bluuebunny/crossref_metadata_2025_split huggingface dataset:
522 Is the Future of Gastroenterology Being Prepared to Prevent Work Related Injuries and Allow for a Long Healthy Career: Question Answered
Authors: Craig Cassandra , Owen S. Craig , Acharya Priyanka , Kedia Prashant 
Published: October 2019

INTRODUCTION:
Gastroenterologists practicing in the United States perform on average 12 endoscopies and 22 colonoscopies per week and spend 43% of their time performing endoscopy. 39-89% of endoscopists report pain and/or injuries related to performing procedures. Recently, there has been an emphasis on optimizing physician trainee mental health, while education and training on managing the physical strain associated with endoscopy is lacking. We hypothesized that gastroenterology fellows are receiving insufficient training in the ergonomics of endoscopy.

METHODS:
A survey consisting of nine questions was distributed to all gastroenterology fellowship coordinators and program directors to distribute to their fellows. Primary outcome targets were the percentage of fellows having undergone any ergonomics training as well as the number of hours of instruction received. Secondary outcomes included the type of work-related injury and the responder's opinion on the need for additional training. Demographic data obtained included age, sex, year in training and overall physical fitness level.

RESULTS:
Ninety-nine fellows completed the survey. The average age was 32.9 years old, 74.8% male, and first/second/third years were equally represented (28.3% vs 34.3% vs 32.3%) with only 5.1% being advanced fellows (5.1%). 53.5% reported good overall health. Only 45.5% have received any training in ergonomics, 8.1% reported more than 2 hours and 92.9% felt they would benefit from additional training. Procedurally related injuries were reported in 27.3% of fellows. Despite a trend towards more females reporting work related injuries it was not statistically significant (P = 0.098). Once again, a trend was seen in second and third years reporting more injuries (P = 0.076). There was no significant difference in perceived health of respondents reporting injuries (P = 0.864) or amount of training received (P = 0.232).

CONCLUSION:
Despite a limited sample size clear trends in endoscopic ergonomics training were identified. The majority of fellows have received no or minimal training and an overwhelming amount believe that they would benefit from additional instruction. With more than 25% of fellows reporting an injury as a direct result of endoscopy, if no changes are made in training curriculum we can assume this number will grow as their careers progress. Our survey demonstrated a need and desire for more formal training in the ergonomics of endoscopy.
526 The Efficacy and Safety of Device-Assisted Enteroscopy and Push Enteroscopy in Cirrhosis Patients
Authors: Al Yassin Altaib , Alazzawi Yasir , Sapho Lidia , Kheder Joan , Cave David 
Published: October 2019

INTRODUCTION:
Small bowel Push enteroscopy (PE) and device-assisted enteroscopy (DAE); including double balloon, single balloon or spiral enteroscopy are modalities that used in evaluating and treating obscure gastrointestinal bleeding and small bowel lesions. Limited data are available on the safety and efficacy of these procedures in the cirrhotic population. The aim of this study is to assess the efficacy and the safety of DAE and PE in cirrhotic patients.

METHODS:
A retrospective chart review of cirrhotic patients from a single center between January 2006 and January 2016 who had device-assisted enteroscopy or PE procedure. Success rate, duration of the procedure, anesthesia time, and procedure complications were collected. Patients' age, sex, MELD score, child-Pugh score (CTP) were also reviewed and analyzed.

RESULTS:
A total of 42 procedures, including 22 PE and 20 DAE, in 33 cirrhotic patients were reviewed. The mean age was 59.3 years (range: 29-86 years). The most common findings were angioectasias followed by ulcers and inflammatory changes. A longer duration time was associated with the device-assisted enteroscopy when compared to the PE group, the mean time was 58 minutes and 37 minutes respectively (P-value of 0.03). The anesthesia time was longer in the DAE with an average of 83 minutes while in the PE , it was 53 minutes (P-value of 0.03). No difference in the time of the procedure was found between the compensated cirrhosis when compared to the decompensated cirrhosis. The device-assisted enteroscopy success rate was 90% versus 100% in PE. No adverse events were seen in both groups. More therapeutic interventions were performed in DAE compared to PE especially bleeding cauterizations and biopsy of lesions while more diagnostic procedures were performed in the PE (Table 1).

CONCLUSION:
Device-assisted enteroscopy and push enteroscopy are safe procedures in cirrhotic patients with a high success rate. Decompensated cirrhosis does not carry an increased risk of a longer procedure time or complication when compared to the compensated cirrhosis.
531 Patients Undergoing Outpatient Upper Endoscopy and Colonoscopy on the Same Day (Double Procedures) Are at Increased Risk for Adverse Respiratory Outcomes
Authors: Saltzman Steven , Weinstein Michael , Ali M. Aamir 
Published: October 2019

INTRODUCTION:
Between 11-15 million colonoscopies and 6-7 million upper endoscopies are performed in the United States annually, with over half the cases occurring in an ambulatory setting (1,2). Recent claims-based data has suggested that infectious complications may be increased when upper endoscopy and colonoscopy are performed together compared to when they are performed separately (3). The purpose of this study is to determine endoscopic and anesthesia variables that increase the risk of periprocedural respiratory complications.

METHODS:
Medical records from 2000 consecutive upper endoscopies and colonoscopies performed at five high volume ambulatory surgery centers were reviewed. Patient characteristics were recorded, along with endoscopic and anesthesia variables. End points chosen to serve as surrogates of aspiration risk were intra-procedure cough, desaturation, placement of a nasal or oral airway, and use of oral suction.

RESULTS:
In 2000 cases, desaturation occurred in 3.25%, cough in 3.5% cases, need for suction in 2.45%, and need for oral airway / nasal trumpet in 0.4%. Multiple logistic regression analysis demonstrated supine position, double procedure, bowel prep taken as a single dose, NPO time of less than 3 hours, BMI >35 kg/m2 and Propofol dose >300 mg, and supine position to be independent risk factors for adverse respiratory events.

CONCLUSION:
Supine position during procedures, double procedures, bowel prep taken as a single dose, NPO duration of less than 3 hours, high BMI and high propofol dose are risk factors for adverse respiratory outcomes during endoscopic procedures.
532 Reduction of Inpatient Non-Emergent GI Procedure Utilization
Authors: Sandhu Naemat , John-Keating Krysta , Platt Alison , Wambold Christine , Barash Eric , Navarro Victor J. 
Published: October 2019

INTRODUCTION:
Non-emergent gastrointestinal (GI) procedures performed on inpatients increase costs in a diagnosis related group (DRG) reimbursement system. They prolong periods of inanition due to preps, interrupt patient rest and disrupt the flow of outpatient procedures. This study involved delivery of an educational intervention for gastroenterologists intended to reduce the number of non-emergent inpatient GI procedures at Einstein Medical Center Philadelphia.

METHODS:
The baseline rate of non-emergent inpatient GI procedure performance was determined for a 6-week period in 2018. Potential barriers contributing to performance of non-emergent inpatient GI procedures were assessed via a survey of twenty gastroenterologists. Total inpatient esophagogastroduodenoscopies (EGDs) and colonoscopies was collected, non-emergent procedures were identified during a 6-week pre-intervention phase A 30 minute didactic to brief all twenty on the American College of Gastroenterology guidelines on emergent GI procedure indications was delivered as the intervention. Post-intervention data was collected for total and non-emergent inpatient GI procedure performance for a 6-week period immediately following the intervention.

RESULTS:
Fear of patients not following up followed by fear of litigation were the most common reasons that caused providers to perform non-emergent inpatient GI procedures (Figure 1). The rate of non-emergent EGDs and colonoscopies dropped from baseline to post-intervention periods; 31% to 8% (Figure 2), and 49% to 20% (Figure 3) respectively. The rate of non-emergent EGDs dropped further from pre to post-intervention, but rose slightly for colonoscopies.

CONCLUSION:
The process of measuring non-emergent GI procedure performance led to a reduction in utilization (Hawthorne effect), in keeping with guidelines. An educational intervention led to a further reduction in inpatient EGD utilization. Implementing steps to eliminate potential barriers may improve non-emergent inpatient GI procedure performance rates.
535 Peppermint Oil Decreases Colonic Spasm Without Significantly Affecting Cecal Intubation Time and Adenoma Detection Rate: A Systematic Review and Meta-Analysis
Authors: Nehme Fredy , Al Momani Laith , Alomari Mohammad , Zafar Yousaf 
Published: October 2019

INTRODUCTION:
Peppermint oil, an essential oil well known as a flavoring agent, is also known to have a relaxation effect on smooth muscles in the colon. Peppermint oil was reported to reduce colonic spasm and is commonly used for symptomatic relief in irritable bowel syndrome. Whether these effects lead to clinically relevant advantages in practice during routine colonoscopy is controversial.

METHODS:
We included randomized controlled trials comparing peppermint oil administered during colonoscopy to placebo. We searched Medline, Google Scholar, and Cochrane through May 2019. Eligible studies were searched for variables of interest including inhibition of peristalsis cecal intubation time, and adenoma detection rate (ADR). All statistical analyses were performed using the R Programming Language. Pooled rates of variables were reported as Odds ratio (OR) and standardized mean difference with 95% confidence interval and heterogeneity was reported as I2 statistics.

RESULTS:
A total of 5 trials were eligible and included in the analysis. Dosage and route of administration were variable, peppermint oil was administered via oral dose pre-procedure in 2 studies and locally during the procedure in 3 studies. There was a total of 623 subjects in the peppermint oil group and 239 in the placebo group. Complete inhibition of colonic peristalsis was significantly more common in the peppermint oil group (OR = 6.12, 1.85-20.26). Cecal intubation time and ADR were comparable between the 2 study groups. There was substantial heterogeneity.

CONCLUSION:
Administration of peppermint oil reduces colonic spasm during colonoscopy. Despite the theoretical benefits of improving mucosal inspection and increasing the ease of colonoscopy insertion with peppermint oil, objective measurements including ADR and cecal intubation time did not differ. However, these studies were limited by the low number of subjects, significant heterogeneity in dosage, route and timing of administration. Given the heterogeneity of the results, larger randomized controlled trials are needed.
537 A Simple Step for Better Prep: The Impact of Nurse Driven Telephone Education on Colonoscopy Bowel Prep
Authors: Mann Sarabdeep , Ahmed Shifat , Al-Jashaami Layth , Alishahi Yasmin 
Published: October 2019

INTRODUCTION:
Bowel preparation affects the completeness, duration, and safety of colonoscopy, as well as the detection of neoplastic lesions. Guidelines have proposed a goal of >85% to achieve adequate bowel cleansing during colonoscopy. However there remain challenges to achieve this metric, as factors including patient health literacy, socioeconomic status, language barriers, and complex instruction tools can influence the quality of bowel prep. Recognizing a period of time when the adequacy of bowel prep at our institution was <85%, a nurse driven telephone education protocol was developed to improve bowel prep at the Phoenix VA Health Care System.

METHODS:
The nurse education team assigned a GI nurse to call patients one week prior to their colonoscopy. During this phone visit, patients were educated to eat a low residue diet one week prior to their procedure. They were further instructed to maintain a clear liquid diet the day prior to the colonoscopy. During the phone encounter, education was given regarding the timing of the bowel prep. Prior to our education initiative, to prevent confusion all patients were instructed to take the first dose of MoviPrep at 6 pm the evening before the exam, and the 2nd dose at midnight the day of the colonoscopy. With the nurse driven telephone education protocol patients received individualized plans for split dose prep, with the 1st dose at 6pm the evening prior to the colonoscopy and the 2nd dose four hours before the colonoscopy. We evaluated the quality of bowel prep seven months prior to and six months after our quality improvement initiative, and collected data on overall impression of bowel prep deemed by the performing gastroenterologist. Statistics were performed with univariate analysis and statistical significance was set at P < 0.05.

RESULTS:
For the preceding seven months prior to our quality improvement initiative, 2115 out of 2569 (82%) colonoscopies achieved adequate quality bowel prep. Following implementation of a nurse driven telephone education initiative, 2271 out of 2384 (95%) colonoscopies achieved adequate prep. This improvement from 82% to 95% was statistically significant (P = 0.0001).

CONCLUSION:
We demonstrate improved bowel prep through nurse driven telephone education. Where resources allow, this can be a simple yet effective tool to improve bowel prep, in turn reducing cost. Further studies are needed to determine the precise cost effectiveness of such interventions, as well the role other ancillary staff may play in education.
543 Analysis of Variation in Pre-Procedural Fasting Duration for Common Inpatient Gastrointestinal Procedures
Authors: Sakulsaengprapha Vorada , Daniel Michael , Cai Jiarui , Martinez Diego , Mathews Simon C. 
Published: October 2019

INTRODUCTION:
Guidelines from the American Society of Anesthesiologists (ASA) recommend no intake of clear liquids and solid food 2-4 hours and 6-8 hours respectively prior to endoscopic procedures. Because excessively long pre-procedural fasting while inpatient can negatively impact a patient's experience and clinical outcomes, our study analyzed the typical fasting duration for patients undergoing colonoscopy, esophagogastroduodenoscopy (EGD), or endoscopic retrograde cholangiopancreatography (ERCP) at a large tertiary care hospital and determined how these wait times varied across multiple variables.

METHODS:
Inpatient data for colonoscopy, EGD, and ERCP was extracted as part of a quality improvement evaluation using administrative data and information from the electronic medical record at The Johns Hopkins Hospital between July 2016 and January 2018. The duration of nil per os (NPO) status was calculated from time the NPO order went into effect to the time “Patient in Procedure Room” order was entered. Patients who were NPO greater than 72 hours were excluded as NPO status was more likely secondary to non-procedure factors. Kruskal-Wallis Test/Wilcoxon Test/Pearson Test were used in analysis depending on the outcome type and data distribution.

RESULTS:
During the study period, there were 753 colonoscopies, 1325 EGDs, and 550 ERCPs performed on inpatients. The median NPO wait time for colonoscopy was 11.9 hours; 12.6 hours for EGD; and 13.1 hours for ERCP (median for all procedures was 12.6 hours; interquartile range 9.6-16.1 hours). Hispanic patients spent more time NPO than non-Hispanic patients (median of 13.9 hours vs. 12.4 hours, P-value = 0.018). There was no statistically significant associations between NPO duration and patient sex, total number of comorbidities, intensive care unit days, length of stay, inpatient unit location, inpatient team, or type of provider placing the orders (physician vs. non-physician).

CONCLUSION:
The duration of pre-procedural inpatient fasting was between 9.6-16.1 hours for the majority of patients, which consistently exceeds ASA guidelines for pre-procedural fasting. There are many scenarios where longer fasting is clinically indicated particularly for safety; however, these data suggest that for many patients there may be an opportunity to liberalize NPO duration and keep within recommended guidelines. This change may contribute to improved patient experience and minimize potential clinical impact of prolonged fasting.
550 Discordance in Colorectal Polyp Size Determination Between Colonoscopy and Pathology Reporting
Authors: Corona Edgar , Bastani Roshan , Yang Liu , Shao Paul , Mwengela Didi , Didero Michelle , Asokan Ishan , Bui Alex , Hsu William , May Folasade 
Published: October 2019

INTRODUCTION:
National guidelines recommend that patients with colorectal adenomas ≥1cm undergo surveillance colonoscopy to prevent colorectal cancer. Polyp size is often assessed twice, once during colonoscopy and again during pathology examination. It remains unclear whether these measurements vary and which should govern surveillance intervals.

METHODS:
We retrospectively analyzed a random sample of primary care patients who underwent polypectomy between January 1, 2013 and January 1, 2016 in a large academic healthcare center. Chart abstractors reviewed electronic health record data for colonoscopic polyp descriptors and measurements, corresponding pathology measurements, and histology. We excluded cases with normal histology, missing pathology, fragments, unreliable polyp matches between reports, and >5 polypectomies. We performed a paired t-test to assess polyp size discordance between reports and calculated Cohen's kappa coefficient to assess agreement whether the size was ≥1 cm.

RESULTS:
We reviewed 1,528 patient charts, and 831 (54.4%) met inclusion criteria, representing 1,532 polyps. Sizes ranged from 0.1-3.0cm on colonoscopy and 0.1-2.7cm on pathology reports. On colonoscopy report, the majority (881, 57.5%) used only a descriptive term rather than a numeric value to describe size (Table 1). Descriptive size terms were diminutive (513), tiny (39), small (328), and large (1). Only 2.8% of polyps described as diminutive, small, or tiny on the colonoscopy report were ≥1cm on the corresponding pathology report. Among the 367 (24.0%) polyps with discrete numeric sizes on both reports, size discordance varied by >0.2 cm for 50% of polyps (Figure 1). More of these polyps were ≥1 cm on colonoscopy (70) than on pathology (51) report, and there was remarkable clustering at 1 cm by colonoscopy report estimation (Figure 2). There was moderate agreement (kappa = 0.52) on size ≥1 cm. Among tubular adenomas (TA) ≥1 cm on colonoscopy or pathology report (36), 10 (27.8%) were ≥1 cm on both, 18 (50.0%) were ≥1 cm on colonoscopy only, and 8 (22.2%) were ≥1 cm on pathology only.

CONCLUSION:
There is considerable discordance between colonoscopic and pathology polyp size measurements, with more polyps sized as ≥1 cm by colonoscopic estimation compared to pathology, which has implications for surveillance frequency. Future studies should investigate the implications of discordant measurements on clinical outcomes and inform guidelines on surveillance intervals.
551 Comparing Advanced Adenoma Detection Rate of Water Exchange, Cap, and Endocuff Colonoscopy: Pooled Data of Randomized Controlled Trials With Air Insufflation as the Common Comparator
Authors: Shao Paul , Bui Aileen , Jia Hui , Leung Felix 
Published: October 2019

INTRODUCTION:
Advanced adenomas, defined as adenomas ≥10mm, significant villous features (>25%), or high-grade dysplasia, are important targets for colorectal cancer screening. They represent the subpopulation of adenomas that are most likely to progress into carcinoma and are associated with increased risk for future CRC incidence. Advanced adenoma detection rate (AADR) is therefore an important measure in assessing new screening methods. Water exchange (WE) colonoscopy has been shown to improve AADR consistently while modern accessories, such as cap and endocuff, have variable impacts on AADR. We assessed the impact on AADR between WE, cap and Endocuff by indirect comparison with standard air insufflation (AI) as the common comparator.

METHODS:
A literature search was done to identify all relevant RCTs comparing WE, Cap and Endocuff with AI colonoscopy published since 2000 as full text in English and included AADR among the outcomes. EMBASE, Medline, SCOPUS, and Cochrane Library were searched systematically using the following terms in their titles, abstracts, or keyword lists: colonoscopy, and water exchange, cap, or Endocuff. Two investigators screened the articles manually and separately. The results were compared, and a discussion was held with a third investigator to resolve any discrepancies.

RESULTS:
1,453 articles resulted from keywords search and were manually screened. 14 RCTs met criteria and were included in the analysis. A total of 12,085 subjects underwent AI, WE, cap (CC) or Endocuff-assisted (EC) colonoscopy. AADR of WE, CC, and EC were compared against AI. Table 1 shows that WE significantly increases AADR compared to AI (8.1% vs 6.0%, P = 0.0001, Fisher exact test). CC does not significantly change AADR compared to AI (8.7% vs 8.2%, P = 0.585). No significant difference in AADR exists between EC and AI (16.6% vs 17.0%, P = 0.815). AADR in WE, CC, and EC as a percentage change of AI are 35.0%, 6.1% and -2.4%, respectively. While WE significantly increases AADR, CC and EC do not significantly impact AADR. Compared to CC and EC, WE has a higher percentage increase in AADR (vs the common comparator of AI). This may be related to the low AADR in the AI group in the WE trials.

CONCLUSION:
WE appears to significantly increase AADR, especially in patient cohort with lower AADR. Cap and Endocuff does not have significant impact on AADR.