Faculty Bibliography

INTRODUCTION: Immunosuppressed patients such as those with malignancies are susceptible to reactivation of tuberculosis (TB), which can affect the gut. CMV should also be considered as a cause of colitis in these patients. CASE DESCRIPTION/METHODS: A 68-year-old man with a history of T-cell lymphoma of the kidney and nasal cavity and latent TB presented with weight loss and cough. He was cachectic and had diffuse rhonchi in the lung bases. CT of the chest showed areas of cavitation. Multiple sputum cultures positive for acid-fast bacilli (AFB) and a positive mycobacterium tuberculosis (MTB) PCR confirmed active TB infection. The patient developed repeated episodes of melena with a hemoglobin level of 5.0 g/dL, MCV of 71.5 fL, iron of 4.5 ug/dL, transferrin saturation of 1%. Colonoscopy revealed extensive diverticulosis in the sigmoid colon and evidence of a prior cecectomy with ulceration of the ileocolonic anastomosis. Biopsies showed dense mature lymphocytic infiltrate and granulation tissue with no evidence of T-cell lymphoma. A CT revealed a 4 cm segment of terminal ileum with mild wall thickening, mucosal hyperenhancement and thickened folds of a distal loop of jejunum. Stool AFB culture and MTB PCR were both positive, indicating a probable diagnosis of TB enteritis. A push enteroscopy showed a 60 mm infiltrative lesion with ulcerated bases and three smaller lesions of similar appearance on the anterior wall of the stomach along with jejunal ulceration. Ulcer biopsies revealed large cells with inclusions consistent with CMV enteritis. Stains for AFB were also positive. Biopsies of the stomach lesions revealed an ulcerative oxyntic mucosa with dense atypical lymphoid infiltrate. Markers were consistent with a diagnosis of Burkitt's Lymphoma (BL). The patient was treated with TB therapy, ganciclovir, and R-CHOP. DISCUSSION: Immunosuppression due to this patient's BL likely led to dissemination and reactivation of latent TB and susceptibility to infection with CMV. The stomach and bowel are the most common sites of extranodal involvement in BL. The incidence of TB in malignancy is highest in non- Hodgkin's lymphoma like BL. Bowel involvement in TB is seen in less than 5% of cases in the United States. Common endoscopic findings include ileal or ileocecal disease, non-confluent involvement of the colon, and nodular mucosa with areas of ulceration. The diagnosis can be made by biopsy showing caseating granulomas, a positive TB culture or PCR result, or by clinical suspicion with improvement following treatment. (Figure Presented)

INTRODUCTION: Colonoscopy is the only colorectal cancer screening modality that permits direct visualization of the entire colon and removal of polyps. Low-quality bowel preparation has been associated with lower adenoma detection rates, increased procedure time, and increased hospital cost. An inadequate preparation limits the diagnostic accuracy and overall efficacy of colonoscopy. Factors that contribute to inadequate bowel preparations include age, male sex, inpatient status, low socioeconomic status, low English proficiency, obesity, diabetes, and cirrhosis. We investigated the complex relationship between socioeconomic factors and medical comorbidities on the quality of inpatient colonoscopy preparation.
METHOD(S): We conducted a retrospective chart review of inpatient colonoscopies between October 2017 and April 2019. All patients received a single-dose preparation of polyethylene glycol. We collected data including demographics, medical history, indication, and bowel preparation. A Boston Bowel Preparation Score of 6 or above or an Aronchick score of "good" or "excellent" was used to define an adequate preparation.
RESULT(S): A total of 230 patients were included in the final analysis (Table 1). An inadequate bowel preparation was reported in 16.1% of our inpatient colonoscopies. Within the inadequate preparation group, a greater percentage of patients were male (17.3% vs. 12.3%), had low English proficiency (18.3% vs.15.3%), were not diabetic (17.7% vs.12.3%), and did not have prior bowel surgery (16.4% vs. 0.0%). Within the age, race/ethnicity, and insurance subgroups, patients who were age 80+ (21.4%), Asian-American (25%), unreported race/ethnicity (29.4%), uninsured (25%), and prisoners (22.8%) had a greater percentage of inadequate preparation (Table 2). A logistic regression was performed to assess the effects of age, sex, race/ethnicity, insurance, English fluency, diabetes, restricted mobility, and prior surgery on bowel preparation. The logistic regression model was not statistically significant.
CONCLUSION(S): No significant socioeconomic or medical predictors of bowel preparation were found in this inpatient population which is in contrast to prior literature. While less than 20% of our patient population had inadequate bowel preparation, this is still significant in the broader context of quality, safety, and healthcare costs. Identifying strategies to increase the quality of bowel preparation still remains at the forefront of our field. (Table Presented)

INTRODUCTION: Informed consent involves a thorough understanding of procedural risks, benefits, and alternatives. Among patients with Limited English Proficiency (LEP) it is difficult to ascertain comprehension even with the use of a certified medical interpreter. Prior studies have demonstrated that use of video during informed consent improves patient comprehension relative to traditional verbal consent. This quality improvement initiative aims to improve patient comprehension of endoscopy and colonoscopy though utilization of an educational video in the patient's primary language as a component of informed consent.
METHOD(S): Short videos explaining the risks, benefits, and alternatives for endoscopy and colonoscopy were produced in English and Spanish. All patients underwent a traditional verbal consent process, with the use of a certified medical interpreter if indicated. A group also watched the educational video. Following either the video or the traditional verbal consent, the patients filled out a questionnaire in their preferred language to assess comprehension of the planned procedure and its risks, benefits, and alternatives.
RESULT(S): A total of 74 questionnaires were administered. Group 1 underwent traditional consent alone and group 2 watched the video prior to traditional consent. The colonoscopy cohort included 35 English-language and 11 Spanish-language patients; the endoscopy cohort included 21 English-language and 7 Spanish-language patients. The mean patient score on the colonoscopy questionnaire for group 2 was 77% compared with 54% for group 1 (P = 0.003). In the endoscopy cohort, group 2 also scored higher than group 1 (P = 0.0004). Among Spanishspeaking patients, group 2 had better comprehension scores than group 1 (86% vs 33%, P < 0.0005).
CONCLUSION(S): Our results demonstrate a significant improvement in patient comprehension with the use of video education as part of the consent for colonoscopy and endoscopy. This difference was most notable for Spanish-speaking patients. Future directions include translation of the video into additional languages and incorporation into the standard pre-procedure consent at our institution in order to improve quality of care for patients who are both language concordant and language discordant with their providers. (Figure Presented)

Strongyloides stercoralis infection typically presents with nonspecific gastrointestinal symptoms and no definitive or pathognomonic endoscopic findings. Disease burden can vary depending on a patient's immune status. Immunocompromised patients with strongyloidiasis can develop tremendous disease burden, extraintestinal dissemination, and are at risk for coinfection with other organisms. We present the case of an immunocompromised patient presenting with multiple gastrointestinal complaints found to have S. stercoralis hyperinfection and concomitant cytomegalovirus gastroenteritis.

Chinese American immigrants are at increased risk for Helicobacter pylori infection and stomach cancer. Despite their increased risk, very few prevention strategies exist which target this vulnerable population. The purpose of this article is to present the stakeholder engaged development, review, assessment, refinement, and finalization of a H. pylori treatment adherence and stomach cancer prevention curriculum specifically designed to engage vulnerable, limited English proficient Chinese Americans in New York City.

Scleroderma (SSc) is a disease caused by collagen deposition resulting in fibrosis within multiple organs, including the gastrointestinal tract, skin, joints, kidneys, lungs, and heart. We report a rare case of a patient with diffuse SSc who presented with a large bowel obstruction from a fecal bezoar impaction. The bezoar was successfully removed using colonoscopy after lavage, cold forceps, balloon dilator, and cap-assisted disimpaction. We demonstrate that patients with SSc are at risk for bezoar formation and true mechanical obstruction in the lower gastrointestinal tract, which may require more aggressive endoscopic treatment if conservative measures fail.

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.