ABSTRACT
Background: Gastrointestinal bleeding is one of the consequences of COVID-19, which is associated with increased hospitalization and patient mortality. This study was conducted to determine the prevalence of endoscopic findings and the outcome of gastrointestinal bleeding in patients with COVID-19 who were hospitalized from September to December 2019 in Al-Zahra Hospital, Isfahan. Method(s): In this cross-sectional study, out of 5800 patients who were admitted to Al-Zahra Hospital in Isfahan from September to December 2019 due to COVID-19 (according to the positive PCR test result), 87 patients who underwent endoscopy due to upper gastrointestinal bleeding by a skilled gastroenterologist, were selected and studied. Demographic characteristics, underlying diseases, use of anticoagulants, and laboratory findings were studied and evaluated and finally, the disease was evaluated and compared based on endoscopic findings. Result(s): Based on the results obtained from this research, the patients with endoscopic lesions had higher average age (P=0.041), lower blood oxygen saturation percentage (P=0.028), and higher bleeding intensity (P=0.018). The frequency of using anticoagulant drugs in the group whose endoscopy results were abnormal was higher but insignificant. Hemoglobin, platelet, lymphocyte, and CRP levels were higher in the group whose endoscopy was normal, and NLR, LDH, and D-dimer levels were higher in the group whose endoscopy was abnormal (P<0.050). Three people (11.55%) from the group with normal endoscopy and 18 people (29.5%) from the group with abnormal endoscopy died, but the frequency of death was not significantly different between the two groups (P=0.070). Conclusion(s): The findings of the present study showed that the COVID patients with upper gastrointestinal bleeding who had endoscopic lesions had significant differences in some characteristics such as age, bleeding intensity, and blood oxygen saturation percentage with patients with normal endoscopy. Also, the frequency of death in patients with endoscopic lesions was relatively higher. Therefore, COVID patients with gastrointestinal bleeding should undergo endoscopy as soon as possible and necessary measures should be taken to control and prevent gastrointestinal bleeding.Copyright © 2022 Tabesh et al. Tehran University of Medical Sciences. Published by Tehran University of Medical Sciences.
ABSTRACT
COVID-19 is mainly a respiratory illness caused by the SARS-CoV-2 but can also lead to GI symptoms. The primary host receptor which mediates the mechanism as SARS-CoV-2 enters the cell is the ACE2 receptor. Therefore, GI symptoms can be common in COVID-19, and in some cases, they are the first manifestation even before fever and respiratory symptoms. In addition, the liver function tests alteration often is related to a worse prognosis. The exact incidence of GI symptoms is a matter of debate. Moreover, wide variation concerning GI symptoms frequency exists, but the predominant ones seem to be diarrhea, anorexia, nausea, vomiting, and abdominal pain or discomfort.This review summarizes the most relevant findings of COVID-19 on the digestive system, including the liver, biliary tract, pancreas, the most common GI symptoms, and the atypical clinical GI manifestations.Copyright © 2022 Sociedad Medica del Hospital General de Mexico. Published by Permanyer.
ABSTRACT
Introduction: As the U.S. population ages, gastroenterologists will provide care for an increasing number of older patients - many of whom use Medicare. In recent years there have been significant policy changes surrounding Medicare reimbursement for physicians. Understanding reimbursement trends can help reveal the financial impact of these policies on gastroenterologists. Our study aims to analyze the trends in Medicare reimbursement of common gastrointestinal (GI) services from 2007 to 2022. Method(s): The top 10 GI procedures and their respective CPT codes were identified through a joint list published by the American College of Gastroenterology, American Society of Gastrointestinal Endoscopy, and American Gastroenterological Association. The top 5 5 CPT codes relating to office/inpatient visits provided by gastroenterologists to Medicare Part B beneficiaries was identified using data from CMS. The Physician Fee Schedule Look-Up Tool from CMS was queried for the selected CPT codes from 2007 to 2022, to determine the facility reimbursement rate by Medicare for each service. The reimbursement data were adjusted to January 2022 U.S. dollars using the U.S. Department of Labor's Bureau of Labor Statistics' consumer price index inflation calculator. Result(s): The unadjusted physician reimbursement for GI procedures exhibited an average decrease of 7.0% (95% CI, 29.9% to 24.1%) from 2007 to 2022. After adjusting for inflation, the mean decrease in physician reimbursement for procedures was 33.0% (95% CI, 235.1% to 230.9%). The mean annual growth rate in reimbursement was 22.6% (95% CI, 22.8% to 22.4%). The unadjusted physician reimbursement for inpatient and outpatient visits exhibited an average increase of 32.1% (95% CI, 4.8% to 59.3%). After adjusting for inflation, physician reimbursement for patient visits exhibited a mean decrease of 4.92% (Figure 1). Conclusion(s): The analysis revealed a steady decline in adjusted and non-adjusted reimbursement between 2007 and 2022. Decreasing Medicare reimbursement may impact health outcomes, healthcare access, and patient satisfaction. Reimbursement policies must be scrutinized particularly in the light of high inflation and increased costs due to additional costs associated with care during the COVID-19 pandemic, staffing shortages, and increased staffing salaries. (Figure Presented).
ABSTRACT
Introduction: Preventive care guidelines for patients with Inflammatory Bowel Disease (IBD) emphasize the need for a patient-centered interdisciplinary approach, with assessment and management of the patient's physical and mental health as well as the IBD. There is no data about compliance with current IBD preventive care guidelines in Puerto Rico. This study aims to evaluate current IBD preventive care in the clinic, and knowledge among patients and gastroenterologists about the preventive care guidelines. The 3-phase study includes retrospective medical record review, an anonymous online survey of gastroenterologists, and an anonymous survey of patients. We report the results of the patient survey. Method(s): Adult patients with an established diagnosis of at least 6 months of ulcerative colitis (UC), Crohn's disease (CD) or indeterminate colitis (IC), were recruited from the IBD Clinics and through IBDrelated social media. Questionnaires were filled in the clinic and online using Google forms. Statistical analysis was performed using descriptive statistics. Comparisons of proportions and means between groups was based on Fisher's exact and chi square tests. The study was approved by the MSC IRB. Result(s): 83 patients completed the survey, 42 from the clinics and 41 through social media. 60% had CD, 47.4% were diagnosed more than 10 years ago, 57.9% were younger than 38 years old and 68% were on immunosuppressants/biologics. 83.13% and 60.24% of patients knew that COVID and Influenza vaccines were indicated, respectively. However only 42.17%, 36.14%, 32.53% and 31.33% of patients knew about indications for HPV, pneumococcal, varicella and zoster vaccines, respectively. There was a significant difference about knowledge regarding screening for latent TB (p=0.019), anxiety and depression (p= 0.03) and smoking status (p=0.033) between CD and UC/IC patients, as shown in Table. Conclusion(s): Our study showed a significant lack of knowledge about IBD preventive care in patients. Strategies to improve patient education are needed. The results of the review of records from the clinic as well as the knowledge of gastroenterologists will point out other deficiencies in the healthcare system and help design methods to improve patient care. Another aspect that needs to be explored is access to preventive measures such as vaccines. (Table Presented).
ABSTRACT
Objectives: Post Covid severe vomiting together with proximal muscle weakness is a misleading combination, this describes a rare but definite clinical association between myasthenia gravis and autonomic failure and strengthen the concept that subacute autonomic neuropathy is an autoimmune disorder. Content: A 39 ys old adult female presented with postCovid severe vomiting for one year with 40 kgs loss Upper gastrointestinal endoscopy revealed gastric dilatation associated with eosophageal and gastric stasis and hypertrophic pyloric stenosis. the gastroenterologist sought neurological consultation for the coexisting unexplained limb weakness before operation EMG & NCV was all normal except instability of the MUAPs Slow rate Repetitive supramaximal stimulation (RNS) revealed significant decremental response with no significant high rate stimulation incrementation Chest CT revealed an anterior mediastinal mass Surprisingly, She had an old CT during the covid infection that showed the same mass. Thoracoscopic resection revealed type B1 thymoma Following tumor resection, the patient improved gradually, Few months later endoscopy revealed a normal stomach with strong peristaltic waves and the patient was symptom free Infections are recognized to trigger exacerbations and crisis in MG Dysautonomia is not a commonly recognized feature of myasthenia gravis, but there have been rare reports of myasthenia gravis coexisting with autonomic failure, usually in association with thymoma. The autonomic dysfunction can present as isolated gastroparesis these observations support a rare but definite clinical association between myasthenia gravis and autonomic failure Neurophysiology could reveal undiagnosed MG with thymoma causing autonomic dysfunction in the form of gastroparesis and agonizing vomiting. Keywords: Myasthenia gravis;Gastroparesis;Autonomic failure;Thymoma;PostCovid vomiting. French language not detected for EMBFRA articles source xmlCopyright © 2023
ABSTRACT
Introduction: Lyndon B. Johnson (LBJ) hospital is a part of the Harris Health System, which provides comprehensive care to the uninsured and underinsured population in Harris County, TX. LBJ serves a population with 55% unemployment and a median household income of $22000. Access to endoscopy is limited by resource availability, and the completion of scheduled endoscopies is essential for public health. We aimed to assess if insurance status was associated with no- show for scheduled endoscopic procedures at the LBJ GI Lab. Method(s): All patients scheduled for outpatient endoscopy during the year 2021 were collected. Included patients must have completed a GI clinic appointment, anesthesia screening, pre-procedural COVID test, confirmed attendance on pre-procedure call, and not showed for scheduled endoscopy (Figure 1). Patient's insurances statuses were: FAP (county payment assistance), Harris County Prisoners (no costs), Medicare/Medicaid (variable costs), Private Insurance (variable costs), Self-Pay, and Texas Family Planning/HCHD Presumed (temporary FAP) (Table 1). Result(s): Comparative analysis of insurance types demonstrated that patients who were Self-Pay were 5.96 times more likely (P< 0.002) not to show up for previously scheduled endoscopic procedures, while patients with the TFP/HCHD insurance were 10.1 times more likely (P< 0.001) to not show when compared to patients who were covered by the county's FAP. Conclusion(s): Our analysis demonstrated a statistically significant association between insurance status and the incidence of no-showing for endoscopy. Upon literature review, there was limited data on rates of endoscopy no-shows in relation to the out-of-pocket commitment for individuals. Further investigation into this topic would significantly affect both the academic and private practice of gastroenterologists. We plan to continue this quality assessment by meeting with the patient eligibility department to assess if modifications of benefit profiles could optimize procedural attendance.
ABSTRACT
Introduction: Crohn's disease (CD) and ulcerative colitis (UC) can be difficult to manage and, due to a lack of meaningful quality measures, patient (pt) care may vary by provider. To understand where gaps in care may exist for these pts, this study assessed specific healthcare resource utilization (HRU) and medication metrics that may be potential quality of care (QOC) indicators. Method(s): Using a large commercial US claims database (2019-2020), pts with CD or UC were identified. Potential QOC indicators were selected based on clinical guidelines and recommendations from measures of quality organizations and included CD or UC prevalence;gastroenterologist (GE) and IBD-related non-GE outpatient visits;IBD-related emergency department visits or hospitalizations;excessive steroid use (prednisone equivalent >=10 mg/day for >=60 consecutive days or a single prescription of >=600 mg prednisone);excessive steroid users on corticosteroid (CS)-sparing therapy;excessive steroid users with central dual-energy X-ray absorptiometry (DEXA) or osteoporosis pharmacologic treatment;use of targeted immunomodulators (TIMs) and oral mesalamine (CD only);imaging assessments;and assessment of inflammatory biomarkers. National percentages of pts achieving each metric are reported. Result(s): In total, 41,555 CD and 52,507 UC pts were identified in 2019, resulting in a 0.3% and 0.4% prevalence, respectively (Table). Over a third of CD pts (39.8%) and almost half of UC pts (45.5%) did not visit a GE in 2019. Around 10% CD pts, and up to 6.4% of UC pts, had IBD-related ED visits or hospitalizations. 17.1% CD and 14.5% UC pts were excessive steroid users, yet < 9% CD and UC pts, received DEXA scans and/or bone treatments. A third of excessive steroid users with CD (34.5%), and over half (53.0%) of those with UC, did not receive CS-sparing therapy. The rate of TIM use was over two times higher in CD vs UC pts (CD: 44.3%;UC: 18.9%). Despite evidence that mesalamine is ineffective in CD, 18.7% of pts with CD were prescribed it. Inflammatory biomarker level testing rates were < 50% in both CD and UC. Similar outcomes were reported in 2020, with lower HRU, possibly due to COVID-19. Conclusion(s): This analysis of QOC indicators highlights various areas for improvement that may provide better treatment outcomes and reduce HRU for pts with CD and UC. Future research is needed to assess outcomes in pts that are not being routinely monitored. (Table Presented).
ABSTRACT
Background: Chronic constipation is a common health concern. Defecatory disorders are considered one of the mechanisms of chronic idiopathic constipation. This study aimed to evaluate the effect of concurrent irritable bowel syndrome (IBS) on the success rate and response to biofeedback therapy in patients with chronic constipation and pelvic floor dyssynergia (PFD). Method(s): This prospective cohort study was performed at the Imam Khomeini Hospital Complex in Tehran from October 2020 to July 2021. Patients aged 18-70 years with chronic constipation and PFD confirmed by clinical examination, anorectal manometry, balloon expulsion test, and/or defecography were included. All patients failed to respond to treatment with lifestyle modifications and laxative use. The diagnosis of IBS was based on the ROME IV criteria. Biofeedback was educated and recommended to all patients. We used three different metrics to assess the patient's response to biofeedback: 1) constipation score (questionnaire), 2) lifestyle score (questionnaire), and 3) manometry findings (gastroenterologist report). Result(s): Forty patients were included in the final analysis, of which 7 men (17.5%) and 21 (52.2%) had IBS. The mean age of the study population was 37.7 +/- 11.4. The average resting pressure decreased in response to treatment;however, this decrease was statistically significant only in non-IBS patients (P = 0.007). Patients with and without IBS showed an increase in the percentage of anal sphincter relaxation in response to treatment, but this difference was not statistically significant. Although the first sensation decreased in both groups, this decrease was not statistically significant. Overall, the clinical response was the same across IBS and non-IBS patients, but constipation and lifestyle scores decreased significantly in both groups of patients with and without IBS (P < 0.001). Conclusion(s): Biofeedback treatment appears to improve the clinical condition and quality of life of patients with PFD. Considering that a better effect of biofeedback in correcting some manometric parameters has been seen in patients with IBS, it seems that paying attention to the association between these two diseases can be helpful in deciding on treatment.Copyright © 2023 The Author(s).
ABSTRACT
Introduction. The prevalence of infant regurgitation in Latin American children is between 8.0% and 9.4% according to the Rome III criteria. Objective. To determine the prevalence of infant regurgitation in Latin American children according to the Rome IV criteria and its possible as-sociations. Materials and methods. A descriptive observational study of prevalence type was carried out in seven Latin American countries. The Functional International Digestive Epidemiological Research Survey database was used to select the sample. Children under 12 months of age who were diagnosed with infant regurgitation using the Pediatric Rome IV Gastrointestinal Symptoms Questionnaire were included in the study. Results. 1802 infants (80.7% from South America, 6.7 +/- 3.8 months of age) were analyzed. Infant regurgitation was diagnosed in 6.8% (52.5% women;39.8% mixed race;46.7% Colombians);peak age: 6 months. There was a greater chance to present infant regurgitation in infants between 1 and 6 months of age, of indigenous race, from Central America, born by C-section, premature, treat-ed in a public institution, by a pediatric gastroenterologist and during the Covid-19 pandemic. There was a lower chance to present infant regurgitation in infants with complementary feeding. Conclusion. Infant regurgitation is frequent in Latin American infants, its prevalence is lower compared to that described in other countries, with risk factors such as race, origin, C-section, prematurity, site and level of care, and the Covid-19 pandemic. The protective factor is complementary feeding.Copyright © 2023, Sociedad Argentina de Gastroenterologia. All rights reserved.
ABSTRACT
Patients with hidradenitis suppurativa (HS) often present to our tertiary service with severe perianal disease that is extremely debilitating. We are able to provide a holistic service for our patients through our perianal virtual clinic (PVC), a weekly service comprising dermatologists, colorectal surgeons, gastroenterologists and a gastroenterology clinical nurse specialist. Virtually, we discuss and optimize the management of patients who have a diagnosis of either HS or gastrointestinal/ cutaneous Crohn disease (CD), or both. Through discussion of the medical management, review of pelvic magnetic resonance imaging scans and the discussion of surgical treatment in detail with our colleagues, we are able to streamline treatment for these complex patients. We provide a review of the activity in this service over the last 2 years, from January 2019 to December 2020. As part of the clinical work in our tertiary hidradenitis clinic, we routinely treat patients with significant perianal HS. These patients have discharging sinus tracts and fistulating disease in apocrine gland-bearing areas. A proportion have gastrointestinal or cutaneous CD. From a medical perspective, these patients have often failed multiple therapeutic interventions, and surgery can provide a useful adjunct to treatment. Surgical intervention involves extensive laying open and debridement of disease, including biopsy, and seton control of anal fistulae. Perianal skin cancer can be identified at the time ofsurgery, a complication known to affect those with chronic inflammation and those on immunosuppressive drugs. In the last 2 years, following surgery, one patient has been diagnosed with cutaneous squamous cell carcinoma (SCC), one with SCC in situ and one with extramammary Paget disease. In reviewing the activity of the PVC, we discussed 26 patients with HS and severe perianal disease in 2019 and 42 patients in 2020, despite interruption to the service due to the COVID-19 pandemic in 2020. This increase in activity reflects our expanded service and the severity and complexity of the patients referred. We identify those that may benefit from early surgery and also take referrals of patients with both HS and CD that may need optimization of medical therapy. In total, eight patients were admitted under the joint care of the colorectal and dermatology teams for surgery in 2019 and seven in 2020. The PVC has become an important one-stop service in the optimization of complex treatment for patients with perianal HS and/or CD referred to our tertiary service.
ABSTRACT
Background: Patients with Immune Mediated Inflammatory Diseases (IMIDs) treated with immunosuppressive drugs are at an increased risk of infections and a more complicated course of the infection, including vaccine-preventable infections. National and international guidelines have specified vaccination strategies in patients with IMIDs. However, the adherence to these guidelines in clinical practice is uncertain. Therefore, we evaluated the current vaccination status of patients with IMIDs at the outpatient clinic of the Erasmus MC Rotterdam. Method(s): Between August 2022 and October 2022, a survey was sent out to patients with various IMIDs at the rheumatology, dermatology and gastroenterology outpatient clinics. Only patients on immunosuppressive treatment were included. The survey contained questions on patient demographics, disease characteristics and current vaccination status. Result(s): The survey was sent out to 3,345 patients with IMIDs, of whom 1,094 patients filled in the questionnaire (response rate 32.7%). Mean age was 51 +/- 16 years and 40.8% were male (Table 1). Patients were treated by a dermatologist (n=306), gastroenterologist (n=414) and/or rheumatologist (n=527). Overall, 55.1% of patients received a yearly influenza vaccination and 9.2% occasionally (Table 2). Furthermore, 8.7% of patients received the pneumococcal vaccination five-yearly and 1.4% occasionally. Both the influenza and pneumococcal vaccination rates were highest in patients with rheumatoid arthritis (64.1%, and 14.7%, respectively). On the contrary, patients with hidradenitis suppurativa had the lowest rates for both the influenza vaccination (32.3%) and pneumococcal vaccination (n=0). Overall, 91.7% of patients (n=1,003) received one or more COVID-19 vaccinations. Conclusion(s): Patients with Immune Mediated Inflammatory Diseases are insufficiently protected against vaccine-preventable infections due to low vaccination rates. Better implementation strategies of current guidelines on seasonal influenza vaccination and pneumococcal vaccination are required. A high rate of COVID-19 vaccination was observed, possibly indicating the willingness of patients to receive vaccinations. Further research into facilitators and barriers to vaccination in these specific patient populations is required.
ABSTRACT
Background: The coronavirus disease 2019 (COVID-19) pandemic significantly changed the (medical) world and has impacted gastroenterology in multiple aspects. Objective(s): Since the beginning of the pandemic, a tremendous body of information on the novel virus and COVID-19 infection has been published. This review aims to give insights into those aspects that are of special interest in gastroenterology. Material(s) and Method(s): Basic literature, case series, and expert opinions on COVID-19 infections from the gastroenterologist's point of view are discussed. Result(s) and Conclusion(s): Gastrointestinal symptoms occur frequently during COVID-19 infection but do not negatively impact the course of disease. Although severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) has been isolated from stool, the possibility of fecal-oral spread is still under debate. Continuation of immunosuppressive therapy in patients with chronic inflammatory bowel disease during the COVID-19 pandemic is safe. However, systemic steroid therapy is associated with an increased risk for a severe course of infection. Vaccination against COVID-19 is safe and effective in patients receiving immunosuppressive therapy. The COVID-19 pandemic has significantly impacted patients and structures of the medical system, including inpatient and outpatient gastroenterology services. Maintaining high-quality healthcare for all patients under pandemic circumstances and ensuring supportive healthcare structures also for healthcare workers including high-quality education will be a future challenge.Copyright © 2023, The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.
ABSTRACT
Introduction: Coronavirus disease 2019 (COVID-19) and its consequences on individuals with inflammatory bowel diseases (IBD) are not yet fully understood despite the fact that evidence on this topic are rapidly evolving. Aims & Methods: This comprehensive study of clinical data aims to enhance the gastroenterologists' ability to manage inflammatory bowel disease during these Covid-19 pandemic dominated times. Until November 2021, a thorough search of PubMed and Embase for published data served as the primary source for the examined research, which was solely composed of English-language sources. Additionally, websites of gastroenterology societies and organizations dedicated to inflammatory bowel disease (IBD) were searched for consensus statements and recommendations for patients and clinicians (IBD). The information sources, the search strategy, and the eligibility criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statements were followed Results: There are 1560 publications on this subject, including 30 randomized controlled trials, including 64,259 patients with inflammatory bowel disease (IBD). There are twenty-four studies (n = 51,920) that examined the effect of COVID 19 on inflammatory bowel disease (IBD) management. Crohn's disease affected 52.9% of patients, ulcerative colitis affected 42.0%, and indeterminate colitis affected 5.1%. These trials showed that the use of corticosteroids, azathioprine, or mesalamine was related to adverse outcomes, but the use of anti-TNFs was linked to improved outcomes. Seven randomized controlled trials evaluated the safety and efficacy of the COVID-19 vaccine in inflammatory bowel disease (IBD) patients and found that vaccination was extremely effective, with a seroconversion rate of 96.49% and no significant increase in adverse outcomes when compared to the general population. Conclusion(s): Patients with inflammatory bowel disease (IBD) are at an increased risk of severe COVID-19 infection. There is a substantial influence on the management of inflammatory bowel disease (IBD) patients during the pandemic, as certain IBD drugs have been connected with a worsening of outcomes. Although the COVID vaccine has been shown to be effective, additional research is needed to determine the long-term consequences of COVID 19 infection and vaccination.
ABSTRACT
Introduction: In 2016, WHO announced a plan to eliminate viral hepatitis C as a public health threat by 2030. However, for achieving this goal, not only access to highly effective drugs, but also the ability to detect hidden infections by launching national screening programs is important. Lithuanian health authorities decided as a first step of the program, to pay general practitioners (GPs) a special fee for a service of promoting and performing serological tests for hepatitis C virus (HCV) antibodies (14.3 per screened person): 1. For the population born in 1945-1994 (once per life), and;2. For persons who inject drugs and AIDS patients (annual HCV testing). The program will start in July 1st, 2022. Here we present the results of pilot study in the primary health care centre of seaport Klaipeda conducted before starting of hepatitis C screening program in Lithuania. Aims & Methods: Patients were invited to participate in the HCV screening by GPs during the visits. Additionally, regional media, social networking sites, and leaflets were used to inform about the possibility of being tested free of charge. Screening involved a blood test for the presence of antibodies to HCV (TOYO rapid test, Turklab Tibbi Malzemeler A.S., Turkey). Patients who tested positive were referred to a gastroenterologist for further examination. A case-control study was performed to identify risk factors for hepatitis C infection. All seropositive patients (case group) were invited to participate in a telephone interview, and 65 out of 81 (80.2%) responded. The control group (n=130) matched by gender and age with the cases was randomly selected from seronegative patients and interviewed by telephone using the same questionnaire as the case group. The associations of possible risk factors with HCV infection were analysed using univariable and multivariable logistic regression analysis. Result(s): From November 2020 to February 2022, 4867 patients were screened in the primary health care centre in Klaipeda. Positive test results were found in 81 (1.7%) patients. Of all screened patients, 4167 (85.6%) were born in 1945-1994, and 79 (1.9%) of them were seropositive. Seroprevalence of HCV antibodies was higher among men than women, 49 out of 2363 (2.1%) and 32 out of 2504 (1.3%) respectively (p=0.03). In men, the highest HCV seroprevalence was found in age groups of 30-39 years (3.6%) and 40-49 years (3.5%), in women - in 50-59 years (1.9%). In case-control study, injection of illegal drugs was reported by 23.8% of HCV positive patients;27.0% of seropositive patients were in prison for more than 3 months. The odds ratio (OR) of HCV infection in patients who reported blood transfusions before 1993 was 6.8 (95% CI 2.0-23.2) compared to those who did not have a blood transfusion or had it later. HCV infection was diagnosed more often among patients who were blood donors before 1993 compared to those who were not donors or were later (OR 4.6;95% CI 2.1-10.2). Having a tattoo increased the odds of HCV infection by 6.5 times (95% CI 2.8-14.8). Conclusion(s): Despite the COVID 19 pandemic, the pilot study revealed active participation of individuals in HCV screening organised by the primary health care centre. Although adults > = 18 years of age were invited to the pilot study, all serologically positive cases of hepatitis C fell into the following categories: 1) born in 1945-1994;and 2) persons who inject drugs.
ABSTRACT
Background and Aims: Substantial practice variation exists in both the diagnostic criteria for and the post-diagnosis monitoring of celiac disease (CeD). Differences include standards for serological diagnosis, endoscopic practices, models of care, and long-term clinical monitoring, all confounded by the COVID-19 pandemic. With the exponential rise of gluten-related disorders, revised ESPGHAN guidelines and new healthcare barriers, it is helpful to explore practice patterns to inform updates to clinical guidelines and future research endeavors. The purpose of this survey was to understand the expertise and practice parameters of pediatric gastroenterology (GI) clinicians across North America for the diagnosis and management of children with celiac disease. Method(s): A 23-item survey designed by a working committee of the NASPGHAN Celiac Disease Special Interest Group was distributed electronically to NASPGHAN members, including attending physicians, fellows, and advanced practice providers from September to December 2021. Four themes were explored: 1) screening and diagnosis;2) monitoring;3) impact of the COVID-19 pandemic;and 4) education and training. The implementaion of the ESPGHAN non-biopsy serologic diagnosis (based on the 2020 guidelines: tissue transglutaminase IgA (TTG-IgA) 10x upper limit of normal and a second sample with a positive endomysial antibody) by providers was explored. Descriptive statistics were tabulated by region, clinical role and those who identified as working at a celiac center. Result(s): A total of 284 surveys were completed with a response rate of 11.1% (264/2552). The majority of respondents were from the United States (89%, n=235) and Canada (8%, n=22) with 2% (n=5) from Mexico. Serology-based diagnosis as per ESPGHAN 2020 guidelines was accepted by 54.5% (n=12/22) of Canadian respondents and 39.6% (n=93/235) from the U.S (p=0.17). Since the COVID-19 pandemic, 36% of respondents have increased their application of non-biopsy diagnosis. Canadian respondents reported offering the ESPGHAN non-biopsy approach to diagnosis more often during the COVID-19 pandemic (Canada 74% vs US 33%, <0.0001). A higher precentage of patients who lived in Canada (52%) with positive celiac serologies waited >1 month to be evaluated by GI than the US (30%);p=0.03. There was also a significant difference between access to endoscopy within a month between patients who lived in Canada and the US patients (Canada 77% >1 month, US 20% >1 month;p=<0.001). Investigations at follow-up which were completed most frequently by those who identified as working at a celiac center (n=108) included complete blood count, thyroid function tests, liver enzymes, iron profile, Vitamin D and TTG-IgA (Figure 1). Among these respondents, 49.1% (n=53/108) repeat family screening ranging every 1-5 years. Specialty training in CeD remains limited as only 25.7% (n=61/237) staff pediatric gastroenterologists had celiac-focused didactic lectures, and 23.3% (n=55/237) participated in a CeD specialty clinic during their fellowship. Conclusion(s): This survey revealed heterogeneity in current practices for the diagnosis and management of CeD in North America and the influence of the COVID-19 pandemic in increasing the use of the ESPGHAN no-biopsy approach to diagnosis. An education gap was identified for CeD in pediatric GI fellowship training. Further studies are needed to understand the impact of these variable practices and future research priorities and clinical guidelines should take this variation into consideration. (Figure Presented).
ABSTRACT
Background: Clinical documentation is a means to document care and supports several important areas including inter-provider and patient communication, reimbursement, patient safety, and overall patient care. However, a significant knowledge gap exists with respect to the evaluation and potential improvement of the quality of outpatient clinical documentation. This may be related in part to a lack of standardized tools or metrics to assess clinical documentation. Aim(s): 1) To develop a reliable outpatient assessment & plan clinical documentation scoring tool;and 2) To assess its impact on improving clinical outpatient documentation quality amongst pediatric gastroenterologists. Method(s): Development of a clinical documentation scoring tool: A tool was developed to score the assessment & plan sections of outpatient clinical notes for both clarity and soundness (Table). It was implemented in 2020, and after two rounds of division-wide scoring, a formal IRB-approved investigation of scale reliability was undertaken. An additional round of scoring took place in 2021. The implementation of telemedicine in response to the COVID-19 pandemic permitted subanalyses of telemedicine vs in-person clinical documentation. QI Project: Assessment & plan documentation of new outpatient visits within a single center were extracted between 2020 and 2021 (18 months). Ten notes were compiled from each clinician, and the chief complaint was used as a guide to increase variability. All identifiers were removed. Using the tool, division clinicians then scored 10 clinic notes from other members of the division. Following each cycle, peer scores were provided back to each clinician. In addition, anonymized scores were shared amongst the division's clinical providers. Scales Reliability Assessment: After the first two rounds of the QI project, IRB approval was secured for a separate study. Division clinicians used the developed tool to rate the clarity and soundness of assessment and plan documentation from a set of 10 examples (Set 1). The same providers were asked to complete a second set of 10 examples (Set 2) several months later. Both sets were comprised of 5 overlapping cases to calculate the inter-rater and intra-rater intra-class correlation coefficient (ICC) for both scales. Result(s): Scale Reliability Analyses: The above protocol created 3 different scoring sets for calculating the inter-rater ICC of the clarity and soundness scales: Set 1, Set 2, and Combined Set 1 & 2. The Clarity Scale inter-rater ICC for these sets were 0.71 (N=9), 0.51 (N=11), and 0.51 (N=8), respectively. The Soundness Scale inter-rater ICC for these scoring sets were 0.51 (N=9), 0.31 (N=10), and 0.32 (N=8), respectively. The Clarity Scale intra-rater ICC was 0.77 and 0.55 for the Soundness Scale (N=8 for both analyses). Quality Improvement: We found a trend toward increasing clarity and soundness scores with each subsequent round of scoring (Figure). The number of evaluations which scored less than a 3 on the clarity scale decreased from (52/407) 12.8% to (34/394) 8.6% and finally (36/433) 8.3%. Of note, scoring of clarity and soundness in notes derived from telemedicine vs in-person visits were similar. Conclusion(s): There is great interest in QI in Pediatric Gastroenterology, although it is difficult to find universally applicable targets. The assessment & plan sections of the outpatient note is of central importance and has the potential to be a useful area for QI. Scoring the clarity of notes is relatively reproducible, and this program has the potential to yield substantial improvement amongst a clinical team. Soundness of the assessment & plan documentation is more subjective and will require additional revision in order to achieve favorable reliability.
ABSTRACT
Background Global health interest continues to rise among pediatric trainees including those entering pediatric fellowships. While global health opportunities are being incorporated into many pediatric fellowship programs, there remains a paucity of global health training in pediatric gastroenterology, hepatology, and nutrition (GHN) fellowships. In a 2014 survey by Jirapinyo et al. only 17% of responding GHN fellowships offered global health training activities. A 2018 survey by Crouse et al. showed that 34% of responding GHN fellowships offered global health electives, and none had formal global health tracks. We believe that creating a formalized global health track for GHN fellows will not only appeal to the increasing interest among applicants, but also provide a firm knowledge base on GHN topics specific to a more global level, build international collaborations, and contribute a unique perspective in our field. We aim to describe our experience with the development and implementation of a novel global health track in a pediatric GHN fellowship. Methods Planning commenced January 2021. A multidisciplinary team was assembled bringing together experts in different areas including those in other subspecialties involved in global health fellowship training. The team involved in development included GHN program director, GHN division chief, pediatric emergency medicine global health fellowship director, director of the pediatric infectious disease fellowship tropical and global medicine track, and Baylor international pediatric AIDS initiative (BIPAI) chief medical officer. Input was also received on certain aspects of the curriculum from the pediatric viral hepatitis program director, dieticians, a radiologist, an ultrasound technologist, and the pediatric point-of-care ultrasound fellowship program director. Existing clinical niche track curriculum developed within the GHN department at Texas Children's Hospital were used as a guide for the structure and different aspects to be incorporated into the track including, but not limited to, clinical activities, procedural opportunities, research, education, and teaching. Results A comprehensive, multifaceted global health curriculum was developed, and implementation began in July 2021. Clinical activities include participation in pediatric and adult viral hepatitis clinics, nutrition focused clinics, and tropical medicine clinic. Global health electives abroad were explored but deferred given travel restrictions during the COVID-19 pandemic. For procedural opportunities an ultrasound curriculum was developed including point of care ultrasound training as well as more focused training in liver, biliary, and gastrointestinal disease. A fellowship research project was developed in conjunction with the Baylor International Pediatric AIDS Initiative (BIPAI) network in sub-Saharan Africa with mentorship both from faculty in the GHN department as well as the BIPAI network locally and abroad. The project is public health focused examining hepatitis B screening rates and prevalence among people living with HIV in sub-Saharan Africa. Education includes attendance of lectures given in different departments as well as cross departmental within the institution, and global lectures attended virtually. Other educational activities include review of a global health focused GHN topics and assembly of a library of resources including recent seminal papers for current and future fellows to use for review. Last, completion of the Diploma in Tropical Medicine and the Certificate of knowledge in Clinical Tropical Medicine and Travelers' Health Examination. Teaching opportunities include involvement in general global health education for US-based medical students and residents interested in pursuing careers in global health, and teaching residents and faculty on topics such as viral hepatitis, malnutrition, and diarrhea. Conclusion We have developed to our knowledge the first formal global health track in pediatric GHN fellowship that is feasible to integrate into the 2nd and 3rd year and omplete in the available time frame. Participation in the global health track by the first fellow is still in process and improvements are being made based on experience. A multidisciplinary team including support within the fellowship program and experts in global health training is essential to the success of a pediatric GHN global health track. International relationships either previously established by the fellow, within the department, or the institution are also necessary for the success of the track. We believe that this track will help to equip future gastroenterologists to pursue a career with a focus in global health. Future directions include recruiting future fellows to complete the curriculum within our institution, formal evaluation by fellows participating in the curriculum, and securing ongoing funding. We also hope to incorporate global health electives abroad when feasible.
ABSTRACT
BACKGROUND: Electronic health record systems (EHRs) represent one of the most widely adopted digital healthcare technologies in the past decade. Among the potential benefits of EHRs has been the quantification of individual physician time spent performing key components of clinical workload. Epic EHR is a global system with the majority market share in North American acute care and ambulatory arenas and may offer a means to quantify the clinical workload of pediatric gastroenterology, as a subspecialty field of medicine. OBJECTIVE(S): To quantify clinical workload of pediatric gastroenterology across Epic EHR systems. METHOD(S): From January 2020 through April 2022, we evaluated Signal EHR data captured in Epic for all pediatric gastroenterologists (PGI), defined as physicians (MDs) with an Epic specified PGI profile. Signal data provides detailed data on clinician time spent daily (defined by days where a MD was clinically active or logged into the EHR) interfacing with the EHR, including clinical work process data in 4 key areas: In-Basket (including communications with patients and other healthcare providers), Orders, Notes and Letters, and Clinical Review. For our study purposes, clinical workload was characterized by 4 monthly metrics: days with appointments;appointments per scheduled day (data from April-July 2020 during COVID-19 lockdown were not included to accurately reflect current practice);pajama EHR time (5:30 PM to 7 AM);and EHR time outside templated clinic hours. Proportional time spent in different clinical arenas was reported for April 2022 only. Monthly process metrics captured in each of the 4 key areas focused on work volume and time spent. Outcome metrics were reported as average+/-standard deviation (SD) and median (interquartile range (IQR)). All metrics were evaluated for change over time using regression modeling. Statistical significance was set at p<0.05. RESULT(S): Signal data from 993 PGI at 213 institutions were analyzed. 95.8% (n=204) institutions were located in the US. Clinical workload Over the reporting period, PGI had clinical appointments an average of 43+/-3% [median (IQR) = 46% (35%, 57%)] days per month or about 3 days per week. PGI had 7.6+/-0.3 [7.0 (5.8, 8.9)] clinical appointments per scheduled day. On average, PGI spent an additional 23.7+/-1.6 [14.4 (4.6, 30.2)] pajama time minutes and 36.1+/-1.9 [30.3 (15.8, 43.3)] minutes outside scheduled hours interacting with the EHR each day. Clinical workload metrics remained stable over the study period. On average, PGI spent 60% time in the ambulatory arena, 9.7% in inpatient, 0.3% in the emergency department and 30% in other. In-Basket The average time spent in In-Basket by PGI was 23.0+/-1.3 [20.4 (13.2, 26.5)] minutes per day. Average time in In-Basket increased significantly over the study period (p<0.0001). Primary drivers for this change included increases in certain types of In-Basket messages, including results (p=0.01), patient medical advice (p<0.0001), hospital chart completion requests (p<0.0001), prescription authorization requests (p=0.003), and staff messages (p<0.0001). Orders On average, PGI prescribed 1 medication every other appointment, or 0.5+/-0.02 [0.4 (0.3, 0.6)] medications per visit. PGI ordered 2.2+/-0.3 [2 (1.4, 2.8)] tests/evaluations per appointment. Notes and Letters The average note length was 6392+/-193 [6072 (4344, 7696)] characters, equivalent to over 3.5 pages of text. Time spent in notes was 10.2+/-0.4 [9.7 (6.7, 13.1)] minutes per appointment and 46.9+/-2.4 [43.6 (29.9, 56.2)] minutes per day. Length of notes increased significantly over the study period (r=0.51, p=0.01) but time spent in notes did not. Clinical Review PGI spent an average of 17.7+/-1.5 [17 (12.7, 20.3)] minutes per scheduled day in chart review, equivalent to 4+/-0.2 [3.9 (2.7, 5.3)] minutes per appointment. CONCLUSION(S): Quantification of some key components of clinical workload inherent to PGI is possible using EHRs. PGIs routinely spend time outside of work hours performing EHR work. Over the past 2 years, In-Basket time has contributed substantially to PGI workload and has trended towards increasing messages from both external (patients and pharmacies) and internal sources (staff and hospital compliance). Considerable PGI time has also been spent constructing clinical notes of lengths that appear to have increased during the same 2-year period. Limitations to the study include non-standardized, opaque metric definitions and unclear fidelity of provider categorization. We would also note that our results document increasing EHR-related workload burdens on PGIs that can contribute to physician burnout. Through identification of best outcome metrics, quantification of PGI clinical workload using EPIC Signal data may allow quality improvement activities that reduce provider burden while enabling our subspecialty field to benefit from widespread implementation of EHRs.
ABSTRACT
Background: Care in hospitals is generally focused on prolonging life and may not adequately address the needs of dying patients. The incidence of oncologic diseases is rising, and efforts should be made to guarantee a better quality of death and dying. Aim: to evaluate the end-of-life care in patients with cancer under gastroenterologist care. Methods: Cross-sectional study including all in-patients with cancer who deceased in a Gastroenterology department in Portugal between 2012-2021. Demographic characteristics, clinical attitudes, therapeutic interventions and symptom control up to 6 months prior to the patient’s death were assessed. Results: We included 120 patients, 73% male, mean age 71±12.5 years. The most common cancers were hepatocellular carcinoma (35%), gastric cancer (16%), pancreatic cancer (15%) and cholangiocarcinoma (14%). One third of the patients had ECOG of 0-1 at admission and 77% (n=92) had advanced disease (stage IV or Barcelona Clinic Liver Cancer C/D). The median number of emergency consultations and hospitalizations in the 6 months before death was 2 (IQR 1-4). In their last month of life, the median time of hospitalization was 21.5 (IQR 12-25) days. It was documented the presence of an available caregiver in 56%(n=68) and spiritual support in only 2% (n=2) of the cases. One quarter of the patients experienced not adequately controlled pain and 72% received opioids. Palliative care consultation occurred in 60% (n=72) with a median time between that and death of 12 (IQR 3-18) days. Invasive procedures (diagnostic and therapeutic endoscopy, ERCP and EUS) were performed in half of the patients, achieving technical and clinical success in 62% (n=38) and 32% (n=19) of the cases, respectively. The mean time between those interventions and death was 12±10 days. The prognosis was discussed with the patient and family in 35% and 68% of the cases, respectively. At least 73% of the patients had visits at the end of life, which was negatively affected by the COVID-19 pandemic (p=0.022). Conclusions: In our cohort, we found a high hospitalization length of stay in the last month of life and high percentage of invasive treatments until shortly before dying. Thus, it is urgent to define and implement metrics of quality of death to prevent futile/potentially inappropriate treatment. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.