Gobind Anand

What Is the More Effective Antibiotic Stewardship Intervention: Preprescription Authorization or Postprescription Review With Feedback?

Background The optimal approach to conducting antibiotic stewardship interventions has not been defined. We compared days of antibiotic therapy (DOT) using preprescription authorization (PPA) vs postprescription review with feedback (PPRF) strategies. Methods A quasi-experimental, crossover trial comparing PPA and PPRF for adult inpatients prescribed any antibiotic was conducted. For the first 4 months, 2 medicine teams were assigned to the PPA arm and the other 2 teams to the PPRF arm. The teams were then assigned to the alternate arm for an additional 4 months. Appropriateness of antibiotic use was adjudicated by at least 2 infectious diseases-trained clinicians and according to institutional guidelines. Results There were 2686 and 2693 patients admitted to the PPA and PPRF groups, with 29% and 27% of patients prescribed antibiotics, respectively. Initially, antibiotic DOTs remained relatively unchanged in the PPA arm. When changed to the PPRF arm, antibiotic use decreased (-2.45 DOT per 1000 patient-days [PD]). In the initial PPRF arm, antibiotic use decreased (slope of -5.73 DOT per 1000 PD) but remained constant when changed to the PPA arm. Median patient DOTs in the PPA and PPRF arms were 8 and 6 DOT per 1000 PD, respectively (P = .03). Antibiotic therapy was guideline-noncompliant in 34% and 41% of patients on days 1 and 3 in the PPA group (P < .01) and in 57% and 36% of patients on days 1 and 3 in the PPRF group (P = .03). Conclusions PPRF may have more of an impact on decreasing antibiotic DOTs compared with PPA. This information may be useful for institutions without sufficient resources to incorporate both stewardship approaches.

Targeting Dysbiosis for the Treatment of Liver Disease

The gut microbiome is composed of a vast number of microbes in the gastrointestinal tract, which benefit host metabolism, aid in digestion, and contribute to normal immune function. Alterations in microbial composition can result in intestinal dysbiosis, which has been implicated in several diseases including obesity, inflammatory bowel disease, and liver diseases. Over the past several years, significant interactions between the intestinal microbiota and liver have been discovered, with possible mechanisms for the development as well as progression of liver disease and promising therapeutic targets to either prevent or halt the progression of liver disease. In this review the authors examine mechanisms of dysbiosis-induced liver disease; highlight current knowledge regarding the role of dysbiosis in nonalcoholic liver disease, alcoholic liver disease, and cirrhosis; and discuss potential therapeutic targets.

A population-based evaluation of severity and mortality among transferred patients with acute pancreatitis

Objectives This study aimed to compare severity of acute pancreatitis (AP) and mortality rates between transferred and nontransferred patients and to determine the factors that influence the decision to transfer. Methods A retrospective analysis coding a statewide administrative database in Maryland was conducted. Severity was defined by presence of organ failure (OF), need for intensive care unit (ICU), mechanical ventilation (MV), or hemodialysis. Results There were 71,035 discharges for AP, with 1657 (2.3%) patient transfers. Transferred patients had more multisystem OF (5.6% vs 1.2%), need for ICU (22.8% vs 4.3%), MV (13.1% vs 1.4%), hemodialysis (4.2% vs 2.7%), and higher mortality (6.1% vs 1.1%) compared with nontransferred patients (P < 0.0001). After adjusting for disease severity, mortality was similar between the transferred patients and the nontransferred patients (OR, 1.37; 95% confidence interval, 0.96–1.97). Younger (OR, 0.99), African American (OR, 0.55), and uninsured (OR, 0.46) patients were less likely to be transferred, whereas patients with multisystem OF (OR, 3.5), need for ICU (OR, 2.3), or MV (OR, 2.1) were more likely to be transferred (P < 0.0001). Conclusions Transferred patients with AP have more severe disease and higher overall mortality. Mortality is similar after adjusting for disease severity. Disease severity, insurance status, race, and age all influence the decision to transfer patients with AP.

Electrohydraulic lithotripsy to treat basket impaction of large common bile duct stone

Choledocholithiasis with large bile duct stones greater than 10 mm are at increased risk for failure of traditional endoscopic extraction techniques. One extraction method for large stones is the use of a wire basket to grasp the stone, crush the stone, and then extract the pieces. Occasionally, lithotripsy basket wires can become embedded within the stone, or the wires may fracture. If the wires become embedded, typically an extra-endoscopic mechanical lithotripsy device is used to forcibly crush the stone. When extra-endoscopic mechanical lithotripsy cannot be used, cholangioscopy with laser or electrohydraulic lithotripsy (EHL) has been described. Here we present a case in which cholangioscopy with EHL was used as a rescue technique for an impacted lithotripsy basket (Video 1, available online at www.VideoGIE.org).

Factors and Outcomes Associated with MRCP Use prior to ERCP in Patients at High Risk for Choledocholithiasis

Background. Consensus guidelines recommend that patients at high risk for choledocholithiasis undergo endoscopic retrograde cholangiopancreatography (ERCP) without additional imaging. This study evaluates factors and outcomes associated with performing magnetic resonance cholangiopancreatography (MRCP) prior to ERCP among patients at high risk for choledocholithiasis. Methods. An institutional administrative database was searched using diagnosis codes for choledocholithiasis, cholangitis, and acute pancreatitis and procedure codes for MRCP and ERCP. Patients categorized as high risk for choledocholithiasis were evaluated. Results. 224 patients classified as high risk, of whom 176 (79%) underwent ERCP only, while 48 (21%) underwent MRCP prior to ERCP. Patients undergoing MRCP experienced longer time to ERCP (72 hours versus 35 hours, p < 0.0001), longer length of stay (8 days versus 6 days, p = 0.02), higher hospital charges (

Totally One-sided: Painless Unilateral Proptosis

23,488 versus

Underdiagnosis of Lynch Syndrome Involves More Than Family History Criteria

19,260, p = 0.08), and higher radiology charges (

Overall Mortality and Pancreatic Cancer Mortality Among Patients With Pancreatic Cystic Neoplasms

3,385 versus

Sa1645 - Comparison of the Fukuoka Consensus Guidelines and the American Gastroenterological Association Guidelines as Predictors for Developing Pancreas Cancer Among Patients with Pancreatic Cysts

1,711, p < 0.0001). The presence of common bile duct stone(s) on ultrasound was the only independent factor associated with less use of MRCP (OR 0.09, p < 0.0001). Conclusions. MRCP use prior to ERCP in patients at high risk for choledocholithiasis is common and associated with greater length of hospital stay, higher radiology charges, and a trend towards higher hospital charges.

Su1340 - Predictors of Pancreatic Cancer Development in a Large National Cohort of Patients with Pancreatic Cysts: A Case-Control Study

PRESENTATION An 88-year-old woman’s startling ophthalmologic symptoms were initially attributed to infection during an outpatient examination. When treatment offered no improvement, she presented to Johns Hopkins Hospital, where she reported progressive left eye swelling of 2 weeks duration. Seven years earlier, she had undergone mastectomy, chemotherapy, and radiation for breast cancer. Her medical history was also significant for a prior stroke, hypertension, and dementia. Initially, the patient noticed the onset of left-eye redness and swelling; she commented that her eye gradually “popped out.” An outside ophthalmology evaluation resulted in a diagnosis of conjunctivitis, and she was prescribed a regimen of tobramycin/dexamethasone ophthalmic suspension and moxifloxacin ophthalmic solution. Yet, her symptoms persisted. Two days prior to her presentation at the hospital, her son noticed ipsilateral cheek swelling. Given the progression of symptoms and her profoundly compromised appearance, the patient and her son sought further evaluation at the hospital. She did not have fever, chills, sweats, headaches, nausea, or vomiting. In addition, she denied having ocular pain, discharge, or visual compromise. She was admitted to the Osler Medical Service.