bluuebunny/crossref_metadata_2025_split huggingface dataset:
A98 EFFECT OF A PROLONGED MULTIVITMAIN SHORTAGE ON HOME PARENTERAL NUTRITION PATIENTS: SINGLE CENTRE EXPERIENCE
Authors: Lam N C , Wang C , Schwenger K , Arca-Juico C , Chin K , Macgillivray A , Yuen C , Pang I , Allard J 
Published: February 2024

Abstract

Background
Multivitamin shortages in home parenteral nutrition (HPN) are scarce but have a significant impact on patient morbidity. Recently, Ontario, Canada experienced a HPN intravenous multivitamin shortage that lasted over 3 months. As per the American Society of Parenteral and Enteral Nutrition (ASPEN) guidelines, patients were instructed to use an over-the-counter multivitamin supplement during the shortage. However, due to the nature of HPN patients, the risk for malnutrition related complications remains high, specifically thiamine deficiency.

Aims
This study aims to assess the relationship between the multivitamin shortage and thiamine deficiency. We conducted an analysis before and after the intravenous multivitamin shortage in HPN patients and compared anthropometric, biochemical and clinical outcomes in those who followed the oral multivitamin recommendation versus those who did not.

Methods
This retrospective descriptive study included HPN patients in a single-centre program in Toronto, Canada who required HPN ≥ 5 days/week. These patients were followed throughout the multivitamin shortage which lasted from February - June 2023. Patients were categorized into two groups: those who consumed an oral multivitamin and those who did not. Clinical and biochemical data were collected pre and post-multivitamin shortage. Data was collected on compliance with taking oral multivitamins. The primary outcome was the presence of any adverse clinical outcome related to a micronutrient deficiency.

Results
Twenty-five HPN patients were included. 56% (n=14) of patients were compliant with oral multivitamin usage and met the ASPEN recommendations for supplementation. Compliant patients were significantly older and were on significantly longer duration of HPN. Two patients were diagnosed with WE and had brief hospitalizations. Both patients experienced complete resolution of their symptoms after treatment with high-dose thiamine. Hence, compliance with oral multivitamins did not correlate to developing WE. The median time from the shortage to the development of WE was 2 months. Though not statistically significant, those who developed WE were more likely to be female, utilized a venting gastrostomy tube, and utilized HPN for longer.

Conclusions
Complications related to micronutrient deficiency are rare in the HPN population but shortages in intravenous multivitamins can increase the risk of conditions such as WE. In our study, compliance with oral multivitamins did not guarantee protection from developing adverse outcomes, likely due to limitations in absorption due to altered gastrointestinal anatomy. A regimented protocol for screening should be implemented in HPN patients, especially during long shortages of key HPN components like multivitamins.

Funding Agencies
None
A101 TRENDS IN MEDICAID SPENDING FOR HEPATITIS C TREATMENT FROM 2012-2021
Authors: Malik G , Tsai C H , Congly S E 
Published: February 2024

Abstract

Background
Hepatitis C virus (HCV) infection is a pervasive disease that reduces quality and quantity of life. Medicaid is the largest health insurance program in the United States that provides coverage to individuals with low income including children, pregnant individuals, and people with disabilities. Due to the impact of HCV on individuals and the world goal for elimination of HCV by 2030, an analysis of healthcare costs attributed to hepatitis C medications is imperative to guide further policy and coverage changes.

Aims
To analyze Medicaid spending and utilization for hepatitis C treatment from 2012 to 2021 and provide a reflection on the impact it has on healthcare costs in the USA.

Methods
The Centers for Medicare & Medicaid Services public database was accessed to obtain Medicaid spending on Hepatitis C medications from 2012-2021. Data extracted included brand and generic drugs to treat HCV, total annual spending, total dosage units prescribed, total number of claims, and average spending per dosage unit and claim. Microsoft Excel was used for data analysis and creation of graphs.

Results
A total of 20 oral medications were included in this study. Total spending on all medications per year increased from $184 million in 2012 and peaked in 2016 at $3.3 billion. In 2021, the highest amount of Medicaid spending was on Mavyret ($658 million) followed by generic sofosbuvir-velpatasvir ($389 million) and Epclusa ($262 million). The total number of claims decreased from 135,542 in 2012 to 121,101 in 2021 with a peak in 2016 at 159,826. During the same time, the average spending per claim increased from 2012 ($6,518) to 2021 ($146,792). In 2021, the highest average spending per claim was seen with Harvoni ($30,941) followed by Sovaldi ($27,247), Vosevi ($23,877), and Epclusa ($22,917). In the same year, Mavyret had the greatest number of claims at 51,500 followed by generic sofosbuvir-velpatasvir (50,115), Epclusa (11,437), and Vosevi (2,177).

Conclusions
Despite the number of claims declining from 2012 to 2021, the average spending has increased due to the significant cost of HCV medications on Medicaid spending. The highest spending was noted to be with originator medications while generic formulations had the highest number of claims. Understanding the trends in spending on HCV medications can help guide insurance coverage changes for those depending on Medicaid. Lastly, shifting policies towards increased use of generic medications can help with increasing access and reducing costs to the population.

Figure 1. Total annual spending per year in billions ($ USD, blue bars) and total number of claims (orange line) per year from 2012 to 2021.

Funding Agencies
None
A102 EUS-GUIDED GASTROENTEROSTOMY IS COST-EFFECTIVE COMPARED TO SURGICAL GASTROJEJUNOSTOMY AND ENTERAL STENTING FOR PALLIATION OF MALIGNANT GASTRIC OUTLET OBSTRUCTION
Authors: Miller C , Rostamianmoghaddam Y , Khakban A , Barkun A , Chen Y 
Published: February 2024

Abstract

Background
Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is an emerging modality for the treatment of malignant gastric outlet obstruction (GOO), which combines the benefits of the traditional treatments by providing a robust bypass using a minimally invasive, endoscopic approach. The health economic aspects of this new treatment compared to the traditional treatment approaches are not known.

Aims
To conduct a cost-consequence analysis to compare the costs and benefits of using EUS-GE, surgical gastrojejunostomy (SGJ) and enteral stenting (ES) for the management of malignant GOO.

Methods
A decision analytical model, comprising a decision tree and a time-dependent state-transition model with three health states (no recurrent GOO, recurrent GOO, and death), was designed. The costs and benefits of the first month are included in the decision tree, after which, simulated patients enter the time-dependent state-transition model and the costs and consequences of each intervention are estimated for each monthly cycle until the end of a twelve-month time horizon. To address uncertainty around parameters, the expected values of costs and other outcomes were obtained through probabilistic analysis. The model parameters were assigned probability distributions and 10,000 Monte Carlo simulations were conducted using randomly sampled values drawn from these distributions. The outcomes were the estimated total cost and the probability of recurrent GOO in the follow-up time. We compared the incremental cost of avoiding recurrent GOO between these three strategies. A willingness-to-pay threshold of $50,000 to avoid recurrent GOO was established a priori.

Results
The total estimated costs for EUS-GE, SGJ, and ES, were $82,575 (SD, $16,240), $149,731 (SD, $27,254), and $77,324 (SD, $14,529), respectively. SGJ (6.84% [SD, 1.34]) had a lower GOO recurrence rate compared to EUS-GE (8.70% [SD, 1.64] and ES (23.37% [SD, 3.82]; however, when comparing SGJ with EUS-GE and ES, the incremental cost to avoid GOO recurrence was $ 3,611,345 and $37,854, respectively. The cost of avoiding GOO recurrence using EUS-GE compared to ES was $35,774.

Conclusions
EUS-GE has emerged as a cost-effective option in treating patients with malignant GOO. It is associated with a much lower cost per avoided recurrent GOO when compared to SGJ, and it is more effective in preventing recurrent GOO than ES at a cost that is well below the pre-set willingness-to-pay threshold of $50,000.

Cumulative rate of GOO recurrence for EUS-GE, SGJ and ES

Funding Agencies
None
A103 A COMPREHENSIVE REVIEW OF ENTEROLITH ILEUS SECONDARY TO COMPLICATIONS OF ILEAL DIVERTICULA AND INVESTIGATIONS INTO OPTIMAL MANAGEMENT
Authors: Miranda C J , Aijaz A , Carlson A M , Hossein-Javaheri N , Ali M H , Ismail M 
Published: February 2024

Abstract

Background
Acquired ileal diverticula are rarely found in adults and are only apparent in 1.9% of small bowel contrast studies. Even more rarely, these diverticula can lead to enterolith formation which can obstruct the bowel, a term coined “enterolith ileus”. Both surgical and non-surgical approaches have been espoused in tackling this complication but definitive literature on optimal management is lacking and is limited to scattered case reports and case series. With this phenomenon carrying significant morbidity and mortality, we have conducted a comprehensive review of all available case reports to summarize our understanding of enterolith ileus secondary to ileal diverticula.

Aims
To understand the varying clinical presentations of enterolith ileus from ileal diverticula complications and understanding optimal management for the pathology.

Methods
A comprehensive search of PubMed, OVID, CINAHL, and Cochrane databases up to February 2023 was conducted to identify all studies reporting clinical information on enterolith formation in ileal diverticula leading to small bowel obstruction. Relevant data were extracted from selected studies to determine clinical courses and optimal management.

Results
Our literature review identified 61 case reports of enterolith ileus secondary to complications of ileal diverticula. The mean age of the patients was 51.64 years (SD 20.9), with 27% of them being female. The most common symptoms reported were abdominal pain (87%), nausea, and vomiting (51%), followed by constipation (18%) and melena (5%). Notably, localized abdominal tenderness was a common finding, observed in 74% of cases across 29 out of 34 studies reporting physical examination findings. Diagnostic investigations, including abdominal X-rays and CT scans, consistently revealed dilated bowel loops and signs of bowel obstruction. Surgical intervention was eventually required for almost all patients (97%), with diverticulectomy performed in 47%, enterectomy in 12%, and surgical resection of the bowel in 32% of cases respectively. These surgical interventions demonstrated high success rates, effectively resolving the condition in most cases. Complications, such as wound infection (2 cases), postoperative ileus (3 cases), anastomotic leak, and wound dehiscence (1 case each) were observed in a limited number of patients.

Conclusions
Our findings highlight the critical importance of prompt diagnosis and management of enterolith ileus secondary to complications of ileal diverticula. We recommend avoidance of initial conservative management as surgical intervention has proven almost always necessary and is highly successful in tackling this pathology. Early recognition and intervention can help minimize the risk of morbidity and mortality associated with this condition.

Funding Agencies
None
A104 ATYPICAL PRESENTATION OF HSD3B7 DEFICIENCY
Authors: Morrissey M , Kawada P 
Published: February 2024

Abstract

Background
Bile acid synthesis disorders are the result of deficient activity of one of 17 enzymes required for conversion of cholesterol into bile acids. One such bile acid synthesis disorder is 3β-hydroxy-Δ5-C27-steroid oxidoreductase (HSD3B7) deficiency, an autosomal recessive inherited disorder caused by a defect in 3β-hydroxy-Δ5-C27-steroid dehydrogenase (C27 3β-HSD) enzyme. Ultimately, this bile acid synthesis disorder is due to a HSD3B7 gene mutation. With only 53 cases reported between 1993 and 2015, HSD3B7 deficiency is rare. Additionally, the existing literature is primarily in the form of case reports, with the majority of patients with HSD3B7 deficiency presenting in the neonatal period, often with cholestatic jaundice.

Aims
To showcase an atypical presentation of HSD3B7 deficiency, in an 11 year old male with recurrent epistaxis and a coagulopathy of vitamin K deficiency. Additionally, to complete a review of the literature available on HSD3B7 deficiency.

Methods
Case report, chart review, and literature review.

Results
11 year old male who initially presented to Pediatric Hematology with prolonged PTT and INR in the context of recurrent epistaxis and easy bruising. Upon further work up, the patient was found to have low levels of vitamin K dependent factors, as well as low vitamin levels of A, D, and E. Additionally, the patient had elevation of AST, ALT, GGT, ALP, and total bilirubin. Normalization of the INR and PTT were achieved with vitamin K supplementation. Genetic testing was sent to work up the abnormal liver enzymes and revealed HSD3B7 deficiency. Fast atom bombardment ionization was subsequently completed and confirmed the diagnosis.

Conclusions
There is limited clinical data available regarding HSD3B7 deficiency. The classic presentation of this bile acid synthesis disorder is in a neonate with cholestatic jaundice, hepatomegaly, fat-soluble vitamin deficiencies, and lipid malabsorption. Therefore, the initial presentation of an 11 year old with recurrent epistaxis and prolonged INR and PTT is thus an atypical presentation of HSD3B7 deficiency. This case report demonstrates that there is diversity in the age of presentation and accompanying signs and symptoms in HSD3B7 deficiency.

Funding Agencies
None
A105 PILOT STUDY ON THE ACCURACY OF CHATGPT IN ARTICLE SCREENING FOR SYSTEMATIC REVIEWS IN GASTROENTEROLOGY
Authors: Na C B , Sinanian G , Gimpaya N , Mokhtar A , Chopra D , Scaffidi M , Yeung E , Grover S 
Published: February 2024

Abstract

Background
Systematic reviews synthesize extant research to answer a research question in a way that minimizes bias. After articles for potential inclusion are identified by sensitive searches, screening requires human expert review, which may be time-consuming and subjective. Large language models such as ChatGPT may have potential for this application.

Aims
This pilot study aims to assess the accuracy of ChatGPT 3.5 in screening of articles for systematic reviews in gastroenterology by (1) identifying if articles were correctly included and (2) excluding articles reported by authors as difficult to assess.

Methods
We searched the Cochrane Library for gastroenterology systematic reviews (January 1, 2022 to May 31, 2023) and selected the 10 most cited studies. The test set used to determine the accuracy of Open AI’s ChatGPT 3.5 model for included studies was the final list of included studies for each Cochrane review. The test set used for studies challenging to assess was the “excluded studies” list as defined in the Cochrane Handbook. Figure 1 shows the prompt used for the screening query. Articles were omitted if they did not have digital sources, abstracts or methods. Each article was screened 10 times to account for variability within ChatGPT’s outputs. Articles with ≥5 inclusion results were counted as an included study.

Results
ChatGPT correctly identified included studies at rates ranging from 60% to 100%. ChatGPT correctly identified exlcuded studies at rates ranging from 0% to 50% (Table 1). A total of 265 articles were screened.

Conclusions
In this pilot study, we demonstrated that ChatGPT is accurate in identifying articles screened for inclusion in Cochrane reviews; however, it is inaccurate in excluding articles described by the authors as being difficult to assess. We hypothesize that the GPT 3.5 model can read for keywords and broad interventions but is unable to reason cognitively, as an expert would, as to why a study may be excluded. We aim to review reasons for exclusion in future work.
Table 1. Screening Results of ChatGPT

Figure 1. ChatGPT Screening Prompt

Funding Agencies
None
A112 THE EDMONTON PANCREATICOBILIARY INFLAMMATION AND CANCER (EPIC) PROGRAM – A NEW MULTIDISCIPLINARY COORDINATION OF CARE INITIATIVE
Authors: Sandha G S , Abdulhussain H , Krahn T , Timmermans M , Buchanan G , Bereznicki E , Mathura P , Kwan A , Perryman S , Veldhuyzen van Zanten S 
Published: February 2024

Abstract

Background
Pancreaticobiliary (PB) cancer is associated with a poor prognosis. A timely diagnosis and a coordinated, multidisciplinary effort may improve outcomes as patients navigate the healthcare system for investigations and treatment.

Aims
To establish and pilot a multidisciplinary (gastroenterology [GI], hepatopancreatic biliary [HPB] surgery, radiology, oncology, palliative medicine, and nutrition) collaborative care pathway (CCP) to coordinate timely referral and access to management for patients with PB cancer.

Methods
With multidisciplinary expert input, a CCP for PB cancer patients was developed. A donation to our hospital foundation facilitated the hiring of a nurse navigator (NN) to coordinate this process. The EPIC program was initiated as a 6-month pilot project on 01/07/23 for all consecutive patients referred to the University of Alberta Hospital with suspected PB cancer. Referrals were triaged by GI and HPB surgery into resectable, borderline resectable, or unresectable arms of the CCP. EUS biopsy and/or ERCP for stent were performed as needed. A referral to medical oncology was made after a diagnosis was established. Descriptive statistics were completed.

Results
At 3 months, 64 patients (39 M, 25 F), mean age 67±12 years (range 19-95 years), were referred to EPIC. Presenting symptoms were abdominal pain (73%), weight loss (40%), jaundice (27%), nausea/vomiting (21%), itching (8%), and new-onset diabetes (5%). Site of cancer was pancreas (77%, 49/64), bile duct (20%, 13/64), and ampulla (3%, 2/64). Timelines to care access were compared with a similar pre-CCP patient cohort as shown in Table.

Conclusions
The role of the NN is to reduce variability and coordinate timely referral, scheduling, and follow-up based on the care pathway, and to serve as a point of contact for ongoing patient issues. The EPIC program pilot is on track to meet the timelines set forth in the care pathway. Primary care outreach to increase awareness of symptoms and for prompt investigation may further improve access to care in these patients.
Note: negative numbers indicate days where the GI/HPB review occurred before the CT/MRI, or intervention before GI/HPB review

EPIC COLLABORATIVE CARE PATHWAY

Funding Agencies
None
A114 IMPROVING THE QUALITY OF PARACENTESIS PRACTICES IN PEOPLE WITH ADVANCED CIRRHOSIS IN AN AMBULATORY CARE SETTING
Authors: Sedarous M , Lee E , Verma A , Quinn K , Hirschfield G 
Published: February 2024

Abstract

Background
Spontaneous bacterial peritonitis (SBP) is a lethal complication of decompensated cirrhosis carrying a 90% mortality rate when left untreated. Despite AASLD recommendations, there is a practice gap regarding fluid cell count (FCC) collection during paracentesis.

Aims
We initiated prospective quality improvement (QI) project to improve FCC collection in an ambulatory care setting from a baseline of 78% to a goal of 100% compliance between September 11, 2022 and April 17, 2023.

Methods
We examined the effects of a quality improvement initiative in 233 adult patient encounters with cirrhosis undergoing paracentesis in an ambulatory setting located within a quaternary care centre in Toronto, Canada within the study timeframe. Using a multidisciplinary approach, the quality improvement initiatives included focused groups, education regarding AASLD guidelines, development of a paracentesis bundle, and streamlining workflow process. Descriptive statistics were collected. Statistical analysis using run charts and p-charts were conducted using QI Macros. Approval was obtained from the QI Review Committee at the institution where this QI initiative took place.

Results
Baseline adherence for collecting ascitic FCC per paracentesis procedure was 78%. Inconsistencies during process mapping such as variations in documentation, printing FCC labels and consistency in FCC collection were identified as root causes. Thus, bedside paracentesis bundles were introduced to standardize process and improve workflow. Post-intervention, the FCC rate increased marginally to 79.6% with no special cause variation identified (Figure 1). Subgroup analysis demonstrated FCC collection rates of 100% amongst registered nurse (RN) and nurse practitioners (NP), 97% amongst resident physicians, and 92% amongst attending physicians. Subsequently, another subgroup analysis was completed demonstrating 97% FCC collection rate amongst general hepatology group, while 40% FCC rate amongst specialty hepatology group. Overall rate of SBP was 1.62% (N=3).

Conclusions
This prospective QI study revealed a gap in guidance pertaining to the role of ascitic fluid cell count collection in patients with cirrhosis undergoing paracentesis in ambulatory settings. Further studies ascertaining rationale for not sending FCC may be helpful in elucidating why there is a gap in clinical practice. Additionally conducting studies in ambulatory settings to assess FCC collection's impact on morbidity and mortality will provide vital evidence and clarity for the role of FCC in this vulnerable patient group.

Figure 1: P-chart demonstrating percentage FCC Collection per week from September 11, 2022 to April 17, 2023. UCL indicates upper control limit; CL, center line; LCL, lower Control Limit.

Funding Agencies
Toronto Centre for Liver Disease funded the MSc QI program for Mary Sedarous (writer) who completed this study as her MSc QI project.