bluuebunny/crossref_metadata_2025_split huggingface dataset:
421 Improving Proton Pump Inhibitor Prescribing Practices in an Academic Safety Net Primary Care Clinic: Quality Improvement Project
Authors: Nallapeta Naren S. , Bakhai Smita Y. 
Published: October 2019

INTRODUCTION:
Proton Pump Inhibitors (PPI) overuse in both inpatient and outpatient settings have increased drastically over the last 2 decades. Overuse of PPIs continues despite evidence based guidelines and prolonged PPI use carries serious adverse effects. The aim of this quality improvement (QI) is to reduce the percentage of patients inappropriately prescribed PPIs between the ages of 40-75 years from a baseline rate of 80% to < 60% within 1 year at ECMC internal medicine clinic (IMC).

METHODS:
We used the Plan-Do-Study-Act (PDSA) model and performed a root cause analysis to identify barriers for the reduction of inappropriate use of PPIs. The major barriers included system, provider and patient-based barriers including lack of electronic medical record (EMR) alerts, gaps in knowledge in both the provider and the patient, fear of discontinuation of the PPI. QI team included nursing and ancillary staff, residents, attending physicians, social worker. Outcome measure was to reduce the percentage of patients inappropriately prescribed PPIs from 80% to < 60% in 1 year. Process measures included measuring the percentage of patients who are appropriately referred to GI clinic for an EGD and the percentage of patients on PPI who have their GERD assessed during the clinic including assessment for alarm symptoms. Balancing measures included potential increase in patient wait times in the clinic and esophagogastroduodenoscopy (EGD) wait time. The major interventions included (1) creating a customized EMR template; (2) provider education; (3) tracking continuity of care visits and medication reconciliation; (4) patient education; (5) assessing barriers and response to discontinuation; (6) Pocket guides for physician education.

RESULTS/OUTCOME MEASURES:
Average rates of PPI discontinuation were 51.1% (n = 92/180), resulting into 30.0% inappropriate chronic PPI use from the baseline rates of 80% within 1 year. Process measures: The total percentage of patients on long term PPI use who had an EGD was recorded as 51.1% which improved from the baseline of < 30%. The EGD completion rates in eligible patients was 43.6% from baseline of < 20%.

CONCLUSION:
We exceeded the goal, achieved >50% reduction in inappropriate use of chronic PPI use within 1 year. Lack of automated medical decision support tool was identified as the biggest barrier. Optimization of EHR and education to QI team members were crucial for the success of this QI. Future directions include enhancing patient engagement and spread to other clinics.
423 Blown out Myotomy (BOM), a Complication Following Laparoscopic Heller Myotomy and Per-Oral Endoscopic Myotomy
Authors: Krause Amanda J. , Triggs Joseph R. , Carlson Dustin A. , Campagana Ryan A. , Jain Anand , Kahrilas Peter J. , Hungness Eric , Pandolfino John E. 
Published: October 2019

INTRODUCTION:
Achalasia results from a failure of lower esophageal sphincter relaxation and an absence of normal peristalsis. Achalasia is diagnosed by High-Resolution Manometry (HRM) and can be treated with Laparoscopic Heller Myotomy (LHM) or Per-oral Endoscopic Myotomy (POEM). LHM and POEM are highly effective with more than 90% clinical efficacy reported in the literature. Although success rates are encouraging, patients may experience complications and recurrent symptoms. We identified patients, status post LHM or POEM, who had a BOM, a pseudodiverticulum at the prior myotomy site, on follow-up. Our aim was to assess what factors are associated with a BOM and how this affects patient reported outcomes.

METHODS:
We retrospectively identified patients from the Northwestern Esophageal Center Achalasia Natural History Study undergoing HRM between 1/2015 and 10/2017, following LHM or POEM, as therapy for achalasia. Patients must have also had a post-treatment esophagram within 1 year of HRM. A BOM was defined radiographically as a wide-mouthed outpouching (>50% increase in esophageal diameter) in the area of the prior myotomy (Image).

RESULTS:
129 consecutive patients were identified; demographics are in Table 1. A BOM was identified in 17.8% of patients. Comparing patients with a BOM to those without, initial achalasia subtypes were overall different (P = 0.004), type III achalasia specifically was more common (39.1% vs. 14.2%, P = 0.014), and LHM was more common than POEM (73.9% vs. 26.1%, P = 0.013), respectively (Table). Anterior vs. posterior approach for POEM and wrap type (Nissen, Dor, Toupet), when LHM was performed, were not predictors of BOM occurrence. Multiple treatments (prior LHM, POEM or pneumatic dilation) was not associated with an increased risk of BOM formation. The Integrated Relaxation Pressure (IRP) was significantly higher in patients with BOM compared to those without (15.0 mmHg vs. 11.0 mmHg, P = 0.025). Eckardt Scores (ES) were significantly higher, both statistically and clinically, in patients with BOM (5 vs. 2, P = 0.002).

CONCLUSION:
Our analysis suggests that an esophageal myotomy to treat spastic achalasia, treatment with LHM, and a higher post-treatment IRP are more common in patients with a BOM. These findings suggest that increased wall strain, whether it be from residual spastic contractility, continued outflow obstruction from fundoplication, or an incomplete myotomy, may be the underlying mechanism of failure.
424 POEM Training and Skills Evaluation Tool: A Pilot Study
Authors: Schlachterman Alexander , Alajlan Bader , Machicadorivero Jorge , Turkeltaub Joshua , Wagh Mihir S. 
Published: October 2019

INTRODUCTION:
Hands-on training for Per-Oral Endoscopic Myotomy (POEM) in the United States is limited and without a structured curriculum and assessment tool. Training to competency in POEM is critical and POEM trainees must acquire multiple cognitive and technical skills to achieve proficiency.

METHODS/METHODS AND AIM:
The aim of this study was to develop a POEM training and skills evaluation tool. This pilot study was performed at a tertiary academic medical center in the US from 5/2018 – 11/2018. The training protocol included initial swine explant models followed by live human cases, proctored by a single endoscopist experienced in POEM who graded trainees for each task on a 5-point scale (1 = trainer had to take over, 2 = trainer provided technical assistance, 3 =trainer provided substantial verbal guidance, 4 =trainer provided minimal verbal guidance, and 5 =trainee performed completely independently). Three trainees were prospectively graded on specific cognitive (identification of GE junction, incision site selection, identification of esophageal wall layers, recognition of planes during tunneling, identifying structures at GEJ and cardia in the tunnel, and identification of circular and longitudinal muscles) and technical skills (entry into the submucosal space, submucosal tunneling, myotomy and hemostasis) essential for successful POEM completion. Competency was considered at skill level ≥ 4 for each skill.

RESULTS:
Three trainees (interventional endoscopy fellows) completed a total of 18 cases (8 cases on animal explant models and 10 human cases) and were evaluated by one expert supervisor. Cognitive skills were acquired early in training with trainee scores of ≥ 4 by the 3rd swine explant case and 3rd human case. Technical skills required more cases and direction. Level ≥ 4 in technical skills was achieved by the 8th human case. Entry of the endoscope into the submucosal space was the most difficult step. No adverse events occurred in the human cases.

CONCLUSION:
This pilot study introduces a POEM training and skills evaluation tool for training to competency. Submucosal entry, tunneling and myotomy were the most challenging to learn while cognitive skills were learned early in training. The main limitations of this study include single site study with small number of trainees and procedures, and a single instructor. Evaluation of POEM procedures performed by more trainees at multiple sites will be necessary to further validate the utility of this tool.
427 Admission Trends for Food Impaction and Foreign Body Associated With Eosinophilic Esophagitis
Authors: Senatore Frank , Bhurwal Abhishek , Brant Steven 
Published: October 2019

INTRODUCTION:
The prevalence of eosinophilic esophagitis (EoE) is estimated to be 0.5-1 in 1000 and is increasing across the United States. New cases of EoE are being diagnosed, in part due to increased awareness of the disease. Recent epidemiological studies have demonstrated that the natural course of EoE is a progressive transformation from an inflammatory to a complicated fibrostenotic disease. Increased prevalence has driven sentiment for an evidence-based management algorithm for EoE. We identified trends in hospital admissions for complicated EoE demonstrated by food impactions/foreign bodies (FI/FB) and highlight gaps in the current management.

METHODS:
This is a retrospective cohort study using the 2011-2014 Nationwide Inpatient Sample (NIS) utilizing International Classification of Diseases, 9th Revision. Study included all patients above age 18 with principal or secondary discharge diagnoses of FI/FB. Primary outcomes were trends of the FI/FB cohort with associated diagnoses of EoE. Secondary outcomes included length of stay (LOS). Proportions were compared using fisher’s exact test and continuous variables using student t-test. Multivariable and Poisson regression was performed for LOS and hospitalization charges.

RESULTS:
From 2011 to 2014, the number of FI/FB admissions analyzed were 11,041, 10,730, 10,460, and 9,925, respectively. EoE was a principle diagnosis in 73.2%, 86.4%, 86.8% and 92.6% of these admissions, respectively. The average LOS for FI/FB admissions for patients without EoE (no EoE FI/FB) was 4.11 days; average LOS for FI/FB admissions for patients with EoE (EoE FI/FB) was 0.95 days (P < 0.001). Mean age of EoE FI/FB was 30.23 years vs 55.32 years in no EoE FI/FB (P < 0.001). 90.02% of EoE FI/FB were Caucasian, 3.66% African American and 4.48% Hispanic, compared to 71.78% Caucasian, 11.47% African American, and 11.08% Hispanic in no EoE FI/FB. 3.33% of EoE FI/FB underwent EGD with biopsies compared to 0.64% of no EoE FI/FB (P = 0.0002). Cost of admission for EoE FI/FB was $16,606.80 vs $38,282.34 in no EoE FI/FB (P < 0.001).

CONCLUSION:
EoE is the most common underlying etiology in cases of food impaction. This study suggests that progressive, complicated EoE is also growing in incidence. Increased admissions rates, low LOS and low numbers of patients undergoing EGD with biopsies suggests that EoE is not being appropriately surveilled nor directly addressed with patients in terms of highlighting its long-term complications and importance of implementing a management strategy.
429 High Clinical Impact of Wide Area Transepithelial Sampling (WATS) Positive - Forceps Biopsy Negative Diagnoses of Barrett Esophagus and Associated Dysplasia: A Retrospective Cohort Study of 423 Patients
Authors: Kaul Vivek , Gross Seth , Corbett F. Scott , Infantolino Anthony , Tofani Christina 
Published: October 2019

INTRODUCTION:
Wide Area Transepithelial Sampling with 3-Dimensional Computer-Assisted Analysis (WATS) when used adjunctively to forceps biopsies (FB) has been demonstrated in multiple prospective studies to significantly increase detection of Barrett’s esophagus (BE) and associated neoplasia in patients undergoing either BE screening or surveillance. The clinical impact of WATS positive-FB negative diagnoses has never been evaluated. The aim of this IRB-approved clinical utility study was to determine changes in patient management when BE and/or dysplasia was detected by WATS but not by FB.

METHODS:
Between 2013-2018, we identified 423 consecutive patients from WATS clinical registries who had a WATS positive diagnosis of BE or dysplasia and a negative FB result; 317 patients were diagnosed with BE, 90 with low grade dysplasia (LGD) and 16 with high grade dysplasia (HGD) by WATS only. Physicians subsequently completed an extensive survey to determine if the positive WATS diagnosis resulted in a change in patient management such as enrolment in a surveillance program, endoscopic ablation/antireflux surgery, initiating proton pump inhibitors (PPIs) or increasing the patient’s dose of PPI.

RESULTS:
The clinical impact of WATS positive-FB negative diagnoses for patients with BE, LGD or HGD is summarized in Table 1. WATS had a direct impact on the clinical management of 97.8% of the 317 BE patients including enrolment in a surveillance program (96.2%), ablation/antireflux surgery (3.7%), or starting or increasing the dose of PPIs (60.2%). WATS impacted the management of 94.4% and 93.7% of LGD and HGD patients respectively. For instance, 30% and 50% respectively had ablation, 73.3% and 68.8% had increased frequency of or new enrollment in surveillance, and 56.7% and 62.5% had PPIs prescribed or the dose increased. Seven of 8 HGD patients not ablated were lost to follow up. One of 8 HGD patients not ablated developed invasive adenocarcinoma also identified with WATS upon follow-up endoscopy.

CONCLUSION:
The results of this study demonstrate that physicians have a high degree of confidence in WATS diagnoses even when the concurrent FB is negative. This is evidenced by the fact that physicians changed their patient management in 96.9% of all cases, often significantly with invasive treatments such as ablation, EMR, and even antireflux surgery in a small %age of patients. As an adjunct to FB, WATS has high clinical utility and adds value to the management of patients with BE and associated dysplasia.
430 Esophageal Food Bolus Impactions Are More Likely to Occur During the Weekends
Authors: Kroner Paul T. , Kesler Alex M. , Bilal Mohammad , Simons-Linares Roberto , Mönkemüller Klaus E. 
Published: October 2019

INTRODUCTION:
Esophageal food impaction is a commonly encountered clinical scenario that may warrant emergent intervention, but epidemiological studies are lacking. No major studies have examined the inpatient prevalence of food impaction during the weekend. Therefore, the aim of our study is to assess the inpatient prevalence of food impaction during the weekend compared to week days.

METHODS:
Case-control study using the NIS 2016, the largest public inpatient database in the US. All patients with ICD10CM codes for food bolus impactions were included. None were excluded. The primary outcome was determining the odds of food bolus impaction during the weekend days as compared to the weekdays. Secondary outcomes included determining rates of esophageal perforation, hospital costs, charges and length of stay (LOS) when comparing admissions during a weekend to admissions during a weekday. Multivariate regression analyses were used to adjust for age, gender, Charlson Comorbidity Index, income in patient zip code, hospital region, location, size and teaching status.

RESULTS:
7,025 patients with food bolus impaction were identified. 2,475 underwent emergent EGD (within 24 hours) and 1,935 were admitted during the weekend. Mean patient age was 66.7 years (47.9% were female). Primary outcome: after adjusting for confounders, patients admitted for food impaction displayed significantly higher odds of admission during the weekend days (aOR:1.5, P < 0.01) when compared to the weekdays. No significant difference in esophageal perforation was observed between the two cohorts. Patients admitted during the weekend displayed lower hospitalization costs compared to patients admitted during the weekdays (aMean: -$1,756, P = 0.02), but no differences in hospitalization charges or length of stay were observed. All outcomes are displayed in Table 1.

CONCLUSION:
The odds of being admitted for esophageal food impaction are higher on weekends than weekdays. There are no different odds of esophageal perforation. This may be reflecting the previous studies demonstrating increased odds of food impaction during leisure times, as weekends in the US are often reserved for leisure activities rather than work. Interestingly, patients admitted during the weekend actually have lower adjusted mean hospital costs. This may suggest that these patients are likely admitted for observation or stay longer periods of time in the ED and hence do not generate the same hospital bill as an admission.
432 Post Procedural Pain Assessment in Patients Undergoing Balloon Cryotherapy Compared to Radiofrequency Ablation (RFA) for Barrett’s Esophagus: A Prospective Multi-Center Study
Authors: Khara Harshit S. , Trindade Arvind , Elias Puja S. , Smallfield George B. , Diehl David L. 
Published: October 2019

INTRODUCTION:
The two most commonly used modalities for ablation of dysplastic Barrett’s Esophagus (BE) are radiofrequency ablation (RFA) and cryotherapy, wherein cryoballoon (CB) ablation has emerged as a highly effective new modality. A common side effect of ablation is pain, making it an important factor when discussing treatment options. It is speculated that CB causes less pain than RFA, as CB preserves the extracellular matrix while maintaining depth of ablation, but no head-to-head comparison trials exist to date.

METHODS:
We designed a multi-center, prospective cohort study with aims to compare pre- and post-procedural pain outcomes for CB versus RFA in ablation-naïve BE patients. IRB approval was obtained, and the study was registered on clinicaltrials.gov. Patient demographics; pre- and post-procedural pain scores and at 48 hrs, 1-week and 4 weeks using PQAS on a scale of 0-10; ablation procedure details; pain medication use; and any adverse events were collected in REDCap. Statistical analysis was performed with SAS 9.2 using the t test, chi-square test and the Fisher’s exact test.

RESULTS:
We enrolled 97 ablation-naïve dysplastic BE patients, of which 2 withdrew, leaving 95 for analysis (53 CB, 42 RFA). Baseline demographics and level of dysplasia were similar in both groups, with overall 79% males, and mean age 64.8 yrs. The number of patients using oral analgesics was similar between both groups, P = 0.459. Although there were more patients with pre-procedure pain in the CB group (8% vs 5%), the incidence of post procedure pain after RFA was significantly higher (79% vs 70%) compared to CB, and this difference persisted at 2 days (74% vs 60%), 1-week (59% vs 28%), and 4 weeks (14% vs 8%) post procedure, P = 0.0073 (Figure 1). The pattern of mean pain level was slightly different, with higher mean pain score pre- and post-procedure in the CB group (0.5 vs 0.2 and 3.6 vs 2.8) compared to RFA, but then reversed to be higher in the RFA group at 2 days (2.8 vs 2.2), 1-week (2.1 vs 0.9), and 4 weeks (0.6 vs 0.4), P = 0.0025 (Figure 2).

CONCLUSION:
Cryoballoon ablation is associated with significantly less post procedural pain when compared to RFA which appears to have a more protracted pain course and may have an impact on lifestyle resumption and follow up. Most patients have resolution of pain by 4 weeks irrespective of treatment modality. This first head-to-head study about post ablation pain between CB and RFA may help guide treatment discussions regarding post ablation expectations and recovery.
436 Peroral Endoscopic Myotomy Is a Safe and Effective Treatment Modality for Achalasia After Prior Failed Botulinum Toxin Treatment
Authors: Sanaka Madhusudhan R. , Parikh Malav P. , Tang Andrew , Chadalavada Pravallika , Khoudari George , Gupta Niyati M. , Thota Prashanthi N. , Gabbard Scott , Ray Monica , Wadhwa Neha , Murthy Sudish , Raja Siva 
Published: October 2019

INTRODUCTION:
Peroral endoscopic myotomy (POEM) is shown to be effective in patients with recurrent symptoms after prior treatments such as Heller myotomy (HM) or pneumatic dilatation (PD) or Botulinum toxin (Botox) injection into lower esophageal sphincter (LES). However there is lack of a systemic study analyzing POEM in patients with prior Botox treatment alone and not confounded by other treatments. Previous Botox treatment leads to submucosal fibrosis making sub-mucosal dissection and separation of tissue planes more challenging during POEM. Hence, our study aims were to determine the safety and efficacy of POEM in achalasia patients who previously received exclusively Botox treatments.

METHODS:
Medical records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients who underwent timed barium esophagram (TBE) and high-resolution manometry (HREM) prior to POEM along with two-month post-POEM esophageal pH study, TBE and HREM were included. Patients were categorized into two groups as: no prior Botox (treatment naïve) and prior Botox group. Patients with prior HM or PD were excluded from both groups. Baseline patient characteristics, procedural details, TBE, HREM, pH study findings and Eckardt’s scores were compared between the two groups. Post-POEM Eckhardt’s score of ≤3 was considered as successful palliation of symptoms.

RESULTS:
From a total of 200 patients undergoing POEM, 103 patients met the study criteria (prior Botox = 35; treatment naïve = 68). Patients with no prior Botox injections were younger, had high LES integrated relaxation pressure (LES-IRP) on HREM, wider esophagus on TBE at 1 and 5 minutes. In terms of operative details and outcomes, the total myotomy length, operative time, complications, length of stay and 30-day readmission rates were similar for both groups (Table 1). POEM was successful in 96.9% and 93.8% patients in no Botox and prior Botox groups respectively. At two months post-POEM, similar improvements were noted in Eckhardt scores (Figure 1a), LES-IRP and height of barium columns at 1 and 5 minutes, however patients without prior Botox had greater improvement in TBE width at 1 and 5 minutes (Figure 1b,c). The rates of symptomatic GERD and abnormal esophageal pH study were also not significantly different between the two groups (Table 2).

CONCLUSION:
In achalasia patients with prior Botox injections, POEM is feasible and safe. Prior Botox treatment does not influence the efficacy of POEM.