Faculty Bibliography

BACKGROUND:Hepatitis B virus is a viral infection that can lead to acute and/or chronic liver disease, and hepatocellular carcinoma (HCC). Hepatitis B vaccination is 95% effective in preventing infection and the development of chronic liver disease and HCC due to hepatitis B. In 2011, the Centers for Disease Control updated their guidelines recommending that adults at high-risk for hepatitis B infection be vaccinated against hepatitis B including those with diabetes mellitus (DM). We hypothesize that adults at high-risk for hepatitis B infection are not being adequately screened and/or vaccinated for hepatitis B in a large urban healthcare system. AIM/OBJECTIVE:To investigate clinical factors associated with Hepatitis B screening and vaccination in patients at high-risk for Hepatitis B infection. METHODS:We conducted a retrospective review of 999 patients presenting at a large urban healthcare system from 2012-2017 at high-risk for hepatitis B infection. Patients were considered high-risk for hepatitis B infection based on hepatitis B practice recommendations from the Center for Disease Control. Medical history including hepatitis B serology, concomitant medical diagnoses, demographics, insurance status and social history were extracted from electronic health records. Multivariate logistic regression was used to identify clinical risk factors independently associated with hepatitis B screening and vaccination. RESULTS:< 0.05. CONCLUSION/CONCLUSIONS:Patients at high-risk for hepatitis B are not being adequately screened and/or vaccinated. Improvements in hepatitis B vaccination should be strongly encouraged by all healthcare systems.

OBJECTIVES/OBJECTIVE:The aim of this study was to assess the role of hepatitis B (HepB) infection in the causation of pancreatic cancer and the predictors of pancreatic cancer and related mortality. METHODS:We identified pancreatic cancer patients 11 to 70 years of age from the 2013-2014 National Inpatient Sample. Pearson χ test and Student t test were used for categorical and continuous variables, respectively. We assessed the association of HepB and pancreatic cancer along with the independent mortality predictors by multivariate analyses. RESULTS:Of 69,210 weighted pancreatic cancer patients, 175 patients with a history of HepB and 69,035 patients without a history of HepB were identified. Compared with the pancreatic cancer-non-HepB group, the pancreatic cancer-HepB group consisted more of younger (mean age, 60.4 [SD, 7.4] years vs 68.2 [SD, 12.1] years), male, black, and Asian patients with low household income and nonelective and northeast region admissions. The odds of developing pancreatic cancer among the HepB patients were significantly higher (adjusted odds ratio, 1.24; 95% confidence interval, 1.056-1.449; P = 0.008). Black race, age 65 years or older, and male sex demonstrated greater odds of mortality. CONCLUSIONS:This study concluded up to a 24% increased likelihood of pancreatic cancer among the HepB patients. In addition, black race interestingly showed greater odds of pancreatic cancer and related in-hospital mortality.

Background/UNASSIGNED:This study was performed to compare patient-reported tolerability and its barriers in single- vs. split-dose 4-L polyethylene glycol (PEG) bowel preparation for colonoscopy in a large multiethnic, safety-net patient population. Methods/UNASSIGNED:A cross-sectional, dual-center study using a multi-language survey was used to collect patient-reported demographic, medical, socioeconomic, and tolerability data from patients undergoing outpatient colonoscopy. Univariate and multivariate analyses were used to identify demographic and clinical factors significantly associated with patient-reported bowel preparation tolerability. Results/UNASSIGNED:A total of 1023 complete surveys were included, of which 342 (33.4%) completed single-dose and 681 (66.6%) split-dose bowel preparation. Thirty-nine percent of the patients were Hispanic, 50% had Medicaid or no insurance, and 34% had limited English proficiency. Patients who underwent split-dose preparation were significantly more likely to report a tolerable preparation, with less severe symptoms, than were patients who underwent single-dose preparation. Multiple logistic regression revealed that male sex and instructions in the preferred language were associated with tolerability of the single-dose preparation, while male sex and concerns about medications were associated with tolerability of the split-dose preparation. Conclusions/UNASSIGNED:In a large multiethnic safety-net population, split-dose bowel preparation was significantly more tolerable and associated with less severe gastrointestinal symptoms than single-dose preparation. The tolerability of split-dose bowel preparation was associated with social barriers, including concerns about interfering with other medications.

Background and Aims: The Centers for Disease Control (CDC) recommends that baby boomers (adults born between 1945-1965) be screened for hepatitis C (HCV). Patients with HCV are at increased risk of co-infection with hepatitis B (HBV). We investigated HCV screening rates in a baby boomer cohort with chronic HBV or at high-risk for HBV infection from a large healthcare system. Methods: We conducted a retrospective cohort analysis of 792 baby boomers, evaluated at New York Langone (NYU) from 2012-2017 with chronic HBV or at high-risk for HBV infection. CDC guidelines were used to assess whether a patient was considered at high-risk for HBV infection. Medical history including hepatitis serology was extracted from electronic health records. Multiple logistic regression was used to identify clinical risk factors independently associated with HCV screening. Results: Among 792 patients, 419 (52.9%) were screened. Multivariate regression of factors significant (P<.05) on univariate analysis revealed that health insurance, end-stage renal disease (ESRD), chronic liver disease (CLD), diabetes mellitus (DM) and current alcohol use were each independently associated with HCV screening. The strongest predictors of HCV screening were ESRD (OR: 3.346; 95% CI: 1.688-6.634) and CLD (OR: 3.027; 95% CI: 2.102-4.359), while DM (OR: 0.680; 95% CI: 0.497-0.930) was associated with a decreased likelihood of prior screening. Conclusion: In a retrospective study of patients at NYU, the baby boomer cohort with chronic HBV or at high-risk for HBV infection are not being adequately screened for HCV. Improvement in HCV screening should be strongly encouraged by all healthcare systems.

Introduction:Service in the community and academic medicine are often seen by trainees as unrelated. This may be one reason for the lack of faculty diversity and the declining interest in academic medicine among new trainees. Methods:We developed an educational workshop through the application of the Kern model to help medical students and residents understand the relationship between community service work and scholarship as it pertains to a career in academic medicine. Specifically, the workshop helped trainees (1) understand the terms service and scholarship, (2) understand the benefits of achieving community service scholarship, and (3) identify steps to achieve community service scholarship through mock cases and personal stories. Results:The workshop was implemented at five conferences with a total of 139 trainees. Results of a paired-samples t test of learners' responses pre- and postworkshop showed statistically significant growth in their confidence to publish service-related work, as well as more positive agreement with the notion that community service work aligns with an academic medicine career. Discussion:This effective module can help trainees understand how community service and academic medicine are aligned, and raise their confidence in building a foundation for an academic medicine career through conducting community service scholarship.

Introduction:The American Society of Gastrointestinal Endoscopy recommends continuing aspirin prior to routine endoscopy. National data show that few endoscopists follow the current guidelines due to concern about bleeding and perceived minimal downside to stopping aspirin. Utilizing the Kern model, we implemented an educational quality improvement initiative aimed at increasing knowledge of antithrombotic management periendoscopy and during acute gastrointestinal (GI) bleeding. Methods:We implemented an interactive lecture incorporating a large-group discussion to help residents learn to define low- versus high-risk procedures, distinguish thrombotic risk in medical conditions, present the procedural risks associated with use of antiplatelets, and list current practice guidelines. Nursing staff received a tailored lecture with the goal of learning proper management of current antiplatelets and holding parameters for anticoagulants prior to endoscopy. Both groups received pre-and posttest questionnaires evaluating their knowledge. Results:< .001). Discussion:This quality-based educational intervention significantly increased the knowledge of nurses and medical trainees in management guidelines that directly impact patient care. Similar educational programs may be very effective in improving quality and safety.

Introduction: Efficacy of colonoscopy is limited by inadequate preparation. A high social deprivation index has been identified as a risk factor for failure to repeat a colonoscopy when indicated. It is unknown whether or not split dose preparation increases adherence to recommendation for repeat colonoscopy. Few studies to date have evaluated the potential barriers to likelihood of repeating a bowel preparation in an underserved population. The purpose of this study was to identify factors associated with an increased likelihood of repeating a bowel preparation in a population with a high social deprivation index in a split-dose versus a single dose cohort Methods: Demographic, socioeconomic, medical, education and tolerability data were collected prospectively using a multi-language questionnaire. Descriptive statistics and multivariate analyses were performed on all variables assessed by our questionnaire to evaluate for differences in patients who were likely and unlikely to repeat the preparation. Results: Demographics are presented in table 1 (N=990). 336 (34%) completed single dose and 654 (66%) completed split dose colon preparation. Split dose patients were equally willing-to-repeat colonoscopy preparation compared to single dose patients (69.0% vs. 71.6%; P=0.45) (Table 2). Patients who were not willing to repeat split preparation complained of significantly more adverse gastrointestinal symptoms and difficulty completing dosing instructions due to social barriers and tolerability issues compared to single-dose cohort. Multivariable analysis revealed that concerns with time off work (OR: 0.48; 95% CI: 0.29-0.80), availability of appropriate food/drinks (OR: 0.59; CI: 0.36-0.97), tolerability (OR: 0.72; CI: 0.57-0.92), and colonoscopy scheduling (OR: 0.77; CI: 0.63- 0.94) were all factors independently associated with decreased willingness to repeat in the split dose cohort. Nurse's instruction in preferred language (OR: 2.69; CI: 1.22-5.91) and tolerability (OR: 0.71; CI: 0.55-0.92) were independently associated with patient willingness-to-repeat in the single-dose cohort. Conclusion: This study highlights that tolerability significantly effects repeatability in both single and split dose cohorts. It should be noted that patients with a high social deprivation index identify different barriers to single and split dose preparations. This observation could impact choice of preparation as it affects adherence to physician recommendations. (Figure Presented)

Introduction: Effectiveness of colonoscopy is limited by inadequate bowel preparation. Failure of proper cleansing is multifactorial, but includes the inability of patients to tolerate the bowel preparation due to side effects. It is unknown whether or not the experience with split dose preparation increases adherence to recommendation for repeat colonoscopy. Few studies to date have evaluated potential barriers to bowel preparation in underserved populations. The purpose of this study was to identify whether adverse effects of bowel preparation affect the likelihood of repeating a colonoscopy in a split-dose versus a single dose cohort Methods: Demographic, socioeconomic, medical, education and tolerability data were collected prospectively using a multi-language questionnaire. Descriptive statistics and multivariate analyses were performed on all variables assessed by our questionnaire to evaluate for differences in patients who were likely or unlikely to repeat the preparation. Results: A total of 990 patients satisfied the study criteria (Figure 1). 54.6% of the patients were male, 39.7% Hispanic, 41.2% with less than a high school education, and 38.9% without medical insurance. 336 (34%) completed single dose and 654 (66%) completed split dose colon preparation. In the single dose cohort there were no statistically significant differences in the side effects experienced between patients who would and would not repeat the bowel preparation (Table 1). In contrast, in the split-dose cohorts, complaints of bad taste in mouth, nausea/vomiting and headache were statistically significant causes of a patient being unlikely to repeat the bowel preparation (p < .05) (Table 2). Despite the difference in the role of symptoms in willingness to repeat colon preparation between split dose versus single does preparation groups, there was no significant difference in overall willingness to repeat colon preparation between groups (69.0% versus 71.6%, p = 0.45). Conclusion: This study highlights differences in side effects experienced by patients taking a split dose compared to a single dose preparation. Despite these differences, patients in both groups were likely to repeat a colonoscopy. These results should give a provider confidence in prescribing a split dose preparation to a diverse patient population

Introduction: Single balloon enteroscopy (SBE) is a method used for evaluation of the small intestine. It is most frequently used to investigate the cause of obscure gastrointestinal (GI) bleeding, and is useful to investigate other disorders as well. In a case series of obscure overt GI bleeding, Pinto-Pais et al. demonstrated that 93.3% of patients with active bleeding underwent SBE that identified the source, and 64.3% of patients with inactive GI bleeding had a definitive bleeding source identified. The aim of our study was to evaluate the efficacy of SBE at Bellevue Hospital from its introduction at our institution in 2008 through 2015. Methods: A query of our endoscopic software was performed of SBE procedures from January 2008 through September 2015. The main inclusion criterion was patients at least 18 years of age who underwent SBE. The patient's age, past medical history, pertinent laboratory tests, procedural indications, capsule endoscopy findings, pathology results, SBE outcomes, and adverse events were collected. Results: Forty SBEs were performed during this period: twenty-nine anterograde and eleven retrograde. The average age of the patients was 51.9. Procedural indications including bleeding (18), anemia (9), retained video capsule (4), intussusception (2), mass (2), and other abnormal imaging findings (5). Nineteen procedures were successful in reaching the area in question. Diagnoses included one paraganglioma, one adenocarcinoma, one GIST, and one carcinoid. Six procedures led to treatment of AVMs with subsequent improvement in anemia. Adverse events included abdominal pain in 3 procedures. Two of these episodes resolved without intervention and the third patient was lost to follow-up. One patient had mucosal trauma and oozing. One patient had melena and a decline in hemoglobin, which resolved without intervention. One patient had a possible retroperitoneal hematoma after the procedure. Conclusion: This study outlines the diagnostic and therapeutic utility of SBE in varied clinical scenarios in the diverse patient population at Bellevue Hospital, a large tertiary care referral center in New York City. Ongoing studies would include investigating the utility of SBE in symptomatic patients without abnormal findings on imaging or laboratory studies, the use of enteroscopic localization technology to improve patient comfort, safety, and procedural efficiency, and optimizing procedural timing to determine if sensitivity and yield are enhanced

We describe a case of a 36-year-old man with a history of chronic hepatitis C who presented with abdominal pain 3 days after undergoing a percutaneous ultrasound-guided liver biopsy. Initial investigations revealed a venobiliary fistula with haemobilia and obstructive jaundice with direct bilirubin peaking at 9.2 mg/dL. He underwent an endoscopic retrograde cholangiopancreatography with sphincterotomy and stent placement, bilirubin decreased to 3.7 mg/dL, and the patient was discharged. The patient returned with recurrent abdominal pain and upper gastrointestinal bleeding with haemoglobin of 8.6 g/dL, requiring multiple transfusions. He underwent transcatheter arterial embolisation but continued bleeding. Radiofrequency ablation was pursued and was able to achieve haemostasis. The patient was discharged. The patient returned again with a fever of 39.2 degrees C and was found to have a large right hepatic lobe abscess. The patient underwent abscess drainage with drain placement and was treated with antibiotics for 6 weeks. He followed up in the clinic with resolution of symptoms and infection.