Faculty Bibliography

BACKGROUND AND AIMS:Colorectal cancer (CRC) is the third most common cancer for women and men and the second leading cause of cancer death in the USA. There is emerging evidence that the gut microbiome plays a role in CRC development, and antibiotics are one of the most common exposures that can alter the gut microbiome. We performed a systematic review and meta-analysis to characterise the association between antibiotic use and colorectal neoplasia. METHODS:We searched PubMed, EMBASE, and Web of Science for articles that examined the association between antibiotic exposure and colorectal neoplasia (cancer or adenoma) through 15 December 2019. A total of 6031 citations were identified and 6 papers were included in the final analysis. We assessed the association between the level of antibiotic use (defined as number of courses or duration of therapy) and colorectal neoplasia using a random effects model. RESULTS:=79%, p=0.0001) but not of publication bias. CONCLUSIONS:Higher levels of antibiotic exposure is associated with an increased risk of colorectal neoplasia. Given the widespread use of antibiotics in childhood and early adulthood, additional research to further characterise this relationship is needed.

Background/UNASSIGNED:Incidence of early-onset (younger than 50 years of age) colorectal cancer (CRC) is increasing in many countries. Thus, elucidating the role of traditional CRC risk factors in early-onset CRC is a high priority. We sought to determine whether risk factors associated with late-onset CRC were also linked to early-onset CRC and whether association patterns differed by anatomic subsite. Methods/UNASSIGNED:Using data pooled from 13 population-based studies, we studied 3767 CRC cases and 4049 controls aged younger than 50 years and 23 437 CRC cases and 35 311 controls aged 50 years and older. Using multivariable and multinomial logistic regression, we estimated odds ratios (ORs) and 95% confidence intervals (CIs) to assess the association between risk factors and early-onset CRC and by anatomic subsite. Results/UNASSIGNED: = .04). Conclusion/UNASSIGNED:In this large study, we identified several nongenetic risk factors associated with early-onset CRC, providing a basis for targeted identification of those most at risk, which is imperative in mitigating the rising burden of this disease.

DESCRIPTION/METHODS:The purpose of this expert review is to describe the role of medications for the chemoprevention of colorectal neoplasia. Neoplasia is defined as precancerous lesions (e.g., adenoma and sessile serrated lesion) or cancer. The scope of this review excludes dietary factors and high-risk individuals with hereditary syndromes or inflammatory bowel disease. METHODS:The best practice advice statements are based on a review of the literature to provide practical advice. A formal systematic review and rating of the quality of evidence or strength of recommendation were not performed. BEST PRACTICE ADVICE 1: In individuals at average risk for CRC who are (1) younger than 70 years with a life expectancy of at least 10 years, (2) have a 10-year cardiovascular disease risk of at least 10%, and (3) not at high risk for bleeding, clinicians should use low-dose aspirin to reduce CRC incidence and mortality. BEST PRACTICE ADVICE 2: In individuals with a history of CRC, clinicians should consider using aspirin to prevent recurrent colorectal neoplasia. BEST PRACTICE ADVICE 3: In individuals at average risk for CRC, clinicians should not use non-aspirin NSAIDs to prevent colorectal neoplasia because of a substantial risk of cardiovascular and gastrointestinal adverse events. BEST PRACTICE ADVICE 4: In individuals with type 2 diabetes, clinicians may consider using metformin to prevent colorectal neoplasia. BEST PRACTICE ADVICE 5: In individuals with CRC and type 2 diabetes, clinicians may consider using metformin to reduce mortality. BEST PRACTICE ADVICE 6: Clinicians should not use calcium or vitamin D (alone or together) to prevent colorectal neoplasia. BEST PRACTICE ADVICE 7: Clinicians should not use folic acid to prevent colorectal neoplasia. BEST PRACTICE ADVICE 8: In individuals at average risk for CRC, clinicians should not use statins to prevent colorectal neoplasia. BEST PRACTICE ADVICE 9: In individuals with a history of CRC, clinicians should not use statins to reduce mortality.

OBJECTIVES/OBJECTIVE:To determine how self-reported level of exposure to patients with novel coronavirus 2019 (COVID-19) affected the perceived safety, training and well-being of residents and fellows. METHODS:We administered an anonymous, voluntary, web-based survey to a convenience sample of trainees worldwide. The survey was distributed by email and social media posts from April 20th to May 11th, 2020. Respondents were asked to estimate the number of patients with COVID-19 they cared for in March and April 2020 (0, 1-30, 31-60, >60). Survey questions addressed (1) safety and access to personal protective equipment (PPE), (2) training and professional development and (3) well-being and burnout. RESULTS:Surveys were completed by 1420 trainees (73% residents, 27% fellows), most commonly from the USA (n=670), China (n=150), Saudi Arabia (n=76) and Taiwan (n=75). Trainees who cared for a greater number of patients with COVID-19 were more likely to report limited access to PPE and COVID-19 testing and more likely to test positive for COVID-19. Compared with trainees who did not take care of patients with COVID-19 , those who took care of 1-30 patients (adjusted OR [AOR] 1.80, 95% CI 1.29 to 2.51), 31-60 patients (AOR 3.30, 95% CI 1.86 to 5.88) and >60 patients (AOR 4.03, 95% CI 2.12 to 7.63) were increasingly more likely to report burnout. Trainees were very concerned about the negative effects on training opportunities and professional development irrespective of the number of patients with COVID-19 they cared for. CONCLUSION/CONCLUSIONS:Exposure to patients with COVID-19 is significantly associated with higher burnout rates in physician trainees.

BACKGROUND:Colorectal cancer is the second leading cause of cancer death among Hispanic Americans. Puerto Ricans are the second largest Hispanic subgroup in the USA and the largest in New York City, but little is known about predictors of colorectal cancer screening uptake in this population. AIMS/OBJECTIVE:We used the New York City Community Health Survey, a population-based telephone survey, to investigate predictors of up-to-date colonoscopy use over time among Puerto Ricans aged ≥ 50 years in NYC. METHODS:We assessed the association between sociodemographic and medical factors and up-to-date colonoscopy use (defined as colonoscopy within the last 10 years) using univariable and multivariable logistic regression over six time periods: 2003-2005, 2006-2008, 2009-2010, 2011-2012, 2013-2014, and 2015-2016. RESULTS:On multivariable analysis, age ≥ 65 years (OR 1.64-1.93 over three periods) and influenza vaccination (OR 1.86-2.17 over five periods) were the two factors most consistently associated with up-to-date colonoscopy use. Individuals without a primary care provider (OR 0.38-0.50 over three periods) and who did not exercise (OR 0.49-0.52 over two periods) were significantly less likely to have an up-to-date colonoscopy. CONCLUSIONS:Older age, influenza vaccination, having a primary care provider, and exercise are independent predictors of up-to-date colonoscopy use among Puerto Ricans in NYC. Interventions to improve screening colonoscopy uptake among Puerto Ricans should be targeted to those aged 50-64 years and who do not have a primary care provider.

INTRODUCTION: Gastric cancer is one of the most common cancers worldwide, but evidence for screening and surveillance in the US is limited by sparse clinical research. While recent immigrants from endemic regions such as East Asia are known to be at high risk, it's unclear what are the important risk factors in a population with fewer recent immigrants. Therefore, we conducted a matched case-control study in a VA medical center.
METHOD(S): We identified individuals with gastric cancer using both the tumor registry and electronic medical record at VA New York Harbor from 1/1/97 to 10/31/18. Diagnosis was confirmed by pathology report. Controls were identified from patients who underwent EGD during the same period. Variables of interest included age (at time of data extraction or death), sex, race/ethnicity, H. pylori status, smoking, alcohol use, pernicious anemia, and family history. Controls were matched to cases in a 2:1 ratio by age (1/- 3 years) and sex. Univariable and multivariable conditional logistic regression was performed to evaluate associations between potential risk factors and gastric cancer.
RESULT(S): A total of 504 patients (168 cases and 336 controls) were identified. The mean age was 76 years and 98% were men (Table 1). Among cancer patients, 40% were diagnosed with Stage IV disease and 80% had non-cardia cancer (Table 2). On univariable analysis, associations between gastric cancer and race/ethnicity, H. pylori status, alcohol use, and pernicious anemia were observed (Table 3). On multivariable analysis, Black individuals had higher risk of gastric cancer than White individuals (OR 2.73, 95% CI 1.12-6.68). Those with H. pylori eradication had lower risk than those who were H. pylori negative (OR 0.15, 95% CI 0.06-0.38). Former alcohol users also had lower risk than never users (OR 0.26, 95% CI 0.07-0.97).
CONCLUSION(S): In a single-center VA study, we found Black race increased risk for gastric cancer, while H. pylori eradication and former alcohol use reduced risk. While prior US-based studies have found increased risk in East Asian and Hispanic populations, our findings suggest Black individuals are at higher risk in a healthcare system with fewer recent immigrants. Further research is required to explore this potential health disparity. That H. pylori eradication and former alcohol use were protective against gastric cancer may indicate greater adherence to medical advice and healthier lifestyles in these individuals. (Figure Presented)

Background: During the novel coronavirus-2019 (COVID-19) pandemic, physicians in residency and fellowship training programs are serving as essential healthcare workers while also attempting to continue their preparation for eventual independent practice in their field. We aimed to determine how level of exposure patients with COVID-19 affected the experience of graduate medical trainees in terms of their safety, professional development, and well-being during March and April 2020 Methods: We administered an anonymous, voluntary, web-based survey to physicians enrolled in residency or fellowship training programs in any specialty worldwide A convenience sampling of trainees was obtained through distribution of the survey by email and social media posts from April 20th to May 11th, 2020 To investigate the impact of burden of exposure to COVID-19 the trainee experience, we categorized respondents according to their self-reported estimate of the number of patients with COVID-19 that they provided care for in March and April 2020 (0, 1-30, 31-60, >60). Descriptive statistics were performed and the chi square test was used to evaluate for statistical significance. A multivariable logistic regression analysis was conducted to determine independent predictors of physician burnout Results: Surveys were completed by 1420 trainees, of whom 1031 (73%) were residents Most of the fellows who responded to the survey were training in gastroenterology/ hepatology (27%, 85/280) Trainees who cared for a greater number of COVID-19 patients were more likely to report limited access to PPE and COVID-19 testing and more likely to report testing positive for COVID-19 (Figure 1A) Compared to trainees who did not take care of COVID-19 patients, those who took care of 1-30 patients (adjusted odds ratio [AOR] 1 80, 95% CI 1 29-2 51), 31-60 patients (AOR 3.30, 95% CI 1.86-5.88) and >60 patients (AOR 4.03, 95% CI 2 12-7 63) were increasingly more likely to report burnout More than half (835, 58%) of trainees reported concern about their future preparedness for independent practice Trainees who cared for >60 COVID-19 patients compared to those who did not care for any COVID-19 patients reported similar levels of concern about their preparedness for independent practice (56%, 372/636 vs 58%, 71/125 respectively, p-value 0 57, Figure 1B)
Conclusion(s): Physician trainees who were involved in the care of patients with COVID-19 were more likely to report unsafe working conditions and suffered from higher rates of physician burnout Trainees were concerned about the effects of lost training opportunities on their professional development irrespective of the number of COVID-19 patients they cared for

GOALS/OBJECTIVE:The goal of this study was to quantify the association between demographic factors and advanced colorectal cancer (CRC) in patients under age 50. BACKGROUND:CRC incidence in the United States has declined in older individuals but increased in those under age 50 (early-onset). More than 60% of early-onset CRC patients present with advanced disease (stage III/IV), but predictors of stage in this population are poorly defined. STUDY/METHODS:We analyzed CRC cases diagnosed between age 20 and 49 in the United States Surveillance, Epidemiology, and End Results (SEER) 18 database during 2004 to 2015. Logistic regression models were fit to assess the impact of age, sex, race, ethnicity, marital status, and cancer site on the probability of advanced disease. RESULTS:The analysis included 37,044 cases. On multivariable regression, age was inversely associated with advanced disease. Relative to 45 to 49-year-olds, 40 to 44-year-olds had 8% greater odds of having advanced CRC, and 20 to 24-year-olds had 53% greater odds. Asians, blacks, and Pacific Islanders had 10%, 12%, and 45% greater odds of advanced disease compared with whites. Compared with nonpartnered individuals, those with partners had 11% lower odds of advanced CRC. Both right-sided and left-sided colon cancer were more likely to be diagnosed at stage IV compared with rectal cancer. CONCLUSIONS:Among individuals with early-onset CRC, younger age, Asian, black, or Pacific Islander race, and being nonpartnered were predictors of advanced disease at presentation. Colon cancer was more likely to be diagnosed at stage IV than rectal cancer. Patient characteristics associated with advanced CRC may indicate both differences in tumor biology and disparities in health care access.

Bowel preparation with low-residue diet (LRD) has resulted in higher patient satisfaction and similar polyp detection rates compared to conventional clear liquid diet. However, there is limited experience with LRD in veterans, in whom conditions associated with poor bowel preparation are more prevalent than the general population. To examine risk factors associated with inadequate bowel preparation, we conducted a chart review of outpatient colonoscopies at the Manhattan VA Medical Center from February 2017 to April 2018. To examine patient satisfaction and compliance, we administered an anonymous questionnaire to patients undergoing outpatient colonoscopy from March to August 2018. Patients assessed by chart review (n = 660) were 92% male with a mean age of 64 years. An adequate Boston Bowel Preparation Scale score ≥2 in each colonic segment was achieved in 94% of procedures. Higher BMI, diabetes, prior inadequate bowel preparation, bowel preparation duration of two days, and opioid use were associated with inadequate bowel preparation on univariable analysis. On multiple logistic regression, only higher BMI remained a predictor, with every one-unit increase associated with a 6% increased odds of poor bowel preparation. Questionnaire responses showed 84% of patients were willing to repeat LRD bowel preparation, 85% found the process easy or acceptable, and 78% reported full adherence to LRD. These findings demonstrate that bowel preparation quality, patient satisfaction, and compliance were all high among veterans using LRD.