cell NEC. The enlarged ovarian cysts were determined to be an incidental finding, and not a primary source of the malignancy.

DISCUSSION:
Generally, the well differentiated pancreatic neuroendocrine tumors (NET) are hormone secreting; however, the GEP NEC are a highly aggressive poorly differentiated carcinoma and designated as grade 3 tumors. Grading is based on the Ki-67 PI and mitotic count/index (Table 1). Our patient had GEP NEC given her Ki-67 PI was 43%. Chemotherapy and/or surgical resection are the two treatment options, but by the time of late diagnosis the goal of the treatment is generally palliative. Our case emphasizes the importance of pursuing accurate pathological diagnosis, role of EUS in management of pancreatic neoplasms and eliminating the confounding factors (eg ovarian cysts/masses).
3005 Pancreatitis: An Unusual Initial Presentation of Duodenal Adenocarcinoma
Authors: Lambert Karissa , Hamed Amira , Hamed Ahmed Said , Samuel Gbeminiyi , Khalid Hamza 
Published: October 2019

INTRODUCTION:
Duodenal adenocarcinoma is rare. The clinical presentation is often nonspecific, and the diagnosis is made incidentally. We present a case of a 73 year old female presenting with pancreatitis, who was subsequently found to have duodenal adenocarcinoma.

CASE DESCRIPTION/METHODS:
73 year old african american woman with hypertension presented with persistent nausea and vomiting of two weeks associated with burning epigastric pain and ten pound weight loss. She was previously treated for dyspepsia without improvement. She denied alcohol or non-steroidal use. She reports use of chewing tobacco. She denied fever, hematemesis, melena, hematochezia, or change in bowel habits. On physical examination, she was hypotensive and tachycardic. She had dry mucous membranes and delayed skin turgor. Laboratory examination revealed an unremarkable complete blood count. Comprehensive metabolic panel was remarkable for hypokalemia of 2.8 mEq/L, bicarbonate of 37 mEq/L, elevated creatinine of 1.23 mg/dL, elevated alanine aminotransferase of 58 U/L, and an elevated lipase of 369 U/L. Due to persistent abdominal symptoms, computed tomography of the abdomen and pelvis with contrast was performed, which was suggestive of pancreatitis or duodenitis. Patient was admitted for presumed pancreatitis. Intravenous fluids and antiemetics were initiated. Electrolytes were repleted. Right upper quadrant ultrasound and magnetic resonance cholangiopancreatography was without evidence of gallstones, cholecystitis, or biliary obstruction. Esophagogastroduodenoscopy and subsequent endoscopic ultrasound was performed and demonstrated diffuse moderately congested mucosa and an ulcerated mucosa with moderate stenosis found in the third portion of the duodenum. Biopsies were taken, which later revealed adenocarcinoma. Patient was started on total parenteral nutrition and followed-up with surgical oncology.

DISCUSSION:
Considering the rarity of duodenal adenocarcinoma, an early diagnosis is crucial. Clinicians should be aware of the nonspecific clinical and laboratory presentation, such as in our patient who presented with pancreatitis. A higher degree of suspicion and thorough investigation can lead to prompt diagnosis and earlier management and treatment.