Rabin Rahmani

Postoperative Clostridium difficile-associated diarrhea.

BACKGROUND Abdominal surgery is thought to be a risk factor for Clostridium difficile-associated diarrhea (CDAD). The aims of this study were to discern pre-operative factors associated with postoperative CDAD, examine outcomes after postoperative CDAD, and compare outcomes of postoperative versus medical CDAD. METHODS Data from 3904 patients who had abdominal operations at Montefiore Medical Center were extracted from Montefiores clinical information system. Cases of 30-day postoperative CDAD were identified. Pre-operative factors associated with developing postoperative CDAD were identified using logistic regression. Medical patients and surgical patients with postoperative CDAD were compared for demographic and clinical characteristics, CDAD recurrence, and 90-day postinfection mortality. RESULTS The rate of 30-day postoperative CDAD was 1.2%. After adjustment for age and comorbidities, factors significantly associated with postoperative CDAD were: antibiotic use (OR: 1.94), proton pump inhibitor (PPI) use (OR: 2.32), prior hospitalization (OR: 2.27), and low serum albumin (OR: 2.05). In comparison with medical patients with CDAD, postoperative patients with CDAD were significantly more likely to have received antibiotics (98% vs 85%), less likely to have received a PPI (39% vs 58%), or to have had a prior hospitalization (43% vs 67%). Postoperative patients with CDAD had decreased risk of mortality when compared with medical patients with CDAD (HR 0.36). CONCLUSION CDAD is an infrequent complication after abdominal operations. Several avoidable pre-operative exposures (eg, antibiotic and PPI use) were identified that increase the risk of postoperative CDAD. Postoperative CDAD is associated with decreased risk of mortality when compared with CDAD on the medical service.

Aortic and splanchnic artery aneurysms: Unusual causes of biliary obstruction – A retrospective cohort from literature

Mechanical obstruction of the biliary tree and resultant stasis are the cornerstone of a spectrum of diseases ranging from biliary colic to fulminant cholangitis. Infrequently acquired abnormalities of the abdominal vasculature can lead to biliary obstruction. In 2010, we reported a case of acute cholangitis resulting from compression of extra hepatic bile duct by an abdominal aortic aneurysm (AAA). We subsequently conducted a follow up scoping review of literature to identify other cases of acquired abdominal arterial abnormalities resulting in biliary obstruction looking at their management and outcomes. The articles were independently reviewed by two of the authors and pertinent data was extracted. The data was divided on an anatomic basis into two groups: one with primary aortic pathology and one with splanchnic vessel pathology. We identified 39 cases of biliary obstruction secondary to acquired aortic or splanchnic vessel abnormalities; 16 were caused by AAAs and 23 by splanchnic vessels. The cases were managed via conservative, endoscopic, endovascular or open surgical options based on the available technology and expertise. Although uncommon, recognition of aortic and splanchnic arterial abnormalities as a potential cause of biliary obstruction is important as management entails not only cautious decompression of the biliary tree but also addressing the underlying vascular pathology. We recommend that extrinsic biliary compression by an aneurysm or pseudoaneurysm be considered among the differential diagnosis in patients presenting with biliary obstruction and a known lesion of the abdominal vasculature.

Endoscopic Retrograde Cholangiopancreatography in Nonagenarian Patients: Is It Really Safe?

Background/Aims Literature on the safety of endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients is divided. Based on this we decided to examine the safety of ERCP in nonagenarian patients. Methods A total of 1,389 patients, with a mean age of 63.94±19.62 years, underwent ERCP during the study period. There were 74 patients aged 90 years or older with a mean age of 92.07±1.8. Logistic regression showed that nonagenarian patients had a significantly increased odds of in-patient mortality (adjusted odds ratio [AOR]=9.6; 95% confidence interval [CI]=4, 23; p≤0.001). Charlson Comorbidity Index (CCI) ≥2 was also an independent predictor of in-patient mortality (AOR=2.4; 95% CI=1.2, 5.2; p=0.021). Age ≥90 was not associated with increased adverse events; however emergency procedures (AOR=2.4; 95% CI=1.5, 4; p<0.001) and CCI ≥2 (AOR=2.6; 95% CI=1.7, 4.0; p<0.001) were more likely to have adverse events. Conclusions Age ≥90 and CCI ≥2 are independently associated with increased odds of in-patient mortality in patients undergoing ERCP, whereas emergency procedures and CCI ≥2 are associated with an increased adverse event rate. Caution must be exercised when considering ERCP in patients aged ≥90 years and those with a CCI ≥2.

A Self-Expanding Metal Colonic Stent Causing a Contained Splenic Perforation

A 69-year-old woman with a past medical history of colon cancer with metastatic disease to the liver presented to our hospital with nausea, vomiting, and jaundice. At an outside hospital, the patient had had a self-expanding colonic metal stent (SEMS) placed in the colon. Computed tomography of the abdomen revealed an existing colonic stent with a contained perforation extending into the spleen (images: left, coronal; right, sagittal). There was no evidence of peritonitis on exam. The patient was managed conservatively and discharged to hospice.

Severe Hypercholesterolemia: A Unique Presentation of Non-Hodgkin's Lymphoma in a Patient with Neurofibromatosis Type 1.

We report a case of non-Hodgkins lymphoma (NHL) with an unusual initial manifestation as severe hypercholesterolemia and obstructive jaundice in a patient with neurofibromatosis type 1 (NF 1). NHL should be considered in the evaluation of obstructive jaundice alone or in combination with severe hypercholesterolemia. Relief of biliary obstruction led to the resolution of hypercholesterolemia in our 59-year-old male patient, followed by doxorubicin-based chemotherapy for the underlying lymphoma. NF 1 is a genetic condition that results from a defect in a tumor-suppressor gene and it is likely that this led to the development of NHL in our patient. It is important that clinicians are familiar with the gastrointestinal manifestations of NF 1, especially its association with intra-abdominal malignancies, when treating patients with a personal or family history. To the best of our knowledge, this is the first case of NHL presenting initially as severe hypercholesterolemia and it is also one of the few instances where NHL has been reported in association with NF 1.

Sa1159 Venous Blood Gas Calculated Hematocrit is an Accurate Predictor of Hematocrit in Patients With Acute Upper Gastrointestinal Hemorrhage

Background: Proton pump inhibitors (PPI) are a commonly used medication in the medical intensive care unit (MICU). Overuse of PPIs can lead to increased healthcare costs as well as a possible risk of Clostridium difficile infection and aspiration pneumonia. The aim of our study is to analyze the prescribing patterns of PPIs in the MICU in order to identify opportunities for improvement. Materials and Methods: 507 MICU admissions were retrospectively reviewed for data concerning PPI use. PPI prescriptions and their indications were analyzed. Results: Of 507 MICU admissions reviewed, 342 (67.5 %) received a PPI. Of the 342 who received a PPI, 40 patients (11.7%) had no documented indication. In addition, 78 admissions out of the 342 (22.8%) received PPI solely for stress ulcer prophylaxis, where an H-2 blocker would have sufficed. Discussion: Our study revealed that PPIs were frequently prescribed in our MICU, but that up to one third (34.5%) of the prescriptions were inappropriate, and represent opportunities for cost savings and possibly reduced clinical complications. Our next step is to improve the rate of appropriate PPI prescription in our ICU through a combination of educational modules and direct interventions to the availability of the drug in current pharmacy order sets.

333 The Effect of Obesity on Bowel Preparation for Colonoscopy: Results From a Large Prospective Study at an Urban Health Care Center

Background/Purpose: Childhood obesity is a growing epidemic in the United States. However, healthcare providers, including medical students and residents, do not feel prepared to diagnose obesity, perform counseling, or treat obesity and its complications. The purpose of this study is to design a web-based module to adequately deliver educational content pertinent to medical students on the topic of pediatric obesity. The effectiveness of the module was evaluated in terms of content mastery and overall satisfaction using a pre-test, post-test, and post-test survey. We hypothesize that there will be a significant increase in knowledge on key content areas related to the topic of pediatric obesity after viewing the web-based module. Methods: An IRB approved, prospective study of 217 third year U.S. medical students was performed. Students were given a pre-test followed by educational content delivered in the form of a web-based module, then a post-test. Test questions centered on areas of the assessment, evaluation, counseling, treatment, and complications of pediatric obesity. Participants served as their own controls to compare pretest and posttest scores. Overall satisfaction with both the content and method of delivery of the web-based module was assessed using a post-test survey. Results: Completing the web-based module resulted in improved scores when comparing post-test to pre-test scores. Average scores increased from 77.4% correct on the pre-test to 93.6% on the post-test, an overall 16.2% increase in content mastery (95% CI 13.9-18.5, p<0.00001). In addition, students were overall highly satisfied with both the content and delivery method of the module as reported on the post-test satisfaction survey. Conclusions: The web-based method of instruction shows potential for increasing knowledge in the important areas of assessment, counseling, consequences, and treatment plans surrounding the topic of pediatric obesity. Students reported overall satisfaction with this web-basedmethod of instruction. In an era of increasing demands on student time, this web-based module served the purpose of delivering education with objective documentation of improved student knowledge. We plan to expose other health-care learners to the pediatric obesity module.

M1016 Potential Savings for Federal Funding of a Colorectal Cancer Screening Program in Uninsured Patients: A Cost-Effectiveness Analysis

Introduction: The comparability of cost-effectiveness of colorectal cancer (CRC) screening strategies is limited if heterogeneous study data on tests, populations, and designs are combined. Furthermore cost-effectiveness studies frequently suffer from unrealistic assumptions, e.g. concerning differences in screening participation and adherence to follow-up. Based on empirical data from a representative randomised controlled screening trial with FOBT in the Netherlands (Van Rossum, et al. Gastroenterology 2008), we aimed to compare cost-effectiveness of one round of immunochemical faecal-occult-blood-test (OC-Sensor®, I-FOBT) screening, with one round of guaiac based faecal-occult-blood-test (HemoccultII®, G-FOBT) screening and no screening. Methods: We designed a Markov model of the cost-effectiveness of CRC screening with FOBT and no screening in asymptomatic average risk individuals between 50 and 75 years. From a third-party payer perspective we analysed data with first and second order Monte Carlo simulation over 10 years of one year cycles. Empirical data were completed with cancer registry and literature data. Costs were presented in Euros using a discount rate of 4%. Effects were measured as life years gained using a discount rate of 1.5%. Results: I-FOBT resulted in more life years gained and costs saved (i.e. I-FOBT dominated) compared to G-FOBT and no screening. A hypothetical person invited for colorectal cancer screening with I-FOBT would on average save 0.003 life-years and €5 compared to G-FOBT and compared to no screening 0.006 life-years and €45. Ten years after a single round I-FOBT screening, in the Dutch population aged 50-75 years (n= 4,460,265), 25,200 life-years and €220 million would have been saved compared to no screening. I-FOBT remained the dominant screening strategy in sensitivity analyses when varying colorectal cancer incidence and major cost drivers. Conclusions: CRC screening with I-FOBT dominated G-FOBT and no screening. Accounting for uncertainty surrounding important parameters did not alter this conclusion. Table. Cost-effectiveness according to intention-to-screen analysis of one round immunochemical FOBT screening compared to one round guaiac FOBT screening or no screening