bluuebunny/crossref_metadata_2025_split huggingface dataset:
373 Routine EGD Has Minimal Impact on Refractory GERD Management
Authors: Kwak Ye Eun , Coleman Madeleine , Sanchez Mayra , Masoud Amir 
Published: October 2019

INTRODUCTION:
Routine diagnostic esophagogastroduodenoscopy (EGD) is recommended for refractory gastro-esophageal reflux disease (GERD) symptoms despite lack of evidence that it impacts management or outcomes. This study aims to determine if diagnostic EGD impacts management in patients with refractory GERD compared to esophageal manometry, pH testing and intra-luminal impedance.

METHODS:
We performed an observational study of patients with refractory GERD who underwent EGD from 2013 to 2018 at a tertiary hospital. Among 1,213 patients with GERD, we strictly excluded patients with alarm features such as dysphagia, dyspepsia; history of gastroesophageal surgery, or EGD done for other diagnostic procedures, and identified 339 patients who underwent EGD solely for persistent reflux symptoms. We then identified those who had esophageal manometry or pH-impedance studies for further evaluation of GERD, as well as if the findings of these tests resulted in a change in management (medication change or de-escalation, referral for Nissen fundoplication, etc).

RESULTS:
Among 339 patients with refractory GERD, 80.5% of patients were taking PPIs prior to and/or at the time of EGD. The majority of patients had completely normal (163/339, 48.1%) or solely benign or incidental findings (106/339, 31.3%) on EGD. Only 10.6% of patients had esophageal manometry or pH-impedance studies for refractory reflux symptoms, of those, 6.2% followed EGD and only 7 patients had these studies after a completely normal EGD. The majority of patients undergoing manometry had normal studies or minor abnormalities (23/32, 71.8%). All patients who had been ordered for intraluminal impedance or 24 hr pH testing alone could not tolerate the procedure. Six of 15 patients (40%) undergoing 24 hr pH-impedance testing had findings leading to a change in management. Undergoing pH-impedance testing after EGD was associated with a change in management (OR 7.33, P = 0.018). PPI use was not associated DeMeester score or with results of manometry, impedance, or pH testing.

CONCLUSION:
Most patients who underwent EGD for refractory GERD symptoms alone did not have pathological findings prompting a change in management. There were no demographic variables that predicted pathologic findings on EGD. Very few patients underwent subsequent or concomitant esophageal manometry, impedance or pH testing. pH-impedance after EGD was associated with a change in management, and may be a better first step in evaluating patients with refractory GERD symptoms, than EGD.
380 High Resolution Manometry Findings in Patients With Absent Contractility
Authors: Fan Xiaowen , Paik Il J. , Zhang Xiaocen , Kassim Gassan , Hershman Melissa , Verheyen Elijah , Abed Jean , Smith Michael S. 
Published: October 2019

INTRODUCTION:
High resolution manometry (HRM) is a widely utilized diagnostic tool for identifying esophageal motility disorders. The Chicago Classification V3.0 (CC3) applies a hierarchical stepwise approach to the analysis of HRM parameters, allowing for characterization and diagnosis of different disorders. While upper esophageal sphincter (UES) parameters are not utilized in CC3, studies have shown that these values could potentially help in differentiating between different disorders. The aim of this study was to evaluate for trends in esophageal sphincter parameters in patients with absent contractility (AC).

METHODS:
Reports for esophageal HRM performed at a single referral-based motility center between 2013 and 2018 were retrospectively analyzed. We selected patients diagnosed with either AC (study group) or no CC3 abnormality (control group), and divided them by age group. The primary outcome included differences in parameters related to both the lower esophageal sphincter (LES) and UES. Multivariate regression analysis was used to adjust for age group and sex.

RESULTS:
A total of 455 patients were included in the study (Figure 1), 52 with AC (mean age 51.4, 50.0% female) and 403 without CC3 abnormality (mean age 52.8, 69.5% female). The primary indication for HRM was more likely to be dysphagia in AC patients (73.1% vs 30.5%, P < 0.01), whereas GERD was more likely to be reported in controls (67.2% vs 25.0%, P < 0.01). AC diagnosis was associated with a lower LES mean basal pressure (14.9 vs 27.0 mmHg, P < 0.01) and LES mean residual pressure (5.9 vs 7.9 mmHg, P < 0.01). However, UES mean residual pressure (2.1 vs 0.1 mmHg, P = 0.02) and UES mean relaxation time to nadir (296.4 vs 228.5 ms, P = 0.04) were significantly higher compared to control. No significant difference in UES mean basal pressure was identified between the study group and control.

CONCLUSION:
AC affects both the LES and UES, causing decreased LES basal and residual pressures, along with increased UES residual pressures and UES relaxation time to nadir. Our data suggest that AC affects smooth muscle in both the esophageal body and LES, where it causes decreased LES tone. The increased UES residual pressures and relaxation time to nadir might be compensatory adaptation to poor esophageal bolus clearance to prevent esophago-pharyngeal reflux. Utilization of UES parameters in future versions of the Chicago Classification may help users better diagnose and manage AC and related disorders.
389 Are Proton Pump Inhibitors Associated With an Increased Risk in Developing Ischemic Heart Disease in Non-Cardiac Chest Pain Patients?
Authors: Kim Yeseong , Fass Ronnie 
Published: October 2019

INTRODUCTION:
Non-cardiac chest pain (NCCP) is defined as chest pain that persists after cardiac etiologies have been excluded. Treatment of NCCP is targeted towards the underlying cause, most often GERD, which is commonly treated with proton pump inhibitors (PPI). It has been reported that long term PPI use is associated with increased risk for developing ischemic heart disease (IHD). We aim to determine whether PPI use is associated with an increased risk for IHD in NCCP patients, and thus alter the otherwise benign course of the disease.

METHODS:
Cohort analysis was performed using the multi-institutional database IBM Explorys. NCCP patients started on a PPI at least 1 day after diagnosis, and who developed IHD at least 30 days following PPI initiation were included. Identical parameters were used to acquire data on patients prescribed histamine H2 receptor antagonists (H2RA). Data analysis was controlled for 6 known confounding factors for IHD including hyperlipidemia, hypertension, obesity, smoking status, male gender, and diabetes mellitus.

RESULTS:
A total of 13,250 NCCP patients without preexisting IHD received PPI; 1,280 (9.66%) developed new IHD. Of these patients, 740 (57.8%) had ST-elevation MI (STEMI), 340 (26.5%) non-ST elevation MI (NSTEMI), and 200 (15.6%) ischemic cardiomyopathy (ICM). A total of 22,260 NCCP patients without preexisting IHD were never prescribed a PPI; 870 (3.91%) developed new IHD. Of these patients, 490 (56.3%) had STEMI, 210 (24.1%) NSTEMI, and 170 (19.5%) ICM. The unadjusted and adjusted odds ratios of developing IHD in NCCP patients while on PPI compared to not on PPI were 2.63 (95% CI 2.41-2.87), and 1.14 (95% CI 1.03-1.25, P-value 0.0093), respectively. A total of 3,050 NCCP patients without preexisting IHD received H2RA; 250 (8.19%) developed new IHD. Of these patients, 160 (64%) had STEMI, 70 (28%) NSTEMI, and 20 (8%) ICM. Overall, 22,070 NCCP patients without preexisting IHD received H2RA; 1,320 (5.98%) developed new IHD. Of these patients, 790 (59.8%) had STEMI, 350 (26.5%) NSTEMI, and 180 (13.6%) ICM. The unadjusted and adjusted odds ratios of developing IHD while on H2RA compared to not on H2RA were 1.40 (95% CI 1.22-1.62) and 0.90 (95% CI 0.77-1.06, P-value 0.2049), respectively.

CONCLUSION:
PPI use appears to confer a statistically significant, but marginally increased odds in developing IHD in NCCP patients. Thus, PPI use in NCCP only minimally alters the course of the disease. H2RA use does not statistically increase the risk for IHD in NCCP patients.
391 How Useful Is Prolonged 96 Hr versus 48 Hr Wireless pH Monitoring in PPI Refractory GERD?
Authors: Rassameehiran Supannee , Tetangco Eula Geralyn , Lee Jai Eun , Sharma Amol , Rao Satish 
Published: October 2019

INTRODUCTION:
Gastroesophageal reflux disease (GERD) is a common problem. Ambulatory pH monitoring has been used to identify pathological esophageal acid exposure and reflux-symptoms association in GERD, especially when endoscopy is normal, but the utility of prolonged 96 hr monitoring and if PPI therapy during study facilitates better management is unclear. The purpose of the study is to evaluate the clinical utility of prolonged 96 hr wireless pH monitoring, before and after PPI therapy.

METHODS:
We conducted a retrospective study of adult patients presenting to our center between January 2015 and June 2018 with suspected diagnosis of GERD and refractory to PPI therapy. Consecutive patients who underwent 96 hr wireless pH monitoring (Bravo®, Medtronics, Minneapolis, MN) placed endoscopically, 6 cm above LES zone were enrolled. Patients were instructed to stop PPI therapy 7 days prior to the study and to resume their usual PPI therapy on day 3 and day 4 of study. The percent time of esophageal acid exposure (pH < 4) for each day during supine and upright positions and GI symptoms were analyzed using (SPSS™) version 22. Patients were excluded if the entire 96 hr study was not recorded either from battery malfunction or capsule detachment. Data compared between those with normal and abnormal pH study, and between first 48 hrs and next 48 hrs.

RESULTS:
64 patients met inclusion criteria (Table 1). 42 (65%) patients had elevated >4.5%. Total 24 hr acid exposure time; 38% on either D1 or D2 and 62 % on both days and 22 (35 %) had normal acid reflux study (Figure 1, Table 2). Of patients with abnormal study, 23/42 (54.7%) had persistent increase in % acid exposure time on D3 and 17/42 (40.4%) patients on D4 following PPI therapy.

CONCLUSION:
Our study demonstrates that prolonged 96 hr pH monitoring is feasible and clinically useful. We confirmed abnormal acid reflux in 65% of patients and normal acid reflux in 35%. Also, the abnormal reflux profile normalized in 36% of patients on their usual PPI whereas 64% had persistent abnormal acid reflux, despite their usual PPI therapy. Thus 96 hr testing allows improved diagnosis of day time or supine acid reflux symptoms, and identifies patients who are either refractory or responsive to current PPI therapy. This test could improve management of patients with PPI refractory GERD.
392 Baseline Characterization of Patients With Eosinophilic Esophagitis (EoE) Using the EoE Histology Scoring System and Correlations With Endoscopic and Symptom Outcomes: Analyses From a Randomized, Placebo-Controlled Trial
Authors: Collins Margaret H. , Dellon Evan S. , Hirano Ikuo , Katzka David A. , Williams James , Lan Lan , Desai Nirav K. 
Published: October 2019

INTRODUCTION:
It is becoming clear that eosinophilic esophagitis (EoE) activity cannot be measured by eosinophils alone, and that a more complete assessment is needed. The EoE Histology Scoring System (EoE HSS) measures the severity (grade) and extent (stage) of 8 histopathologic features in EoE: eosinophilic inflammation (EI); basal zone hyperplasia (BZH); eosinophilic abscess (EA); eosinophilic surface layering (SL); dilated intercellular spaces (DIS); surface epithelial alteration (SEA); dyskeratotic epithelial cells (DEC); and lamina propria fibrosis (LPF). We aimed to assess EoE histology at baseline using the EoE HSS, and to compare correlations between this and endoscopic and symptom outcomes.

METHODS:
This study analyzed baseline data from a 12-week, phase 2, randomized, placebo-controlled trial of budesonide oral suspension in patients with EoE (MPI 101-06; NCT01642212). Patients were eligible for inclusion if they were aged 11–40 years and had EoE with dysphagia. Esophageal biopsies from patients were examined, and mean EoE HSS total score ratios and mean individual feature scores were calculated at baseline for all patients (irrespective of treatment allocation). A correlation analysis was then performed to compare these scores with Dysphagia Symptom Questionnaire (DSQ) scores and those from the EoE Endoscopic Reference Score (EREFS) system at baseline.

RESULTS:
In total, 87 patients were included for analysis. At baseline, mean (standard deviation) EoE HSS grade and stage total score ratios for all patients were 0.5 (0.2) and 0.4 (0.1), respectively. For individual EoE HSS features, a summary of mean grade and stage scores at baseline is shown in Table 1; the most severe features for grade and stage were EI, BZH, DIS and LPF. At baseline, mean EoE HSS grade and stage total score ratios did not correlate with mean DSQ score, but did correlate significantly with mean EREFS score (grade: R = 0.3166; P = 0.0028; stage: R = 0.3344; P = 0.0015; Table 2). Similarly, mean scores for individual EoE HSS features did not correlate with mean DSQ score at baseline, but did correlate with mean EREFS score for 4 and 3 of the 8 features for grade and stage scores, respectively (Table 2).

CONCLUSION:
The most severe EoE HSS features at baseline for grade and stage were EI, BZH, DIS and LPF. At baseline, there were significant correlations between the EoE HSS and endoscopic severity, but not dysphagia. This suggests that the EoE HSS could become an essential and independent tool to measure EoE activity.
402 Shared Decision Making in Eosinophilic Esophagitis Is Associated With Treatment Satisfaction but Is Inadequately Practiced
Authors: Chang Joy W. , Rubenstein Joel , Mellinger Jessica , Kodroff Ellyn R. , Strobel Mary Jo , Scott Melissa M. , Mack Denise , Book Wendy , Sable Kathleen L. , Kyle Scholeigh (Shay) M. , Paliana Ally , Dellon Evan S. 
Published: October 2019

INTRODUCTION:
Given the similar effectiveness but differing philosophies of treatments for eosinophilic esophagitis (EoE), shared decision making (SDM) between patients and providers is important for improving treatment and adherence. Because little is known about this area, we aimed to describe patient-reported SDM and satisfaction in EoE care.

METHODS:
We developed and administered a web-based survey about SDM and satisfaction around EoE treatment based on a validated 9-item SDM questionnaire (composite range 9 – 54, low SDM defined as < 32). Adults and caregivers of pediatric patients were recruited via patient advocacy groups and at two tertiary care centers. Regular care was defined by seeing the specialty provider at least annually. Multivariable linear and logistic regression was performed to identify predictors of SDM and satisfaction with treatment.

RESULTS:
A total of 243 (47%) adults (mean age 38.7 years, SD 12.1) and 270 (53%) caregivers of pediatric patients (mean age 9.5 years, SD 4.5) completed the survey. A majority (90%) had a diagnosis of EoE alone. Among adults, 31% had regular care with both gastroenterology (GI) and allergy, 30% only with GI, 7% only with allergy, and 32% without specialty care. In contrast, a large majority of the pediatric cohort (70%) had regular follow-up with both GI and allergy, 25% only with GI, 3% only with allergy, and 2% with neither subspecialist. Patients followed by GI providers were more likely to experience greater SDM compared to non-specialists (adjusted β = 6.85; 95% CI 3.31-10.4) (Figure 1, Table 1). Despite this, nearly half of adults (44%) and children (40%) experienced low SDM for EoE management. SDM with allergists alone was similar to non-specialists. There was no difference between adults and children for the effects of provider type. More SDM occurred when patients perceived providers as comfortable with choosing a therapy outside of their recommendation (Table 1). Those receiving more SDM were more satisfied with current treatment, regardless of provider or treatment type (OR 2.77, 95% CI 1.86-4.11; Table 2).

CONCLUSION:
SDM around EoE care is practiced most by gastroenterologists and when patients perceived provider comfort with various options, however many patients still do not experience joint decision making. Because patients are more likely to be satisfied with any treatment when SDM is practiced, it is important to improve patient-centered communication and engagement in managing EoE.
403 Elucidation of Patient Motivators and Barriers to Pursuing Treatments for Eosinophilic Esophagitis
Authors: Chang Joy W. , Rubenstein Joel , Mellinger Jessica , Strobel Mary Jo , Kodroff Ellyn R. , Scott Melissa M. , Mack Denise , Book Wendy , Sable Kathleen L. , Kyle Scholeigh (Shay) M. , Paliana Ally , Dellon Evan S. 
Published: October 2019

INTRODUCTION:
Because comparative effectiveness trials of eosinophilic esophagitis (EoE) treatments are lacking, patient preferences are often incorporated to select the ideal therapy plan. However, treatment uptake and adherence are often complicated by minimized symptoms, financial cost, convenience, perceived risk and knowledge. We aimed to explore motivators for treating EoE and barriers to using common therapies.

METHODS:
We developed and administered a web-based survey on factors which affect EoE treatment choices. Adult patients and caregivers of pediatric patients were recruited via patient advocacy groups and at two tertiary care centers. Descriptive statistics of multiple response questions were performed.

RESULTS:
Of 513 respondents, 47.4% were adults and 52.6% caregivers of pediatric patients (Table 1). The most common motivator to treat EoE was a desire to prevent complications or worsening disease (88.2% adults, 94.2% peds) (Figure 1). However, only half of adults felt that EoE could be a serious disease (54.1%) and 44.4% had trust that medications or diet could control it. The greatest barriers to topical steroids were potential side effects (58.2% adults, 63.4% peds), financial cost (34.1% adults, 19.3% peds), and preference for a medication-free approach (24.8% adults, 25.9% peds) (Figure 2). Inconveniences of a restrictive diet (36.3% adults, 27.6% peds), multiple endoscopies (30.4% adults, 26.8% peds), poor quality of life and socialization (23.7% adults, 27.6% peds), and inadequate nutrition (28.4% peds) were common barriers to diet therapy. Participants reported avoiding dilation because of belief that it is a high risk procedure (30.7% adults, 36.6% peds), discomfort (30.4% adults, 27.6% peds), and financial cost (31.1% adults, 20.6% peds). Additionally, 24.4% adults felt that they would avoid dilation because of inconveniences around having a procedure.

CONCLUSION:
Although only half of patients trusted that therapy could control EoE, preventing complications and worsening disease were the most important factors in pursuing treatment. Common barriers were inconvenience and financial costs. Side effects of steroids, quality of life and nutrition management for diet therapy, and discomfort from dilation were treatment specific barriers. To improve management of EoE and patient engagement, providers need to recognize challenges of both the disease and treatments, elicit patient preferences, and tailor therapy plans to individual attitudes and values.
425 Is the Use of Proton Pump Inhibitors Associated With Increased Risk of Ischemic Stroke: A Systematic Review and Meta-Analysis
Authors: Laique Sobia N. , Riaz Haris , Carey William , Deshpande Abhishek 
Published: October 2019

INTRODUCTION:
The use of proton-pump inhibitors (PPIs) has been associated with various adverse effects including increased risk of major adverse cardiovascular events, community acquired clostridium difficile infection, chronic kidney disease and dementia. Some studies over the past decade have suggested an association between PPIs use and ischemic stroke.

METHODS:
We pooled the data after comprehensive literature search from the PubMed, Embase, Cochrane Library and Scopus databases using ‘proton pump inhibitors’ AND ‘stroke’ as the keywords. RevMan was used for the entry and analysis of data. A random effects model was created given the significant heterogeneity of the included studies and a funnel plot was made to assess the publication bias. Our primary objective was to study whether all-comers patients on PPIs are at an increased risk of stroke. Sub-group analysis was also done to investigate the association between patients on dual anti-platelet therapy [DAPT] (aspirin and clopidogrel) with or without PPIs and stroke.

RESULTS:
After searching 774 titles, 25 titles were selected to be included in the systematic review and 15 articles for the meta-analysis. Our pooled analysis of 155,406 patients (46,652 patients on PPI and 101,892 patients without PPI found a positive association between the use of PPI and stroke (odds ratio = 1.28, 95% confidence interval = 1.12, 1.48, P = 0.001) [Figure 1]. Given the significant heterogeneity of the studies (I2= 60%) a sub-group analysis was done which also suggested an increased risk of stroke associated with PPI use among patients on dual antiplatelet therapy (OR: 1.43, 95% CI: 1.26, 1.66, p< 0.001, I2= 11%) [Figure 2]. Analysis of the included randomized controlled trials revealed an OR: 1.47, 95% CI: 0.66, 3.25 but the results were not statistically significant (p< 0.81) [Figure 3].

CONCLUSION:
In a pooled analysis of over 155,000 patients we found a positive association between the use of PPIs and stroke. Our results are limited by significant heterogeneity and retrospective study design of the observational studies. Rigorous clinical trials are needed to establish the safety of PPIs in relation to stroke, especially among patients on DAPT. Until definitive data emerges, patients on DAPT are probably best served by being off PPIs or being on alternative acid suppression regimen, unless there is a compelling indication for PPI use.