bluuebunny/crossref_metadata_2025_split huggingface dataset:
2816 Mortality of Different Etiologies of Acute Pancreatitis and Effect of Aggressive vs. Non-Aggressive Fluid Resuscitation
Authors: Kesar Varun , Mir Adil , Kanth Rajan , Mouchli Mohamad , Shakhatreh Mohammad , Yeaton Paul 
Published: October 2019

INTRODUCTION:
Acute pancreatitis (AP) is a common cause of GI-related hospitalization. AP can be classified into mild AP, moderately severe AP and severe AP. Severe acute pancreatitis (SAP) and necrotizing pancreatitis (NP) or localized complications with infections account for > 40% of pancreatitis related mortality. Common etiologies include acute biliary pancreatitis (ABP) and alcohol ( AAP). We aimed to study the mortality rate and effect of fluid resuscitation in AP (SAP, NP).

METHODS:
Patients with SAP and NP who received PEG-J were collected retrospectively from a single tertiary care center by utilizing ICD-9 and ICD-10 codes (International Classification of Diseases). Each case was confirmed by manual review. SAP and NP were defined per the 2012 revised Atlanta classification. Descriptive analysis was done by Excel. Fluid resuscitation was defined as aggressive hydration (AH) infusion of crystalloids given at a rate of at least 3.0 mL/kg/h after a bolus of 10-20 mL/kg within 24 hours of presentation.

RESULTS:
Seventy-nine patients with SAP or NP underwent PEG-J placement. Demographics, labs and comorbidities (Table 1). Etiologies of pancreatitis were alcohol 30% (24), biliary 39%, idiopathic 23%. Distribution based on Atlanta classification (Table 2). All-cause mortality of the patients was 12 (15%) and among this group 7 (9%) were related to pancreatitis related complications whereas 4 (5%) patients opted for palliative care and 1 was found to have pancreatic cancer. Among AAP, 4 patients died from reasons not related to pancreatitis, as compared to 4 patients (13%) who died in ABP group which were all related to pancreatitis. In ABP, 28 (90%) patients had data available for fluid. 8 (29%) received AH within first 24 hours and none of them died. 20 (71%) did not receive AH and 3 of them died. This was not significant at P < 0.05 using Fisher exact test. In AAP, 21 (87.5%) had data for fluid. Six (29%) received AH and none of them died. Fifteen (71%) did not receive AH and 3 of them died but the deaths were not related to pancreatitis. Average ICU stay of the overall subjects was 8 days and median hospital stay was 12 days. Average duration of hospital stay in AAP was 19.8 days compared to 20.5 days in ABP. Average ICU stay was 9 days in both groups.

CONCLUSION:
ABP carries higher mortality and more LOS related to pancreatitis compared with AAP. The AH is associated with decreased mortality in ABP but was not statistically significant perhaps due to small sample size.
2818 Physician Perspective on Inpatient Constipation and the Use of the EMR for Prevention
Authors: Moore Andrew , Jones Sabrina K. , Kapil Anuja , Lee Salina 
Published: October 2019

INTRODUCTION:
Constipation is a common problem among patients hospitalized in the United States. Hospitalized patients are particularly vulnerable to constipation due to increased age, decreased mobility, and administration of medications causing decreased bowel motility. Identifying those at risk for constipation on admission and properly discharging patients on bowel regimens when needed can significantly reduce morbidity and mortality of hospitalized patients and save facilities the added costs of complications from constipation. The objective of this study was to assess physician awareness of managing inpatient constipation and receptiveness to changes in the EMR to prevent development of constipation.

METHODS:
We surveyed residents and attendings within the department of internal medicine at an academic institution to assess awareness of inpatient constipation management and to determine if physicians would support a reminder system to start bowel regimens when appropriate within the EMR. Specific questions from the survey are listed below (Figure 1).

RESULTS:
73 resident and attending physicians were surveyed. Physicians marked “sometimes” most often when asked about history taking and medication reconciliation related to constipation on admission and discharge. Most physicians (63%) are in favor of using a protocol as part of the admission order set that would identify those needing to be started on a prophylactic bowel regimen for constipation based on risk factors. Most physicians (82%) do not use as part of their progress note checklist a reminder if patients are on a bowel regimen. Most physicians (79%) are in favor of having a protocol as part of the discharge order set to remind them to discharge patients on a bowel regimen if any constipating medication was prescribed (e.g. opioids).

CONCLUSION:
Constipation is a problem among many hospitalized patients and physicians frequently fail to implement strategies for prevention. More emphasis needs to be placed on preventing constipation from occurring in the inpatient setting. Limitations of the study are primarily the small sample size and its restriction to internal medicine. Future surveys should also be shared with other services including general surgery prior to implementing any changes. We propose an EMR notification system that identifies patients on admission and discharge who would benefit from a prophylactic bowel regimen based on risk factors, and most physicians at this institution would support such a change to the EMR system.
2824 Inpatient Fecal Microbiota Transplantation for the Treatment of Refractory Severe-Complicated Clostridioides difficile Infection
Authors: Pardi Ryan , Saha Srishti , Pardi Darrell , Khanna Sahil 
Published: October 2019

INTRODUCTION:
Currently, surgery is the primary treatment option for refractory, severe-complicated Clostridioides difficile infection (CDI) in the inpatient setting. There are limited series reporting the efficacy of Fecal Microbiota Transplantation (FMT) to treat such cases as an alternative to surgery or in patients who are not surgical candidates. We aimed to assess the response rate and prognosis of these patients after inpatient FMT.

METHODS:
We conducted a retrospective chart review of patients with CDI (watery diarrhea with positive stool assay) admitted in the ICU, and who received FMT from January 2013 to July 2016. Potential cases were identified by diagnosis codes and eligibility was confirmed through manual chart review. Severe-complicated CDI was defined as CDI with any of the following: ICU admission, hypotension, shock, sepsis, megacolon, colectomy or death due to CDI. CDI was termed refractory in the absence of clinical response to antibiotics after 5 days. Recurrence was defined as typical CDI symptoms and positive stool assay within 56 days of treatment with interim symptom resolution. The primary outcome was resolution of CDI (clinical cure with no recurrence). Secondary outcomes included risk of recurrent CDI and mortality. Microsoft Excel was used for descriptive statistical analysis.

RESULTS:
Of 273 patients screened, 6 cases met inclusion criteria. Five patients received FMT via colonoscopy, one via retention enema. The mean age at time of FMT was 72 (range, 54-88) years, 4 (66%) patients were female. All had severe-complicated CDI, 3 had concomitant diverticulosis and none had inflammatory bowel disease (IBD). The median follow-up after FMT was 8.5 (range, 1-18) months. Three patients received non-CDI antibiotics within 6 months post-FMT, 3 received acid suppression therapy (Table 1). FMT was performed after a median of 3 (range, 1-5) episodes of CDI with a median of 4.5 previous courses of antibiotics (range 2-6 courses) (Table 1). Four of the six patients (66%) had resolution of CDI, 2 patients had recurrence. One patient died due to sepsis secondary to CDI; 3 died due to unrelated causes.

CONCLUSION:
In this small retrospective study, inpatient FMT was effective for treating refractory severe-complicated CDI. There was one CDI-related mortality by the end of follow up. FMT may be an alternative therapy in patients with severe-complicated CDI.
2828 Understanding the Role of Osteopathic Manipulative Medicine in the Management of Gastrointestinal Disorders and Symptoms: A Survey Study
Authors: Shah Ruchit N. , Diehl David L. , Graham Jove , Kim Alexander H. , Loughlin Michael T. 
Published: October 2019

INTRODUCTION:
Patients with gastrointestinal (GI) disorders can present with a myriad of symptoms. Osteopathic Manipulative Medicine (OMM) is a well-established anatomy-based modality where adjustments to the neuromusculoskeletal system may restore motility of the viscera via regulation of the autonomic nervous system. OMM is performed by specially trained physicians using palpatory skills to diagnose and treat illnesses. Pharmacologic therapies often lack efficacy for some GI symptoms, so OMM could be a safe and effective alternative treatment. Our aim was to study the clinical use of OMM in the management GI symptoms, and begin to understand which conditions it might be best suited for.

METHODS:
We conducted a web-based survey study targeting academic osteopathic physicians practicing OMM throughout the US. In this 16-item questionnaire, physicians were asked about their use, outcomes, and preferences pertaining to OMM for treating GI symptoms. Data on the types of GI disorders encountered, duration and modality of techniques used, and the respondent’s departmental specialty were gathered. Online surveys were followed by a detailed telephone interview.

RESULTS:
A total of 220 emails were sent and 64 surveys were completed (29%). Ninety-one% of respondents utilized OMM for GI symptoms. Constipation was the most commonly encountered GI symptom with the best response to OMM (87%) followed by bloating (56%) and heartburn (55%). Visceral manipulation techniques such as mesenteric release and colonic stimulation were the most commonly used OMM modalities (98% of respondents). Only 13% of the respondents reported adverse events with transient pain and fatigue being the most common complaints post-OMM. Telephone interviews revealed that nearly 50% of patients achieved a sustained response after 3-4 months of OMM. Respondents did not report a difference to OMM response in patients on chronic narcotics compared to those not on opioids.

CONCLUSION:
The results of this study suggest that a multifaceted therapeutic approach utilizing OMM may have a role in the management of GI disorders. OMM is a safe and cost-effective approach that can be performed in an inpatient or outpatient setting. OMM could also have applications in treating patients with functional GI disorders such as IBS and other motility-related disorders of the brain-gut pathway. Randomized controlled trials and prospective studies need to be conducted to build an evidence-based rationale for OMM in patients with GI disorders.
2829 Patients Eligible for Trials of Microbiota-Based Therapeutics Do Not Represent the Population With Recurrent Clostridioides difficile Infection
Authors: Kelly Colleen R. , Fischer Monika , Grinspan Ari , Rupawala Abbas , Allegretti Jessica R. 
Published: October 2019

INTRODUCTION:
Industry-funded trials of microbiota-based therapeutics for treatment of Clostridioides difficile are ongoing, however due to strict enrollment criteria, not all patients are eligible. Furthermore, given the widespread availability of fecal microbiota transplantation (FMT) and overwhelming evidence supporting its efficacy, patients may refuse enrollment in trials with a placebo-arm.

METHODS:
This is a retrospective study performed at four tertiary referral centers for FMT. The electronic medical record at each was reviewed to capture patients referred for recurrent CDI over a 6- month time period. FMT eligibility was determined based on current CDI treatment guidelines.3 Inclusion and exclusion criteria for a clinical trial of an oral microbiota-based therapeutic were applied to determine eligibility, based on current enrolling trials at these centers.

RESULTS:
Of 199 patients referred for a diagnosis of recurrent CDI, 130 (65%) were deemed to be eligible for FMT based on the number and severity of episodes. Of the patients in whom FMT was determined to be an appropriate option, 94 (72%) met inclusion criteria for an RCT of a microbiota-based therapeutic drug, however 62 (66%) of those meeting inclusion criteria had one or more exclusion criteria (Table 1) precluding participation and 16 (17%) were eligible but refused to enroll. Only 16 (12%) of FMT-eligible patients were enrolled in the drug trial. Conventional FMT using stool-bank donor material was performed in 96 patients (74%) of those deemed eligible to undergo the procedure (Figure 1). Most patients (79%) met a single exclusion criterion, 14.5% met two criteria and 6.5% met three criteria. The most common reason for study exclusion was immunocompromise (17; 27%). Other common exclusions were inflammatory bowel disease (13; 21%), having already received more than 21 days of vancomycin (11; 18%) and diarrhea-predominant irritable bowel syndrome (10; 16%).

CONCLUSION:
Less than half of patients deemed eligible for FMT based on clinical history of recurrent CDI met eligibility criteria for a clinical trial of an encapsulated microbiota product. A smaller but relevant proportion of eligible patients refused to participate. Restrictions on stool banks would have detrimental effects on patient access to FMT. Furthermore, these results demonstrate that a relevant number of patients affected by recurrent CDI are currently being excluded from industry-funded trials.
2835 The Impact of Patient Educational Poster in Colorectal Cancer Screening at a Resident Primary Care Clinic
Authors: De La Guerra Ramiro , Sealey Mary Lynn 
Published: October 2019

INTRODUCTION:
Colorectal cancer (CRC) is the third leading cause of death in the US in women and the second leading cause of death in men. CRC mortality has been progressively declining since 1990, thanks in part to an increased rate of CRC screening. One of the biggest deterrents to CRC screening is lack of information about the various screening modalities and preparation process. Additional information for patients would be beneficial for increased adherence to guideline-directed CRC screening.

METHODS:
In this study, aggregate data was collected via EHR for the WPMA Medicine Resident Clinic cohort to establish baseline patient adherence to CRC screening (defined by referral and follow through with CRC screening e.g. via colonoscopy, ColoGuard, or FIT screening). A poster was developed with information on CRC screening that included information on procedures, specimen collections, and insurance coverage for each modality and placed in resident examination rooms. Adherence data was collected in aggregate every 5 weeks (equivalent to a 5-week cycle of resident cohort rotations). Another resident clinic in which no posters were placed was used as a control group.

RESULTS:
Baseline adherence to CRC screening for the selected cohort was 28.5%. Since the placement of educational posters screening adherence collected in 5-week intervals showing an increase in adherence with rates of 36.0%, 37.6%, 36.2%, 37.3%, a total increase of approximately 8.8%. The control group with similar screening adherence revealed an increase of adherence of 2%.

CONCLUSION:
Data collection is ongoing, and we hypothesize that the implementation of patient education through posters in resident examination rooms will increase adherence to appropriate screening.
2838 An Evaluation of the Multi-Target Stool DNA Test for Colorectal Cancer Screening in Individuals Aged 45-49 at Average Risk for Colorectal Cancer: Act Now Study
Authors: Imperiale Thomas , Kisiel John , Itzkowitz Steven , Scheu Bradley , Piscitello Andrew , Statz Sandra , Berger Barry M. , Limburg Paul 
Published: October 2019

INTRODUCTION:
Due to the rising incidence and mortality of colorectal cancer (CRC) in individuals < 55 years (Siegel R, et al, JNCI, 2017), American Cancer Society (ACS) guidelines now recommend average-risk CRC screening beginning at age 45 years. The multi-target stool DNA (mt-sDNA) test, an FDA-approved screening test for average-risk individuals ≥50 years, is one ACS-recommended option for this age group. To minimize invasive testing in the younger age group, a screening test with high specificity is necessary to triage patients for diagnostic colonoscopy. To date, most endorsed CRC screening tests have not been rigorously studied in younger age groups. The objective of this study (the Act Now study [NCT03728348]) is to quantify the specificity of the mt-sDNA test in average risk individuals ages 45-49.

METHODS:
Act Now is an ongoing prospective, cross-sectional, multi-center study in subjects ages 45-49 at average risk for CRC. 942 subjects are targeted for enrollment and will complete a mt-sDNA test prior to undergoing a screening colonoscopy (blinded to mt-sDNA test results). Specificity for advanced colorectal neoplasia will be determined by comparing mt-sDNA test results to the most advanced finding on colonoscopy, based on procedure report and histopathological findings. Due to the low prevalence of CRC in this age group, mt-sDNA test sensitivity will be a secondary measure.

RESULTS:
To date, 480 subjects have completed a mt-sDNA test and screening colonoscopy. A total of 468 subjects (97.5%) have no first-degree relative (FDR) with CRC and 12 subjects (2.5%) have an FDR diagnosed at age ≥60 years. No subject has had a previous screening colonoscopy. The study population has a mean age of 47.4 years and is 48.8% female. Self-reported race includes 84.2% white, 11.5% black/African American, 3.3% Asian, and 1.0% other. Self-reported ethnicity includes 95.2% not Hispanic or Latino, 4.6% Hispanic or Latino, and 0.2% other. The mean BMI of subjects is 29.6 kg/m2. Most subjects (67.1%) have never smoked cigarettes, while 21.9% are former smokers and 11.0% are current smokers.

CONCLUSION:
The ongoing Act Now study will quantify the specificity of the mt-sDNA test in average risk individuals ages 45-49. Given concerns regarding the resources required to screen this age group for CRC, a noninvasive screening test with high specificity and sensitivity will help to optimize use of colonoscopy resources.
2839 Outcomes of a Positive Cologuard Test in an Outpatient Internal Medicine Practice
Authors: Satiya Jinendra , Dziadkowiec Karolina N. , Bagatell Stuart , Marcus Akiva 
Published: October 2019

INTRODUCTION:
In the United States, colorectal cancer (CRC) is the second leading cause of death. Colonoscopy and fecal immunochemical test (FIT) are recommended as first tier tests for colorectal cancer screening. Cologuard is an attractive and effective modality of screening in patients apprehensive of undergoing a colonoscopy with a sensitivity and specificity of upto 90%. We performed a retrospective chart review to assess the outcomes of cologuard testing and subsequent colonoscopy results in an outpatient population.

METHODS:
A total of 550 patients underwent cologuard testing in our outpatient internal medicine practice. We performed a retrospective chart review to identify patient characteristics in patients with a positive cologuard test and correlate them with colonoscopy findings. Primary outcome was to identify colonoscopy findings in patients with a positive cologuard test. Secondary outcome was to identify patient characteristics in this patient population.

RESULTS:
52 of these patients (9.45%) had a positive cologuard test. The average age of these patients was 68 years. 222 of these were males and 328 females. Most of them were non-hispanic or non-latino whites (39), with two hispanics, and one American Indian. Nine patients refused to report their ethnicity. All of these patients were referred to gastroenterology for a screening colonoscopy. Out of the 52 patients that were referred, 34 (65.38%) underwent a screening colonoscopy. Four patients were lost to follow-up, eight patients could not undergo a screening colonoscopy secondary to significant medical co-morbidities and six declined the colonoscopy. 29 (85.29%) patients had an abnormal colonoscopy with significant findings. Five patients had a normal colonoscopy with no remarkable findings. The total number of polyps found in these patients was 70, ranging from one polyp seen in nine patients to 12 polyps seen in one patient. The most common location for a polyp was the sigmoid colon followed by the transverse colon, with fewest polyps seen in the cecum. The most common histological diagnosis was hyperplastic, followed by sessile serrated and villous adenomas.

CONCLUSION:
We noted a high degree of correlation between a positive cologuard test and the presence of colonic polyps. Cologuard is an effective and convenient non-invasive screening modality in patients that do not wish to undergo a colonoscopy. Appropriate follow-up and referral to gastroenterology is essential for patients with a positive cologuard test.
2840 The Association of Polish Ethnicity and Polyp Risk on Screening Colonoscopy in a Local Brooklyn Population
Authors: Catalano Carmine , Dros Matthew , Reddy Madhavi , Gurram Krishna C. 
Published: October 2019

INTRODUCTION:
The Brooklyn Hospital Center (TBHC) serves an ethnically diverse community with a large Polish immigrant population. There was a perceived increased quantity of polyps in our Polish patients. Multiple adenomas, larger sized adenomas, and adenomas with advanced histology on index colonoscopy are associated with increased risk for colorectal cancer (CRC). Studies in African Americans demonstrated higher incidence of CRC and mortality compared to whites suggesting different ethnic groups may be at increased risk for CRC. The goal of our study is to see if the Polish population is at increased risk for adenomatous polyps, large polyps(≥1 cm), multiple adenomas(≥3), or advanced adenomas(tubulovillous, villous, or high grade dysplasia) when compared to the non-Polish white population.

METHODS:
A retrospective chart review was performed from 1/2012 to 10/2018. Inclusion criteria were patients ≥50 years of age undergoing screening colonoscopy. Exclusion criteria consisted of an incomplete exam, personal or family history of CRC, or indication other than screening. Polish and non-Polish whites were identified by demographic data. 121 Polish patients were matched to 121 non-Polish white patients by gender and age. High-risk patients were those having large, multiple or advanced adenomas. Statistical analysis utilized student’s 2 sample t-test for P-values, with an alpha level of 0.05, and odds ratios (OR) with 95% confidence intervals (CI).

RESULTS:
Each arm consisted of 56 men (46%) and 65 women (54%) with an average age of 64.3 years in both. There was a statistically significant difference between the number of high-risk Polish vs. non-Polish white patients (OR 1.95, 95% CI: 1.07-3.53; P = 0.026). Although not statistically significant, Polish patients had an increased prevalence of total polyps (OR 1.22, 95% CI: 0.73-2.0; P = 0.23), large polyps (OR 1.69, 95% CI:0.88-3.22; P = 0.10), adenomas (OR 1.38, 95% CI: 0.81-2.32; P = 0.23), multiple adenomas (OR 1.63, 95% CI: 0.60-4.35; P = 0.33), and advanced adenomas (OR 1.85, 95% CI: 0.74-4.58; P = 0.18). We also found 2 cases of CRC in the Polish group and no cases in the non-Polish group (P = 0.15).

CONCLUSION:
These results show a statistically significant difference in the number of high-risk Polish vs. non-Polish white patients with an increase rate of CRC in the Polish group although not statistically significant. These findings warrant larger population based studies to further investigate the benefit of earlier screening for these patients similar to African Americans.