Intervention to increase colorectal cancer screening among emergency department patients: results from a randomised pilot study.

BACKGROUND: Colorectal cancer (CRC) is the second leading cause of cancer-related deaths worldwide. Emergency departments (ED) represent a promising setting to address preventive health measures like CRC screening. OBJECTIVES: The current study adapted an existing cervical cancer screening intervention for use in catalysing CRC screening. We evaluated feasibility of identification, provided preliminary effect size estimates and documented participant acceptability. METHODS: This study was funded by the University of Rochester (ClinicalTrials.gov # NCT05004376). We enrolled ED patients, 45-75 years old, in the Greater Rochester, NY region into a randomised controlled pilot from January to May 2022. Patients were excluded if non-English speaking, lacking a cell phone or had a history of CRC, colorectal resection, inflammatory bowel disease or abdominal radiation. Participants were surveyed to determine adherence with recommended CRC screening guidelines. Patients found non-adherent were randomised to receive (1) recommendation for CRC screening only or (2) recommendation and a text-based intervention aimed at generating intention and motivation to get screened. Patients were blind to allocation at enrolment. The primary outcome was patient CRC screening or scheduling. RESULTS: 1438 patients were approached, with 609 found ineligible, 576 declining participation and 253 enrolled. A randomised sample of 114 non-adherent patients were split evenly between the control and intervention arms. Among participants with follow-up data (n control=38, n intervention=36), intervention participants had a 2%-3% higher rate of scheduling or receiving screening (7%-27% relative improvement). When using the complete sample (n=114) and conservatively assuming no screening for those lost to follow-up, differences in screening across arms were mildly decreased (0%-2% absolute difference). Acceptability of CRC intervention was high, and participants offered formative feedback. CONCLUSION: The piloted text message intervention through the ED shows potential promise for catalysing CRC screening. Subsequent replication in a fully powered trial is needed.

P018 How to Improve Transition of Pediatric IBD Patients Through Use of EMR.

BACKGROUND: Despite major medical advances in the IBD world, the incidence of Pediatric Inflammatory Bowel Disease (IBD) continues to increase. This patient population is at risk for higher rates of complications from their chronic disease. The transition from pediatric to adult care is crucial as this population is at an increased risk for loss to follow up, delays in receipt of appropriate medical care, poor adherence, and increased emergency department visits and hospital admissions. To address these issues at our academic center, we piloted an EMR template with the goal of improving the process from both the patient and provider perspectives. We present our review of what we learned from this process and how it shaped our final product. METHODS: This study was an IRB-approved prospective cohort assessment performed at our academic tertiary care center from 2018-2021. An EMR template was designed as a comprehensive summary based on components of the medical record that adult gastroenterology (GI) providers identified as critical to successful transition of care. This template was then integrated into pediatric GI office notes provided to the adult GI team at the start of transition. A 7-question survey was distributed to pediatric providers to assess ease of use and provider perceptions of the template. RESULTS: A total of 64 patients transitioned following implementation of the template and 19 (29.7%) of those had a template in their chart upon transition. Audit of charts revealed that of the 13 pediatric GI providers, only one was actively using the template. Twelve (92%) of the 13 pediatric GI providers responded. Barriers to template use included: ease of use, lack of included narrative history, lack of auto-populated data and accessibility. Subsequently, stakeholders from our Pediatric and Adult IBD centers met to create a universal progress note that would provide one cohesive patient summary. The conception of this medical document now occurs in the pediatric setting; it will accompany the patient through their medical journey and be a permanent part of their medical record. CONCLUSION: Adult and Pediatric Gastroenterologists all agree that effective transition of IBD care is critical to the patient's well-being. However, adult and pediatric providers may have differing views of the importance of certain aspects of the psychosocial and preventative care components of IBD management. In our institution, we are able to provide IBD care to patients for their entire life span. To the benefit of patients, this is becoming more common at academic centers, making the use of a universal IBD template critical for excellent continuity of care. As a result of our inter-departmental meetings, we were able to learn why different aspects mattered at different stages of a patient's life. This allowed us to create a flexible template to incorporate these changing priorities. We believe that our current IBD progress note is a functional mesh of those factors and is less cumbersome than a separate template required by adult providers. Most importantly, it presents a united front, and demonstrates to patients that their care is a continuum within our institution.

P041 Successful Reduction in Opioid Prescription for IBD Flare in the Emergency Department: A Retrospective Study and Quality Improvement Initiative.

BACKGROUND: Opioid use is associated with increased mortality, emergency department (ED) utilization, 30-day readmission rates and decreased quality-of-life in patients with inflammatory bowel disease (IBD). Opioid use in the ED for acute IBD presentations has not been well characterized in the literature. Safe, evidence-based, and effective pain management guidance for IBD flares is needed to promote opioid stewardship in the ED. METHODS: We performed a retrospective cohort study of adult patients who presented to an academic tertiary center ED with IBD flares from June 2019 through December 2019. Demographic and disease specific information and ED course, including analgesic use and numeric rating pain scores at ED presentation and discharge, were collected from the medical record. We designed and implemented a multimodal quality improvement intervention consisting of an evidenced-based IBD pain guideline, customized electronic health record order-set, Gastroenterology (GI) consult note smart-phrase and clinician education to promote opioid stewardship. The impact of our intervention was measured with a repeat retrospective analysis from December 2020 through April 2021. Run charts were generated to correlate the timing of interventions to changes in opioid exposure and prescription. RESULTS: Seventy-one patients were included in the pre-intervention cohort. A total of 78% of patients who presented to the ED with IBD flare were prescribed opioid(s) with an average of 29.3 morphine milligram equivalence (MME) per ED stay. Approximately half (49%) of patients did not receive any non-opioid analgesic and 13% patients received an opioid prescription at ED or hospital discharge. In the post-intervention cohort consisting of 49 patients, there was a significant reduction in the proportion of patients receiving opioids (45% vs. 78%; p < 0.001) and a significant reduction in the average total opioid administration (10.8 vs. 22.6 MME; p < 0.001). For each month during the post-intervention period, the proportion of patients who received an opioid in the ED and the average total opioid administered remained less than the median of the entire study period, which represents a nonrandom pattern. The use of a non-opioid analgesic, IV acetaminophen, was significantly increased (27% vs 3%; p < 0.001) and the risk of new or recurrent gastrointestinal bleeding was negligible in both cohorts (0% vs. 1%; p = 1.0). There was no significant difference between the average pain score (4.9 vs. 5.4 [10-point-scale]; p=0.440) and the difference between reported triage and final ED pain scores (-1.8 vs. -2.0; p=0.729). Furthermore, there was a significant reduction in GI consultation (35% vs. 58%; p <0.016) and a non-significant reduction in hospital admission (63% vs. 80%; p=0.058). CONCLUSION: Almost 80% of patients who present to ED with IBD flare are prescribed opioids, while only half of patients receive non-opioid analgesics. Also concerning was the high rate of opioid prescription at ED or hospital discharge. A multimodal intervention successfully reduced the proportion and amount of opioid prescribing in the ED without compromising pain control or increasing the risk of GI bleeding. This was also associated with a significant increase in a non-opioid analgesic administration and a significant decrease in GI service consultation. These findings support the role of implementing an evidence-based IBD pain management guideline with electronic prescribing support and education in the ED setting for acute IBD flares. Additional research is needed to determine long-term benefits of reduced opioid exposure in this population.

P053 Interstitial Nephritis from IBD: Complicated Conclusions.

CASE: BACKGROUND: Kidney injury in IBD is challenging. Tubulointerstitial nephritis (TIN) is linked to aminosalicylates, but also described in drug-naïve patients, suggesting that TIN may be a direct manifestation of IBD. We describe three cases of TIN in IBD to illustrate the challenges in determining the etiology of the injury. CASES: Case #1: 58-year-old male with a horseshoe kidney deformity, uncontrolled hypertension, GERD and small bowel stricturing Crohn's disease (CD), previously on mercaptopurine and allopurinol, subsequently transitioned to adalimumab, maintaining clinical and radiologic remission. Two years later, he developed acute kidney injury in setting of high fevers and sweats, with negative infectious evaluation. Medications included adalimumab, PPI, valacyclovir and torsemide. Renal biopsy revealed TIN with dense, zonal and focal granulomatous features suggestive of drug-induced hypersensitivity, chronic infection, sarcoidosis or an extra-intestinal manifestation of CD. Case #2: 45-year-old female with SLE, nephrolithiasis, GERD, hypertension and ulcerative colitis (UC), initially on mesalamine, then vedolizumab, with clinical and endoscopic remission. Her SCr increased at the time of her UC diagnosis, and worsened over 6 months while on mesalamine, vedolizumab, PPI and losartan. Renal biopsy demonstrated acute and chronic TIN with eosinophils raising concern for an allergic/drug-induced injury. Nephrology concluded that her TIN was secondary to either UC or one of her medications. Case #3: 33-year-old male with UC transitioned to vedolizumab, having failed budesonide and mesalamine. He had latent TB and received 9 months of isoniazid. While on mesalamine, vedolizumab and PPI, he developed fever, chills and night sweats, with an acute rise in SCr, prompting discontinuation of meds. Three months later, still in remission and with improved SCr, he restarted vedolizumab. A year later he developed low-grade fever with elevated SCr, prompting discontinuation. Renal biopsy revealed acute and chronic TIN with severe interstitial fibrosis, tubular atrophy and focal global glomerulosclerosis. He started prednisone and remained off other IBD therapy for 6 months, but repeat colonoscopy revealed mild colitis. He restarted mesalamine, but again developed elevated SCr 2 months later. Repeat renal biopsy revealed TIN with less interstitial fibrosis and focal global glomerulosclerosis, and nephrology suggested his interstitial nephritis was likely secondary to UC over his medications. He started azathioprine with significant improvement in SCr and clinical remission of UC. DISCUSSION: In all three cases, neither nephrology consultation nor renal biopsy helped distinguish the etiology of renal injury, defaulting to either the IBD meds or an extra-intestinal manifestation of IBD, and not accounting for the acute inflammatory symptoms in two of the cases. While literature review reveals several cases that allege kidney injury as an extra-intestinal target of IBD serious doubts remain. TIN secondary to aminosalicylates is well-documented, but there are few reports of adalimumab-induced granulomatous TIN and only one report of vedolizumab-induced TIN. Each of our patients had well-controlled IBD and multiple confounding variables that could impact kidney function or cause TIN, including hypertension and multiple potential culprit medications, illustrating the dilemma of determining the etiology of renal injury in IBD patients.

Building a Successful and Sustainable Academic Career in Gastroenterology.

Starting a new job as an academic gastroenterologist can be very exciting and anxiety provoking at the same time. This is particularly true when the junior faculty member is faced with the unique challenges of practicing medicine in today's world while still attempting to maintain work-life balance and avoid professional burnout. In discussions with several junior colleagues in the specialty over the years, it became clear that there is a relative lack of structured guidance in the literature regarding helping them navigate these turbulent waters in their early careers and setting them up for professional success in the long term. Although there is no guaranteed single formula or recipe for academic success, in this review, we attempt to outline in a stepwise fashion the critical components that we believe are important for junior faculty to consider as they embark on this journey. The significance and value of each step from job selection through promotion and mentorship is discussed in detail based on insights gleaned from experience and the published literature. The importance of citizenship, networking, mission and community-based activities, and work-life balance is highlighted as well. The concept of appreciating and enjoying the "journey," rather than focusing solely on the destination, is emphasized in this paper. We truly believe that these are critical core concepts for junior faculty to grasp that will allow them to derive immense professional gratification in the long run while building successful professional careers along the way.

Split-Dose Bowel Preparation Reduces the Need for Early Repeat Colonoscopy Without Improving Adenoma Detection Rate.

BACKGROUND AND AIMS: Split-dose bowel preparation is associated with improved mucosal visualization and patient tolerance, becoming a standard of care. However, quality measures data associated with this preparation are limited. At our academic tertiary-care facility, we aim to study the effect of changing from single- to split-dose preparation on colonoscopy quality measures. METHODS: A retrospective cohort study with quality indicators was conducted using electronic medical record data. Cases were identified via ICD9 code V76.51, "Special screening for malignant neoplasms of colon." Single-dose preparation data was collected from 9/1/13 to 8/31/14. Split-dose preparation was implemented 11/2014, and data were collected from 1/1/15 to 8/31/15. RESULTS: A total of 1602 colonoscopies in the single-dose group and 1061 colonoscopies in the split-dose group were analyzed. The Boston Bowel Preparation Scale was significantly improved in the split-dose group 8.64 ± SD 1.25 versus 8.25 ± SD 1.61, p < 0.001. There was no significant difference in adenoma detection rate 40.7% (95% CI 37.8-43.7%) versus 40.5% (95% CI 38.1-42.9%), p = 0.92; however, the rate for recommending an early repeat examination due to an inadequate bowel preparation was significantly decreased to 3.9% (95% CI 2.7-5.0%) versus 8.9% (95% CI 1.52-2.97%), p < 0.001. CONCLUSION: While split-dose preparation significantly improves overall bowel cleanliness, there is no significant adenoma detection rate improvement with high baseline rate, suggesting a threshold which may not improve with enhanced preparations. Split-dose preparation significantly reduces the frequency with which inadequate preparation prompts an early repeat examination, which has important clinical implications on performance, costs, and patient experience, providing further evidence supporting split-dose preparation use.

Hormonal and metabolic adaptation in professional cyclists during training.

The aim of this study was to examine hormonal and metabolic changes in a group of 18 professional male cyclists ((.)VO(2)max 69.9 [95 % CI 64.9 to 74.9] mL x kg(-1) x min(-1) ) during two successive periods of adapted intensive training. The second training period included 4 days of cycling competition. Intensity was increased while volume was decreased in the second training. Anthropometric data were collected before and at the end of the two training periods. Venous blood samples were taken in a basal state before the two training sessions and after each training session. Serum concentrations of cortisol (C), testosterone (T), dehydroepiandrosterone sulfate (DHEAs), and catecholamines were determined as well as branched-chain amino acids (valine, leucine, isoleucine) (BCAA) and free fatty acids (FFAs). At the end of the two training periods, the subjects lost fat mass whereas mean body mass was unchanged. The T/C ratio was reduced transiently after the first training session (45.90 %), while DHEAs/C remained unchanged. T/C and DHEAs/C were significantly increased after the second training session compared to the first (48.40 and 97.18 %, respectively). Catecholamines and FFAs were unchanged. The significant increase in BCAA levels after the second training session was of note as it might constitute a "store shape" of amino acids in anticipation of future intense training loads. Based on the responses of testosterone, DHEAs, and cortisol, and on the training-induced increase in BCAA, there appeared to be hormonal and metabolic adaptation despite the inherent psychological stress of competition.