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Background We aim to investigate factors that may contribute to failure of eradication of dysplastic Barrett’s Esophagus among patients undergoing radiofrequency ablation treatment. Methods A retrospective review of patients undergoing radiofrequency ablation for treatment of Barrett’s Esophagus was performed. Data analyzed included patient demographics, medical history, length of Barrett’s Esophagus, number of radiofrequency ablation sessions, and histopathology. Subsets of patients achieving complete eradication were compared with those not achieving complete eradication. Results A total of 107 patients underwent radiofrequency ablation for Barrett’s Esophagus, the majority white, overweight, and male. Before treatment, 63 patients had low-grade dysplasia, and 44 patients had high-grade dysplasia or carcinoma. Complete eradication was achieved in a majority of patients (57% for metaplasia, and 76.6% for dysplasia). Failure of eradication occurred in 15.7% of patients. The median number of radiofrequency ablation treatments in patients achieving complete eradication was 3 sessions, compared to 4 sessions for failure of eradication ( p  = 0.06). Barrett’s esophagus length of more than 5 cm was predictive of failure of eradication ( p  < 0.001). Conclusions Radiofrequency ablation for dysplastic Barrett’s Esophagus is a proven and effective treatment modality, associated with a high rate of complete eradication. Our rates of eradication from a center starting an ablation program are comparable to previously published studies. Length of Barrett’s segment > 5 cm was found to be predictive of failure of eradication in patients undergoing radiofrequency ablation.

Racial disparities are observed clinically in Crohn’s Disease (CD) with research suggesting African Americans (AA) have worse outcomes than Caucasian Americans (CA). The aim of this study is to assess whether socioeconomic status (SES) rather than race is the major predictor of worse outcomes. We designed a retrospective cohort study of 944 CD patients seen at our center. Patients’ billing zip codes were collected and average income and percent of population living above or below poverty level (PL) for each zip code calculated. Patients were separated by quartiles using average state income level and federal PL. Demographics and hospitalization rates were collected. Poison regression models estimated incidence rate ratios (IRR) for CD-related hospitalizations. Incidence rate (IR) of hospitalization per 100-person years for the lowest income group was 118 (CI 91.4–152.3), highest income group was 29 (CI 21.7–38.9), Above PL was 26.9 (25.9–28.9), Below PL was 35.9 (33.1–38.9), CA was 25.3 (23.7–27), and AA was 51.4 (46.8–56.3). IRR for a CD-related hospitalization for lowest income group was 2.01 (CI 1.34–3.01), for Below PL was 1.26 (CI 1.12–1.42), and for AAs was 1.88 (CI 1.66–2.12). SES and race are both associated with hospitalization among CD patients and need further investigation.

Introduction: Population based data is limited on the prevalence and mortality from gastrointestinal bleeding (GIB) among patients with solid organ transplantation (SOT). Methods: Nationwide Inpatient Sample (2007- 2013) was queried for transplants using ICD-09 for renal transplant (RT), lung transplant (LNGT), small bowel transplant (SBT), heart transplant (HT), and liver transplant (LT). Outcomes were GI bleeding and in-hospital mortality among admissions with SOT. Results: Nationwide Inpatient Sample (2007- 2013) was queried for transplants using ICD-09 for renal transplant (RT), lung transplant (LNGT), small bowel transplant (SBT), heart transplant (HT), and liver transplant (LT). Outcomes were GI bleeding and in-hospital mortality among admissions with SOT. Results: Of 330,875 admissions (mean age 52 ±16.8, 57% male, 53% Caucasian, 97% insured, 27% teaching hospitals) with any SOT, 6,130 (1.9%) were discharged with any diagnosis of GIB. Proportions of admissions with GIB varied from 1.2% in 19,331 admissions with LNGT, 1.7% in 26,726 HT, 1.8% in 208,382 RT, 2.1% in 58,909 LT, and 4.4% in 1,693 SBT. There was a linear increase in frequency of GIB with age, 1% in <18 years to 2.8% in >80 years. Other associations with GIB were coagulopathy (3.5%), heart failure (2.8%), liver disease (2.5%), cancer (2.5%), non-teaching (2.4%) and rural (2.4%) hospitals. The frequency of GIB remained similar over time during the study period. In-hospital mortality was higher among patients with GIB compared to admissions with SOT and no GIB (7.8 vs. 2.3%, P<0.005). Conclusion: About 2% of hospital admissions in the US with any SOT have GI bleeding. Older patients with more comorbidities admitted to rural and non-teaching hospitals are associated with GI bleeding in SOT recipients. GI bleeding among admissions of recipients of SOT increases in-hospital mortality by over threefold. Studies are needed to examine predictors and mechanisms of GI bleeding among SOT recipients as basis for developing strategies to improve in-hospital outcomes of GI bleeding among recipients of solid organ transplantation.

Abstract Background Vedolizumab (VDZ) and infliximab (IFX) are both approved as first line induction agents in moderately to severely active UC. However, there are no head-to-head studies comparing the relative effectiveness of the two. Here we provide a real-world comparison of these two agents. Methods We conducted an ambidirectional cohort study of adult UC patients seen at our tertiary IBD center from 2012 to 2017. Each patient had moderately to severely active UC via clinical Mayo score, was induced with VDZ or IFX, and was followed until assessment of clinical response. Poisson Regression was used to calculate clinical response rates and rate ratios. Results Of 59 patients who met inclusion criteria, 27 and 32 were induced with IFX and VDZ respectively. 18/27 (66.7%) patients induced with IFX vs. 24/32 (78.1%) patients induced with VDZ were clinical responders. Effect size calculation revealed no potential confounders. Response rates per 100 person-weeks (PW) were similar for VDZ (5.21) and IFX (5.38). The effectiveness in terms of induction of clinical response (incident rate ratio, IRR) was not significantly different for VDZ vs. IFX (IRR 0.97, 95% CI 0.53-1.77). Among TNF naïve patients, IRR was also not statistically significant between VDZ (6.74/100 PW) and IFX (6.48/100 PW) (IRR 1.04, 95% CI 0.47-2.29). Among TNF experienced patients there was a higher response rate for VDZ (4.52) vs. IFX (2.29) per 100 PW, but the IRR did not reveal statistical significance (IRR 1.97, 95% CI 0.45-8.63). Conclusion Our study revealed a higher proportion of patients who responded to VDZ vs. IFX however clinical response rates were similar. A key difference between the two groups was the much higher response rate in the VDZ group among TNF-experienced patients - a larger cohort is needed to further elaborate on this difference. VDZ held its own against IFX and this study strengthens its standing as a potential first line agent among TNF naïve and experienced UC patients.

Endoscopic retrograde cholangiopancreatography (ERCP) is often the procedure of choice for drainage of biliary obstruction; however, this technique may not be feasible in all patients. Percutaneous transhepatic biliary drainage (PTBD) and surgery are other options but are associated with high morbidity and post procedural complications. Endoscopic ultrasound (EUS), initially a diagnostic procedure, has evolved into a therapeutic option in patients with failed ERCP. This video focuses on how EUS guided biliary drainage (EUS-BD) can act as a new technique for relieving biliary obstruction in patients with failed ERCP.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is often the procedure of choice for drainage of biliary obstruction; however, this technique may not be feasible in all patients. Percutaneous transhepatic biliary drainage (PTBD) is another option but is associated with high morbidity and post procedural complications. Endoscopic ultrasound (EUS), initially a diagnostic procedure, has evolved into a therapeutic option in patients with failed ERCP. EUS can be performed immediately after attempted ERCP, thereby providing a potentially immediate solution. This project focuses on the implementation of EUS guided biliary drainage (EUS-BD) as a new technique for relieving biliary obstruction in patients with failed ERCP in a tertiary care center. Methods: Prospective analysis of patients with biliary obstruction and failed ERCP requiring EUS-BD was conducted between November 2017 to June 2018. Indication for intervention and reason for failed ERCP were noted. Patients clinical improvement, laboratory data, and procedural complications were documented 1 month after the procedure. Results: 17 patients (M/F, 8/9; median age 67) underwent EUS- BD. 15 patients required drainage secondary to a malignancy while 2 were for choledocolithiasis and cholecystitis. ERCP failure was due to malignant obstruction in 5 patients (29%), inability to cannulate the papilla in 5 patients (29%), duodenal stenosis in 4 (24%), stricture in 1 patient (6%), instability for ERCP in 1 patient (6%), and obstructed duodenum 1 patient (6%). The procedure was technically successful in 13 patients with the remaining 4 requiring PTBD. In patients with successful EUS-BD, there were no complications. Clinical success, in the form of reduced total bilirubin or improvement of obstructive symptoms, was noted in 100% of these patients. Conclusion: Our study showed that EUS-BD is a technique that offers high clinical and technical success rates and low complication rates. The learning curve is short when performed in the hands of an experienced endoscopist. Furthermore, EUS-BD provides immediate solution for failed ERCP rather than investigating other therapeutic options. Further studies are required to establish outcomes in patients with EUS-BD and comparison of this technique to potential alternative solutions such as PTBD or surgery. Limitations of this case series are the number of cases specific to distal biliary obstruction caused by malignancy.