bluuebunny/crossref_metadata_2025_split huggingface dataset:
2920 Prior Pharmacotherapy Patterns Among Patients With IBD in the USA Initiating Biologic Therapy
Authors: Bornheimer Rebecca , Hass Steve , Nag Arpita , Oster Gerry 
Published: October 2019

INTRODUCTION:
Treatment for inflammatory bowel disease (IBD: Crohn's disease [CD] and ulcerative colitis [UC]) has shifted from symptom management using corticosteroids to targeted therapies such as tumor necrosis factor (TNF) inhibitors. Increasing therapeutic options warrants a better understanding of current treatment pathways. This study reports on the pharmacotherapy history of patients with CD and UC prior to initiation of an IBD-targeted biologic.

METHODS:
Using the IQVIATM Real-World Data Adjudicated Claims Database – US, we identified adults (≥18 years) with CD or UC who initiated biologic treatment from Jan 1, 2016 to Jun 30, 2017. Analysis was limited to biologics indicated for CD/UC during the study period. Patients were stratified based on most recent biologic received; the date of initiation was designated the index date. Patients with <12 months of continuous medical coverage prior to the index date were excluded. Patterns of prior IBD-related pharmacotherapy, in terms of number and type of biologics, and time spent on the biologic, were examined in relation to the index biologic, for the study period Jan 1, 2011 to Jun 30, 2017.

RESULTS:
A total of 5210 patients with CD and 3010 with UC were identified. Among patients with CD, 2634, 1436, 737, 241 and 162 began treatment with adalimumab, infliximab, vedolizumab, certolizumab, and ustekinumab, respectively. Among patients with UC, 1285, 977, 587 and 161 initiated treatment with adalimumab, infliximab, vedolizumab and golimumab, respectively. Most patients beginning treatment with infliximab or adalimumab were previously biologic-naïve (CD: 77.8%, 84.6%, respectively; UC: 79.9%, 89.3%, respectively). Patients starting treatment with other biologics, however, typically had received at least one IBD-related biologic previously (Figure 1). Among patients who were not biologic-naïve at initiation of therapy, mean total duration of prior exposure was 26.6 and 17.8 months for patients with CD and UC, respectively.

CONCLUSION:
While newer IBD-related biologics (i.e., vedolizumab, ustekinumab) are typically preceded by treatment with other biologics, most patients receiving one of the first biologics approved for IBD (i.e., infliximab, adalimumab) are biologic-naïve. Patients with a treatment history of two biologics had a longer overall period of biologic exposure than those who had previously received only one biologic.
2925 Effect of Short Bowel Syndrome on Disease Activity in Patients With Crohn's Disease
Authors: Singh Amandeep , Nan Lan , Shen Bo , Kirby Donald F. , Regueiro Miguel 
Published: October 2019

INTRODUCTION:
Despite advancements in medical therapies a significant number of Crohn's disease (CD) patient's end up requiring surgical intervention, often leading to short bowel syndrome (SBS). We aimed to assess the changes in clinical activity in CD patients before and after the diagnosis of SBS and assess the association between endoscopic disease activity and length of remaining bowel.

METHODS:
Using our home parenteral nutrition (PN) database all patients with the diagnosis of CD and SBS requiring PN or IV fluid support between January 1990 and June 2018 were identified. Data on baseline demographics, co-morbidities and concomitant medications was collected. Laboratory data, Simple Endoscopy score [SES], patient reported outcomes (PROs) and medications at baseline and 6-12 months after SBS diagnosis were collected. We also assessed exacerbation of IBD, hospitalization and adverse events after SBS diagnosis.

RESULTS:
A total of 86 patients were included in the final analysis. Out cohort consisted of 58% females and 87% were Caucasians. At the time of SBS surgery, nearly 60% were current or ex-smokers, 38% had perianal disease and 17% had fistulas. After the surgery leading to SBS, mean bowel length was 154.0 ± 68 cms. stoma was present in 77%, colon in 63%, ileocecal valve in 12.5% and 92% of them were PN-dependent. At baseline and after 6-12 months of diagnosis of SBS, there were no significant changes in BMI, laboratory data, endoscopic disease activity or extraintestinal manifestations (P > 0.05 for all). In terms of symptoms, there was a trend towards more diarrhea after the diagnosis of SBS (P = 0.06) but no significant change in abdominal pain and bleeding (P > 0.05) were noted. The use of salicylates decreased after SBS (38% vs. 22%, P = 0.02) but more patients were on vedolizumab after SBS diagnosis (0 vs. 13%, P = 0.001), there were no significant changes in other medications (Table 1). Overall, 59% required hospitalizations after the diagnosis of SBS, but only 15% had CD-exacerbation. There was no significant association between endoscopic disease activity and intestinal length before and after the diagnosis of SBS (Figure 1a,b).

CONCLUSION:
Our study suggests that contrary to common belief of less medication requirement in CD after SBS, some patient might need aggressive medical therapy as there is no significant co-relation between endoscopic disease activity and bowel length. Further studies with longer follow-up are required to confirm these findings.
2928 Patients With Severe Ulcerative Colitis Are Infrequently Treated With Anti-TNFs in a County Hospital
Authors: Penninti Pranav , Pham Codey , Coss Elizabeth , Govani Shail 
Published: October 2019

INTRODUCTION:
Patients with ulcerative colitis (UC) are prone to flares, many of which require hospitalization for administration of corticosteroids. Patients hospitalized with UC may need rescue therapy with anti-TNFs to prevent colectomy. We aimed to study outcomes for patients being treated for UC with corticosteroids at a county hospital in Texas.

METHODS:
A retrospective review of all hospitalizations with an ICD9/10 codes consistent with UC was performed from 2015 to 2017. The charts were manually reviewed to confirm the diagnosis of UC and to determine the hospital course. We included patients admitted for UC flare treated with either oral or intravenous (IV) corticosteroids and found to have severe UC on endoscopic exam. Patients with <30 days of follow up were excluded from evaluation unless they underwent colectomy after admission. Descriptive statistics were calculated using SAS 9.4.

RESULTS:
A total of 118 admissions for UC were reviewed. Of these 19 met our inclusion/exclusion criteria. The median age was 41 years [IQR: 26-53], 12 (63.2%) were of Hispanic ethnicity, 12 were female (63.2%) with a median disease duration of 4 years [IQR: 2-6]. Two patients (10.5%) were on anti-TNFs prior to admission. Median CRP on arrival was 5.8 mg/dL [IQR: 2.8-8.5] and median albumin was 2.9 g/dL [IQR: 2.5-3.0]. The majority (63.2%) were treated with oral steroids versus IV steroids. None of the patients were initiated on an anti-TNF during admission. After discharge, 5 patients were initiated on anti-TNFs. Three (15.8%) underwent colectomy within 90 days of admission. None of the 5 patients initiated on anti-TNF underwent colectomy within 90 days compared to 2 of the 12 (16.7%) who were not started on anti-TNF (P = 1.0). Patients without insurance were initiated on anti-TNF in 22.2% of cases compared to 37.5% of cases in which the patient had insurance coverage (P = 0.62).

CONCLUSION:
In this small study of patients admitted for severe ulcerative colitis, anti-TNF use was not commonly initiated during or after hospitalization. Despite endoscopic and lab evidence of severity, the overall colectomy rate is relatively low in this population. Larger studies of this cohort are necessary to better understand the barriers to anti-TNF use and the long term outcomes of severe UC.
2933 Outcomes of Endoscopic Submucosal Dissection (ESD): A Single Center Experience
Authors: Reyes Jonathan M. , Andrawes Sherif 
Published: October 2019

INTRODUCTION:
Endoscopic submucosal dissection (ESD) is a new and advanced endoscopic resection technique; initially developed in Japan for therapeutic and diagnostic management of superficial gastrointestinal malignancies that has limited submucosal involvement and has not metastasized to any regional lymph nodes. ESD provides an accurate histopathological assessment of resected specimens, as en bloc resection of the entire lesions is necessary. ESD is a well-established treatment modality in the East while its interest is beginning to peak in the West.

METHODS:
This is a single-site, internal database review project that was included in a larger study with the University of Florida. The objective of this retrospective study is to evaluate the clinical utility of ESD and its impact on the diagnosis and management of colorectal lesions. This abstract focuses on a sub-sample of 10 patients, over the age of 18, from Staten Island University Hospital, who underwent the ESD procedure for colorectal lesions between July 2014 and September 2018. The team collected demographic information, disease and surgical details: location of lesion, procedural and pathological findings, and any complications.

RESULTS:
The sample size was determined based on the number of colorectal ESD procedures performed in July of 2014 through September of 2018 at SIUH – Northwell Health. The encounters of 10 patients were recorded. The average lesion size was 39.5 mm and average resection size was 43 mm. The average total procedure time was 1 hour and 46.5 minutes. There were no adverse events during any of the procedures. 70% of patients achieved R0 and curative resection while the other 30% went onto Endoscopic Full Thickness Resection or surgical resection.

CONCLUSION:
ESD has proven to be effective for en-bloc and R0 resection for colorectal lesions in both our small sample size and throughout the multicenter analysis. ESD has the potential to offer patients a safer and less invasive option for their early stage colorectal lesions with minimal risk for adverse events as presented from our data (0%) but also confirmed from the larger study. As ESD can be done as an outpatient procedure, patients can avoid hospital admission. Subsequently, ESD provides a better quality of life to patients offering them alternatives to chemotherapy and surgery. ESD should be considered in the treatment algorithm for select advanced lesions in the rectum. Further research will be done for quality improvement measures for this procedure.
2936 Use of Endoscopic Ultrasound for Pancreatic Cyst Surveillance
Authors: Merali Natasha , Gardner Timothy 
Published: October 2019

INTRODUCTION:
Endoscopic ultrasound (EUS) is recommended by several society's guidelines for evaluation of asymptomatic pancreatic cysts. Though relatively low-risk, the procedure is costly and EUS-guided FNA has a low sensitivity for detecting malignant cytology. We evaluated a cohort of patients with pancreatic cysts who underwent EUS to determine if 1) EUS was warranted and 2) where EUS changed management.

METHODS:
We evaluated patients who underwent EUS for pancreatic cysts at our medical center. Cysts were evaluated for size, worrisome features and high risk stigmata. The primary outcomes, based on the Fukuoka guidelines, were whether the initial EUS was recommended and if the EUS procedure resulted in a change in clinical management (shortened surveillance interval, lengthened surveillance interval, or surgical intervention).

RESULTS:
204 patients were included in the study and the baseline characteristics are listed in Table 1. We found that EUS was warranted in only 30.9% of patients, all of whom had acute pancreatitis or worrisome features* seen on prior imaging. Though its use led to a change in management for 130 patients, it lengthened the surveillance interval in 70% of these cases (see Figure 1). In patients in whom shortened intervals were recommended, this was mostly due to worrisome features seen in 43.3% (see Figure 2). Additionally, benign cytology was found in 47.7% of cases, and was read as hypocellular or insufficient in 16.7% of cases (N = 174) (see Table 2). *Worrisome features are defined by the 2012 Fukuoka guidelines as: pancreatitis, cyst ≥3 cm, enhancing mural nodule <5 mm, thickened/enhancing cyst walls, main duct size 5-9 mm, abrupt change in caliber of pancreatic duct with distal pancreatic atrophy, lymphadenopathy, increased serum level of CA 19-9, or cyst growth rate ≥5 mm/2 years.

CONCLUSION:
Our findings demonstrate the overutilization of endoscopic ultrasound in the management of pancreatic cysts, suggesting that if worrisome features are not present, follow up can be determined by cyst size alone.
2944 The Effects of Liver Disease on Cardiovascular Mortality Among Patients With Cardiovascular Disease
Authors: Atem Ngum Kikah , Weerakoon Sitara M. , Olanipekun Titilope , Abe Temidayo , Atem Folefac 
Published: October 2019

INTRODUCTION:
The mediating effect of liver disease on cardiac diseases has not been comprehensively outlined in the medical literature. Liver disease can increase your risk of heart disease which remains the leading cause of death in the United States. In this study, we looked at the overview of the mediating effect of liver disease on patients diagnosed with cardiovascular disease (CVD) and how this affects death due to cardiovascular disease.

METHODS:
We selected patients with a death record from the second-generation Framingham Heart Study database and performed descriptive and analytical tests. Unadjusted tests to understand the variables associated with cardiovascular death were based on t-test and chi-square test when appropriate. A mediation analysis was conducted with patients diagnosed with cardiovascular disease as the independent variable and patients diagnosed with liver disease as the mediator while controlling for possible confounders.

RESULTS:
Liver disease was not a significant mediator for death due to CVD among patients diagnosed with CVD (P = 0.5882) and only 0.13% of CVD death is attributed to the mediation of liver disease. However, the effect of those diagnosed with CVD on CVD death and the total effect of those diagnosed with CVD and liver disease on CVD death were both statistically significant (P < 0.0001 and P = 0.0017, respectively).

CONCLUSION:
Liver disease does not significantly mediate CVD death among patients diagnosed with CVD. However, our study is limited to death due to CVD. Furthermore, the death record only contains information on a single cause of death. Patients could have died from multiple complications, but the death records did not collect this data.
2950 Gastrostomy Tube Placement in Patients With Ascites: A National Inpatient Sample Analysis
Authors: Sohail Abdullah , Khan Ahamd , Gupta Kamesh , Goyal Hemant , Bansal Pardeep 
Published: October 2019

INTRODUCTION:
As the treatment of liver diseases progress, patients with cirrhosis are living longer, and physicians are facing an increasing need for gastric feeding tube placement to provide enteral nutritional support to these patients. Cirrhotic patients are usually considered as a poor surgical risk candidates, making a surgically placed gastrostomy tube an undesirable option; thus, percutaneous endoscopic gastrostomy (PEG) is often considered to an alternate route to provide enteral nutrition. Cirrhotic patients with portal hypertension often have varices or ascites and are inherently more prone to procedural complications. There is limited data on the safety of the gastrostomy tube in patients with ascites. The aim of our study is to assess the outcomes of gastrostomy tube placement in patients with ascites.

METHODS:
We conducted a retrospective review of patients with ascites who underwent gastrostomy tube placement using the largest all-payer database, national inpatient sample (NIS) from 2007-2014 using validated ICD-9 codes. Primary and secondary outcomes included in-patient mortality, length of stay (LOS) and total hospital charges, respectively. We adjusted for confounding factors including age, gender, insurance, zip income, and hospital size and location by using multivariate regression.

RESULTS:
Out of total 2,603,539 hospitalizations for adult patients with ascites, 29,001 patients underwent gastrostomy tube on that hospitalization. Mean age of patients with ascites with gastrostomy 64 ± 2 years with male predominance (55% vs. 45%). The patients with ascites who had gastrostomy tube placed were more likely to die in the hospital (adjusted OR 1.84; 95% CI 1.7-1.9, P = 0.00) as compared to ascites patients without gastrostomy tube. Also, we found a significant increase in mean LOS (28.83 days vs 8.34 days) and mean total charges ($277,404.5 vs $71,874.73).

CONCLUSION:
Our study is the largest evaluation to date of cirrhotic patients who have undergone PEG. This study suggests that patients with ascites who undergo gastrostomy tube placement have increased mortality, length of stay, and hospital charges. The results of this study point towards caution for the use of PEG in patients with ascites.
2953 A Novel Tool to Estimate Early Insulin Resistance and Prevent Metabolic Syndrome and Non-Alcoholic Fatty Liver Disease: Retrospective Study in the Veteran Population
Authors: Houston Trevor , Makar Ranjit , Singh Ashok K. , Fayad Joseph 
Published: October 2019

INTRODUCTION:
Previous studies such as the Homeostasis Model Assessment (HOMA) IR1 have been validated tools to estimate Insulin resistance and a predictor of metabolic syndrome (MS) and its related co morbidities such as Non-Alcoholic Fatty liver disease (NAFLD) and Cardiovascular disease (CVD). In the current obesity epidemic, we need simple validated tools to help detect early insulin resistance and curb the growing epidemic of NAFLD. Proinsulin was reported once and in patents as a marker of pancreatic exhaustion hence we propose a novel tool which take proinsulin into account to help predict risk of development of fatty liver disease.

AIM:
To study proinsulin as a predictor of progression to fatty liver disease in non-diabetic veteran population.

METHODS:
Single center retrospective chart review of 55 patients. Charts from the gastroenterology department at Las Vegas VA clinic were analyzed and data collected including liver enzymes, insulin, proinsulin, fasting blood sugar, HbA1C, albumin and lipid profile levels (Table 1). Using the data provided a logistic regression model was used to identify strong predictors of fatty liver disease. A novel statistical model called the Random Forrest method was also used to identify predictors of fatty liver disease.

RESULTS:
Using the logistic regression model, proinsulin and ratio of insulin to proinsulin were found to be significant in predicting fatty liver disease. The overall accuracy was 80%, with precision and recall for both categories ranging from 66.67% to 86.49% (Figure 2). When using the Random Forest methodology, factors such as total cholesterol, ALT, pro-insulin, triglycerides, insulin, ratio IP, and glucose were found to be the most important predictors of Fatty Liver disease (Figure 3).

CONCLUSION:
Early detection of insulin resistance in non-diabetic patient population and can help intervene with medical and dietary or other management to prevent the development and progression of Metabolic syndrome. Our study suggests that proinsulin should be routinely used in at risk patient population for early detection of insulin resistance and prevention of metabolic syndrome and related comorbidities such as NAFLD. Hence pro insulin is a strong predictor of insulin resistance and future prospective studies can help validate proinsulin as a predictor of NAFLD.
2954 Acute Pancreatitis Outcomes May Not Be Worse in Subjects Post-Liver Transplant
Authors: Wadhwa Vaibhav , Gupta Kapil , Gonzalez Adalberto , Castaneda Daniel , Garg Sushil , Bilal Mohammad , Castro Fernando , Lara Luis 
Published: October 2019

INTRODUCTION:
The association of Acute Pancreatitis and Celiac Disease (CD) has been sparingly reported in the literature. CD is known to affect approximately 1% of the western population. A Swedish national database study reported a 3-fold increased risk of developing pancreatitis in patients with CD. The exact mechanism of this is unknown, but it could be related to an untreated celiac disease affecting the major papilla causing stenosis or exocrine pancreatic insufficiency that has been reported previously. This study aimed to look at the association between acute pancreatitis and celiac disease. We also looked at whether there was any association between chronic pancreatitis and celiac disease.

METHODS:
We performed a retrospective cross-sectional cohort study using the 2013 National Inpatient Sample (NIS) database. We included all patients who were hospitalized with either acute pancreatitis (ICD Code 577.0) or Chronic Pancreatitis (577.1). Patients who had diagnoses of both acute and chronic pancreatitis were considered to have acute on chronic pancreatitis and combined with the chronic pancreatitis group. We then analyzed both groups for the presence or absence of celiac disease. Continuous variables were compared using t-tests, and categorical variables were compared using Rao-Scott chi-square tests. All analyses were performed using SAS Survey Procedures (version 9.4, The SAS Institute, Cary, NC).

RESULTS:
We analyzed more than 35 million hospitalizations in 2013 out of which 378,715 had a primary discharge diagnosis of acute pancreatitis and 155,130 had a primary discharge diagnosis of chronic pancreatitis. The mean age in the acute pancreatitis group was 53.3 yrs and in chronic pancreatitis group was 51.7 yrs. There were more males in chronic pancreatitis group (55.1%) than females (44.9%). There was significantly higher prevalence of acute pancreatitis in CD (2.3%) than non-CD patients (1.2%) (Figure 1, P = 0.001). Similarly, there was higher prevalence of chronic pancreatitis (1.2%) than the control group (0.43%) (Figure 1, P < 0.001).

CONCLUSION:
There is a higher prevalence of acute pancreatitis in patients with CD. Patients were also found to have much higher prevalence of chronic pancreatitis in CD. This could be related to recurrent acute pancreatitis episodes in CD patients. Further studies are needed to validate these findings.