bluuebunny/crossref_metadata_2025_split huggingface dataset:
140 Traditional Serrated Adenomas (TSA) and the Company They Keep: TSA Presence Predicts Synchronous Advanced Lesions
Authors: Duh Erica , Sowa Piotr , Roberts Mary B. , Karnes William 
Published: October 2019

INTRODUCTION:
The serrated group of colorectal polyps include hyperplastic polyps (HPs), sessile serrated polyps (SSPs), and traditional serrated adenomas (TSAs). HPs are generally non-precancerous whereas SSPs and TSAs are considered precancerous. TSAs are associated with high risk of subsequent (metachronous) advanced neoplasms, suggesting that TSAs reflect a predisposition for neoplastic progression. If true, the presence of one or more TSAs should be associated with synchronous advanced neoplasms.

METHODS:
Data was extracted from UCICQD—a prospectively collected database (2012–2019) inclusive of locations, sizes and pathology of all polyps and masses. A “neoplasm” was defined as carcinoma, adenoma, SSP, or TSAs regardless of size. Cases with advanced neoplasm were defined if any neoplasm was malignant, ≥1 cm, contained villous features or high grade dysplasia, or if ≥3 neoplasms of any size were found. TSAs cases were compared to cases of other lesions for rates and odds ratios of synchronous neoplasms and advanced neoplasms.

RESULTS:
A total of 6023 procedures with at least one HP, adenoma, SSP or TSA were included, of which 70 had one or more TSAs (TSA cases). No significant differences in age, body mass index, or gender were seen between TSA and non-TSA cases. TSA cases had a mean of 2.44 neoplasms compared to 1.72 in non-TSA cases (IIR = 1.42 [CI 1.05–1.92] P = 0.022) and were associated with increased numbers of SSPs (IIR = 1.83 [CI 1.04–3.22] P = 0.038) (Table 1). The fraction of cases with synchronous advanced neoplasia was significantly higher in TSA cases (0.786 ± 0.115) compared to cases with one or more adenomas (0.487 ± 0.016), HPs (0.327 ± 0.019) or SSPs (0.592 ± 0.034), P = 0.0002. Relative to cases with one or more HPs, odds ratios for advanced neoplasia were 1.95 (1.75–2.17), 2.98 (2.54–3.5) and 7.54 (4.23–13.44) for cases with adenoma, SSP and TSA, respectively (Table 2).

CONCLUSION:
Prior studies have shown that one or more index TSA(s) predict later risk for metachronous advanced neoplasms, more so than an index colorectal carcinoma. We show that the presence of one or more TSAs is also associated with higher risk for synchronous neoplasms and advanced neoplasms, especially SSPs. This suggests that TSA presence may reflect an unknown genetic predisposition and/or intestinal field defect that promotes tumor initiation and malignant progression. Regardless of underlying mechanisms, our data support an aggressive surveillance strategy for patients with one or more TSAs.
149 Gastrointestinal Pathogen Distribution for Patients With Immunosuppressive States and Acute Diarrheal Illness
Authors: Ziv Yonatan , Ho Tai Hang , Szymczak Wendy A. , Gendlina Inessa , Kwah Joann 
Published: October 2019

INTRODUCTION:
Up until recently, identification of gastrointestinal (GI) pathogens in patients with an acute diarrheal illness (ADI) was limited. The introduction of a new GI pathogen PCR panel now offers a quick, reliable way to identify specific GI pathogens. It has been established that patients with immunosuppressive states are more susceptible to opportunistic GI pathogens, but the prevalence of these pathogens remains unknown. This study aims to compare the pathogen distribution in ADI in patients with immunosuppressive states versus patients without immunosuppressive states.

METHODS:
A database of patients was identified who presented to Montefiore Medical Center with an ADI and a positive GI pathogen PCR panel from April 2018 to November, 2018. Data collected included patient demographics, toxic habits, and previous antibiotic and steroid use within 6 months prior to the ADI. Immunosuppressed patients were identified as having either HIV/AIDS, organ transplant, active hematologic malignancy, primary immunodeficiency disease or current use of immunosuppressive medications. If C. difficile was identified, the patient was included if a confirmatory C. difficile test was positive. The primary outcome was the pathogen identified on GI pathogen PCR panel.

RESULTS:
Of 551 patients identified for this study, 130 patients (23.6% of the cohort) were immunosuppressed. A total of 88 patients had a positive GI pathogen PCR panel for C. difficile and 472 patients had a positive GI pathogen PCR panel for organisms other than C. difficile. The most common pathogen in both the non-immunosuppressed and the immunosuppressed patients was Enteropathogenic E. coli (EPEC) (184 cases, 35.3% and 26.9%). The most common viral pathogen was Norovirus (47 cases, 6.6% and 14.6%), and the most common parasitic pathogen was Giardia lamblia (21 cases, 2.4% and 8.5%). Immunosuppressed patients were more likely to be positive for Norovirus (14.6% vs. 6.6%, P = 0.008), Cryptosporidium (5.4% vs. 0.7%, P = 0.002), Giardia (8.5% vs. 2.4%, P = 0.004), Enteroinvasive E. coli (EIEC) (13.1% vs. 4.5%, P = 0.001) and C. difficile (23.1% vs. 13.7%, P = 0.011). No other differences in pathogen distribution were identified between the two groups.

CONCLUSION:
Patients presenting with ADI with immunosuppressive states were more likely to have Norovirus, Giardia, Cryptosporidium, EIEC or C. difficile identified on GI pathogen PCR panel. Further studies are needed to better define these findings and their clinical implications.
152 Fair Colonoscopy Bowel Preparation Is Not Adequate for Effective Colonoscopy
Authors: Alomari Mohammad , Al Momani Laith , Sarmini Muhammad Talal , Khazaaleh Shrouq , Nehme Fredy , Wadhwa Vaibhav , Thota Prashanthi N. , Sanaka Madhusudhan R. 
Published: October 2019

INTRODUCTION:
Adenoma detection rate (ADR) is an established colonoscopy quality metric with higher rates associated with reduced interval colorectal cancer. Adequate colon visualization and hence sufficient bowel preparation are crucial for effective colonoscopy. Due to inconsistency in the adequate bowel preparation definition using the Aronchick scale, we aimed in this study to investigate the impact of bowel preparation on overall and segment-specific ADR and polypectomy rates (PR).

METHODS:
A retrospective review of all screening colonoscopies in patients ≥50 years of age performed at our institution between 2012 and 2014 was done. Average risk patients who had a complete colonoscopy with excellent, good and fair bowel preparation as per the Aronchick scale were included. Overall, gender-specific and colon segment-specific ADR and PR were calculated and compared using t-tests. All analyses were done using SAS (version 9.4, The SAS Institute, Cary, NC) and a P-value < 0.05 was considered statistically significant.

RESULTS:
A total of 4151 patients were included in the analysis. Average patient age was 60.0 ± 7.7 years and 53.2% were females. A total of 652 (15.7%) had excellent preparation, 2675 (64.4%) had good preparation and 824 (19.9%) had fair preparation (Table 1). Overall ADR was significantly lower in patients with fair preparation (21.1 ± 27.0) than in those with good preparation (27.6 ± 12.8; P  <  0.012). Overall PR, proximal PR, and distal PR were significantly lower in patients with fair bowel preparation (38.0 ± 34.1, 25.0 ± 29.9 and 25.0 ± 29.9, respectively) compared to those with good bowel preparation (45.9 ± 19.8; P  = 0.048; 28.1 ± 16.4; P  = 0.042; 29.4 ± 14.3; P  = 0.044, respectively) (Table 2).

CONCLUSION:
The Aronchick Scale is one of the most commonly used validated bowel preparation quality scales in clinical practice. However, to date, there is no uniform definition of the adequate bowel preparation as some use a composite of “excellent,” “good” and “fair” preparation while others define it as a composite of “good” and “excellent” preparation. In our study, patients with fair standards of preparation had significantly lower overall and segment-specific ADR and PR than those with good bowel preparation. Moreover, in patients with fair colonoscopy preparation, endoscopists didn't reach their recommended overall and gender-specific ADR benchmarks. Thus, an earlier surveillance colonoscopy may be considered in those patients.
158 No Cure, No Comfort: An Urban Center Experience With Palliative Care for Hospitalized Colon Cancer Patients, 2010–2017
Authors: Jamorabo Daniel S. , Renelus Benjamin D. , Kancharla Pragnan , Briggs William M. 
Published: October 2019

INTRODUCTION:
Palliative care is integral to cancer treatment. Our goal was to investigate the frequency of palliative care service contact for colon cancer patients and factors associated with their involvement.

METHODS:
We carried out a retrospective analysis of all colon cancer patients diagnosed at our university-affiliated hospital between 1/1/2010 and 12/31/2017. We used Fisher's exact test to find statistically significant differences in proportions of patients seen by the palliative care service based on sex, race, insurance type, cancer stage, surgical intervention, and chemotherapy administration, hospitalization history, and vital status. Bayesian univariate logistic regression models were fit to each variable to give the probability of palliative care use for each.

RESULTS:
We identified 655 patients diagnosed with colon cancer at our institution, including 361 (55%) women, 280 (43%) with Stage III or IV disease, and 156 (25%) dead at time of last contact. Most were diagnosed as inpatients (385/655; 59%) and hospitalized for any cause (612/655; 93%). Those diagnosed as inpatients had poorer survival for the first 6 years after diagnosis compared to their counterparts (Figure 1). Only 105/612 (17%) admitted for any cause were evaluated by the palliative care team—regardless of sex, race, insurance type, or cancer stage—while 484/612 (79%) underwent surgical intervention and 151/612 (25%) received chemotherapy. Most patients with Stage III and IV disease were more likely to undergo surgery (214/285; 75%) than not, yet were less likely to receive chemotherapy (150/285; 53%) and palliative care team contact (214/285; 75%). Results are summarized in Tables 1 and 2.

CONCLUSION:
The lack of contact with palliative care teams is concerning given both the poorer survival among those diagnosed as inpatients as well as the rate of all-cause admissions. Additionally, the preponderance of surgical interventions without chemotherapy or palliative care in Stage III to IV disease is inconsistent since aggressive treatments typically involve the former while conservative plans should include the latter. The underutilization of palliative care teams may be rooted in lack of staffing, misconceptions that providers and patients have about palliative care, or lack of coordination among specialists. Providers must be mindful of the utility of palliative care specialists and aim to include them earlier in the care of patients at all stages of disease.
161 Optimizing Clinical Assessment and Diagnostic Evaluation in Patients With Chronic Constipation Based on Systematic Analysis of 97 Articles in the Literature
Authors: Brandler Justin , Camilleri Michael 
Published: October 2019

INTRODUCTION:
There is still controversy surrounding the use of symptoms, history, and tests for diagnosis of rectal evacuation disorders (RED) and slow transit constipation (STC). We performed a comprehensive literature-based analysis to ascertain pooled prevalence, sensitivity (SN), specificity (SP), and likelihood ratios (LR) for clinical parameters to determine pre- and post-test probabilities of diagnosing RED and STC without RED.

METHODS:
Using MEDLINE and PUBMED, we examined systematic and clinical reviews, meta-analyses, primers, guidelines, and consensus statements since 1999 to determine the diagnostic utility of history, symptoms, and testing for RED and STC. Studies were included if binary data were available to assess true/false positives or negatives to pool and calculate SN/SP/LR. Given there are no “gold standard” diagnostic criteria for RED or STC, designation of “true” RED or STC was based on confirmation by at least one objective anorectal or colonic transit test. Controls varied across studies; all had normal anorectal and/or transit tests by the specific protocol used in each study. We assessed STC alone (associated with normal anorectal testing).

RESULTS:
We reviewed 97 articles involving studies from many different countries, and 63 articles for RED and 61 articles for STC met inclusion/exclusion criteria. The prevalence of disease phenotypes among 4160 patients with chronic constipation based on objective testing was RED alone 23.3%, normal transit constipation (NTC) alone 31.9%, STC alone 16.2%, and RED + STC 14.3%. To diagnose RED (Figure 1, Table 1), the most clinically significant symptoms included hard/lumpy stools (+LR 269.6, n = 1583) and urinary symptoms (100% specificity, n = 58). The strongest digital rectal exam (DRE) findings were poor anal relaxation (+LR 5.3, n = 529) or increased anal squeeze (+LR 8.4, n = 395). The most predictive anorectal tests were balloon expulsion time >120 s (+LR 5.5, n = 551) and rectoanal pressure gradient < −40 mmHg with high anal pressure on straining on anorectal manometry (100% specificity, n = 101). For STC alone, the most predictive symptom was a call to stool (+LR 10.5, n = 75). Patients without abdominal distension/fullness/bloating were less likely to have RED (−LR 0.2, n = 324) or STC alone (−LR 0.2, n = 93).

CONCLUSION:
Symptom assessments and DREs are critical in the evaluation for RED and STC. RED is highly prevalent in patients presenting with chronic idiopathic constipation.
163 High Incidence of Early Onset Colon Cancer in Ethiopia: Clinical and Therapeutic Evaluation With Genetic Mutational Analyses
Authors: Mohammed Abdulsemed , Sultan Amir , Braimoh Grace , Debes Jose D. 
Published: October 2019

INTRODUCTION:
Colon cancer has been reported to occur early in certain African regions, but the understanding of genetic modifications leading to early disease is incomplete. We aimed to study cases of early colon cancer and genetic modifications leading to these tumors in Ethiopia.

METHODS:
We evaluated all colon masses detected between 2015 and 2018 at Black Lion Hospital, Addis Ababa. Clinical, endoscopic and pathology descriptions were assessed for all cases in 30-year-olds or younger. Subsets of pathology block-tissues were evaluated for genetic modifications via Multiplex Ligation-dependent Probe Amplification.

RESULTS:
A total of 38 cases of colon cancer ages 30 or earlier were identified. These represented 13% of all cases of colon cancer in the 3-year period. The median age was 27 years (IQR 27–30), and 50% of individuals were female. None of the cases reported a family history of colon cancer or had evidence of inflammatory bowel disease (IBD). The most common presenting symptom was rectal bleeding (57%) followed by a change in bowel habit (22%). All but one sample were identified as adenocarcinoma, 78% were confined to the rectum, and 65% had distant metastasis or locally advanced disease at the time of diagnosis. Longer duration of symptoms correlated with the presence of metastasis on diagnosis (P = 0.035). Surgery (23%) and chemotherapy (15%) were the most frequently used treatments. We performed genetic analysis of biopsy tissue in a subset of 3 individuals: a) 21 y/o-male showed decrease copies of APC, increase in K-ras, v600f mutation in BRAF and decrease in MSH2 and MLH1; b) 21 y/o-female showed duplication of exon 4 APC, decrease in K-ras and decreased copies of MSH-2; c) 30 y/o-female showed decreased copies of APC, decreased copies of K-ras and BRAF and decreased copies of MSH2 and MLH1.

CONCLUSION:
We report a high incidence of early colon cancer in Ethiopia with no family history or IBD. Most patients presented with rectal bleeding. Genetic analyses in a subset of patients showed APC and K-ras alterations as well as modifications of mismatch repair pathways.
166 Is Prophylactic Clipping Necessary After the Resection of Large (≥1 cm) Colorectal Lesions? If So, at What Cost?
Authors: Mohan Babu P. , Asokkumar Ravishankar , Yu Jessica X. , Kaltenbach Tonya , Soetikno Roy 
Published: October 2019

INTRODUCTION:
Published data on the risk of delayed bleeding (DB) after endoscopic resection of large colorectal lesions (≥1 cm) are conflicting. Prior systematic analyses were underpowered. We systematically reviewed the current data, focusing on randomized studies, to compare the risk of DB with and without clipping, and to determine its cost-effectiveness. We hypothesized that prophylactic clipping is the preferred strategy.

METHODS:
We conducted a systematic search in PubMed and the Cochrane library to identify RCTs that compared the DB outcomes of prophylactic clipping vs. no clipping after resection of large polyps. We estimated pooled odds ratios (ORs with 95% CIs). Using the 2016 CMS reimbursement rates for procedure and hospitalization and price of clips estimated from the VHA system, we created a decision tree to model the cost: the initial procedure was estimated to be the cost of a colonoscopy with EMR and three clip placement or no clip. We assumed that some patients who had DB required repeat colonoscopy. Our primary outcome is the total cost. We sought to determine the cost of clips that would make the strategies equal.

RESULTS:
Six studies, which included 2002 patients with 3736 polyps in the clipping arm and 1996 patients with 3717 polyps in the no clipping arm met eligibility criteria for the meta-analysis. Prophylactic clipping of large polyps had a reduced risk of DB compared to those without clipping: OR 0.60 (95% CI: 0.38–0.92) with the random effects and OR 0.59 (95% CI: 0.39–0.89) with the fixed effects models. There was no significant heterogeneity (I2 = 7%, P = 0.37). The pooled risks of bleeding with clipping was 2.3% (95% CI: 0.8–6.1%) and 3.6% (95% CI: 1.2–10.3%) without clipping. In the meta-regression analysis, there was no significant difference based on antithrombotic use (P = 0.57) or lesion size (P = 0.79). Using a base case of 3 clips placed in the clipping arm (cost = $522), we found that the strategy of prophylactic clipping cost $1517.91 compared to $1179.69 for no clipping. The prophylactic clipping strategy cost $11,274 for each rebleed prevented. The two strategies however became equivalent in cost if the total cost of clipping is lower than $183.

CONCLUSION:
Our analysis suggests that prophylactically clip placement after resection of large (≥1 cm) polyp reduces the risk of DB. Such a strategy is cost-effective if the cost of the clip(s) used is less than $183.
173 Retrospective Study Correlating Bowel Wall Thickening to Colonoscopy Findings
Authors: Alsheikh Mira , Daneshvar Danial , Gurala Dhineshreddy , Ngu Sam , El Douaihy Youssef , Mulrooney Stephen 
Published: October 2019

INTRODUCTION:
Colonic bowel wall thickening (BWT) on computed tomography (CT) scan is a common but nonspecific finding. It can correspond to an early pathological change, a mere artifact or may be due to inadequate distention of the colorectum (CR). The pattern of BWT can be indicative of malignant, inflammatory, or infectious process. However, the clinical relevance of colorectal thickening on CT is unclear, and if an endoscopic examination is warranted is yet to be determined. The main objective of this study is to assess the sensitivity (Sn) and specificity (Sp) of BWT on CT scan in identifying colorectal cancer (CRC) and to provide evidence to inform a cost-effective and clinically relevant diagnostic strategy.

METHODS:
This was a retrospective cohort chart review of 300 consecutive patients who had BWT described on CT scan of the abdomen (with or without oral contrast) AND who subsequently underwent a colonoscopy. The primary outcome was the Sp of BWT on CT in diagnosing CRC. Ratios of distributions were used to describe the cohort at baseline. The distribution of BWT was also calculated to describe the location of BWT in the different sections of the CR: Ascending (including the cecum), transverse, descending, sigmoid and rectum. The area under the curve (ROC) analysis was conducted to assess for the Sn and Sp of CT's bowel wall thickening in predicting colorectal masses. This was extrapolated to predict any pathology, including colitis, polyps, and diverticulosis.

RESULTS:
The mean age at diagnosis was 61.6. Only 3 patients (1.7%) reported a positive family history (hx) of CRC. 7 (4.1%) reported a prior hx of partial bowel resection and 11 patients (6.4%) reported a hx of IBD. The distribution of the BWT was as follows: Ascending colon 29.1%, Transverse colon 34.3%, descending colon 45.9%, sigmoid colon 61.0%, and rectum 18%. The CT ROC value in predicting a mass seen on endoscopy ranged between 0.491 and 0.524 in all 5 studied sections of the colon. This study suggests that the CT carries a very low accuracy as a diagnostic test for colorectal masses.

CONCLUSION:
In conclusion, this study demonstrates that despite common practice, the CT finding of bowel wall thickening remains a poor indicator of colorectal masses. Nonetheless, Gastroenterologists feel obliged to pursue endoscopic visualization of all CT scans with the finding of BWT for a variety of reasons, including defensive medical practices. Further studies might clarify which subgroups warrant further investigation.
176 Increased Mortality in Patients With Acute Diverticulitis and History of Inflammatory Bowel Disease
Authors: Castaneda Daniel , Hasan Badar , Melendez-Rosado Jose , Charles Roger 
Published: October 2019

INTRODUCTION:
Patients with acute diverticulitis have a benign disease course when antibiotic treatment is provided. Risk factors for poor outcome include extensive disease, age and nutritional status. Notably, underlying background inflammation can predispose to severe disease, such as in patients with inflammatory bowel disease (IBD). The aim of this study is to compare the inpatient outcomes for patients with acute diverticulitis with and without IBD.

METHODS:
This was a retrospective cohort study using the 2014 National Inpatient Sample, the largest publicly available inpatient database in the United States. Inclusion criteria were age older than 18 years and a primary ICD-9 CM code for any diagnosis of acute diverticulitis. There were no exclusion criteria. The primary outcome was in-hospital mortality. The secondary outcomes were morbidity measured by intensive care unit (ICU) admission, shock, multi-organ dysfunction syndrome (MODS), malnutrition and need for partial/total colectomy, and resource utilization measured by length of hospital stay (LOS), total hospitalization charges, need for ultrasound (US), and CT abdomen. Patients with acute diverticulitis were classified as having or not IBD diagnosis using ICD-9 CM codes. Odds ratios and means were adjusted for the following confounders using multivariate regression analysis models: age, sex, race, median income in the patient's zip code, hospital region, rural location, size and hospital teaching status.

RESULTS:
218,720 patients with acute diverticulitis were included in the study, from which 1,835 (0.84%) had a diagnosis of IBD. Mean age was 60.4 years and 58% of patients were female. The population was predominantly Caucasian (76.9%). The in-hospital mortality was higher among IBD patients (1.4 vs 0.4%), with an overall mortality of 0.41%. On multivariate analysis, patients with IBD had higher in-hospital mortality risk compared to patients without IBD (OR 2.77, 95% P = 0.05). When evaluating morbidity and resource utilization, only the length of stay was longer in patients with IBD 0.64 days (P = 0.024). All adjusted odds ratios, adjusted means and p values are shown in Table 1.

CONCLUSION:
Patients with a history of inflammatory bowel disease tended to have increased mortality after an episode of acute diverticulitis. However, no differences on morbidity and inpatient resource usage was seen in comparison to the general population.