Renee Williams

Development and Assessment of a Helicobacter pylori Medication Adherence and Stomach Cancer Prevention Curriculum for a Chinese American Immigrant Population

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.

A Quality Improvement Educational Intervention to Increase Knowledge of Cardiogastroenterology Amongst Medical Trainees and Nursing Staff

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 Eighteen nurses and 75 medical trainees received this intervention. Significant score improvement was noted in both groups. The greatest change was seen in aspirin management (30.5% vs. 95.0% for group 1, 43.7% vs. 91.9% for group 2; p < .0001). For management of antiplatelets after aspirin-induced GI bleed, the medical trainees improved from 50.7% to 93.3%. Chi-square analysis showed a statistically significant difference in knowledge across all areas among medical trainees pre-and posttest (p < .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.

Venobiliary fistula with haemobilia: a rare complication of percutaneous liver biopsy

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 °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.

How We Cleaned It Up: A Simple Method That Improved Our Practice’s Bowel Prep

Colonoscopy is the only screening test that allows for direct visualization of the entire colon and removal of polyps. Poor bowel preparation limits the diagnostic accuracy of colonoscopy, lowering rates of cecal intubation and adenoma detection ( 1–3 ). Th us, adequate bowel cleansing serves to avoid the risk associated with repeat colonoscopies. Split-dose bowel preparation with polyethylene glycol (PEG) has emerged as the preferred regimen for purgative dosing ( 4 ). Medical and socioeconomic factors contribute to the risk of poor preparation, including history of diabetes, cirrhosis, dementia, colonic resection, and spinal cord injury ( 5 ). Medicaid status, interpreter requirement, and being unmarried are some of the social factors linked with poor bowel preparation ( 6,7 ). Furthermore, a complex relationship between these socioeconomic factors, poor health literacy, and low patient participation in health care may decrease the likelihood of adequate preparation ( 6–8 ). Previous studies that examine the eff ect of educational material on the quality of bowel preparation have not focused on populations with high-risk socioeconomic barriers to health care. Bellevue Hospital Center is a New York City public hospital that serves a high proportion of uninsured, underinsured, Medicaid patients and non-English speakers. Data collected on patients presenting to our suite show that ~46% have limited English profi ciency, 29% are uninsured, and 32% have Medicaid. Th e primary languages spoken in our hospital other than English include Spanish and Chinese Mandarin. Review of our data showed that nearly 35% of our patients who undergo colonoscopy have an inadequate bowel preparation requiring repeat procedures. Improving bowel preparation in this setting is a challenge; however, we utilized elements of the Plan Do Study Act (PDSA) cycle to characterize the eff ect of split-dose preparation and the use of a multi-language educational booklet on bowel cleanliness in our high-risk patient population. Th e PDSA cycle is a structure for testing changes to improve quality. Th e steps involve planning a test or observation (Plan), testing it out (Do), analyzing the data (Study), and making changes based on lessons learned (Act). We used a modifi ed version of an educational booklet that was originally developed by Spiegel et al. ( 9 ) at UCLA. Th is quality improvement project tested the implementation of a split-dose preparation and multi-language educational booklet on outpatients from January to December 2014. Th e study population included all outpatients undergoing colonoscopy, including procedures aborted because of inadequate preparation. Inpatients, unknown prep quality, and procedures aborted for reasons not related to the preparation were excluded from the analysis. Data were retrospectively and prospectively collected in monthly “snapshots” and included indication, extent reached, and preparation quality. An adequate preparation was defi ned as a Boston Bowel Preparation Score (BBPS) score of ≥6 with minimum of 2 in each segment or an Aronchick score of “good” or “excellent.” χ 2 testing was performed to evaluate for diff erences in preparation quality before and aft er cycles 1 and 2. Logistic regression analysis was performed with the stats package in R (v3.2.0, Bell Laboratories, Murray Hill, NJ), using prep dosing (single vs. split) and booklet use as independent categorical variables on the outcome variable of prep adequacy. Cycle 1: In January 2014, split-dose bowel preparation with 4 l of PEG and bisacodyl (20 mg) was initiated. Th e standard multilingual nurse teaching instructions were revised to include descriptions of the split-dose preparation. Within the endoscopy suite, the BBPS was implemented to quantify bowel preparation across all procedures to minimize bias. Prior to implementation of the BBPS score, our endoscopy staff quantifi ed bowel preparations using the Aronchick scale. Faculty and trainees were given a brief lecture on the BBPS scoring system prior to initiation of the intervention. Cycle 2: Aft er reviewing results from cycle 1, in August 2014, a multi-language educational booklet utilizing a visual aid was implemented ( Figure 1 ). Th e booklets were professionally translated to Spanish and Chinese, as these languages are the two most commonly spoken languages in our hospital other than English. Booklets were then distributed to the clinics, and the nursing staff was instructed to distribute the booklets during the standard teaching provided to the patients. Th e nurses reviewed the booklet with the use of a certifi ed medical translator for patients who did not speak English, Spanish, or Chinese. Feedback from the nursing staff demonstrated a positive impact of the visual aids for this subset of patients. How We Cleaned It Up: A Simple Method That Improved Our Practice’s Bowel Prep

Sa1138 Patients With Inflammatory Bowel Disease and a History of Cancer: The Risk of Cancer Following Exposure to Immunosuppression

Back ground: The calcineurin inhibitor (CNI) tacrolimus (TAC) has been reported to be effective for induction and maintenance of remission in patients with refractory ulcerative colitis (UC). However, CNI has nephrotoxic potential leading to acute and chronic renal damage in some cases. To date, little is known about the influence of long term administration of oral TAC on renal function in patients with UC. Aim: The aim of our study was to evaluate the incidence and the severity of renal function impairment in UC patient who received TAC treatment. Methods: In this retrospective study, the medical charts of 71 adult patients with steroid-refractory UC treated with TAC between 2012 and 2014 in a single Japanese center were analyzed. In principle, TAC was orally administrated as a 2 week-induction (target trough levels 10-15ng/ml) followed by a maintenance therapy (target trough levels 5-10ng/ml). Estimated glomerular filtration rate (eGFR) was evaluated during the treatment. Acute kidney injury (AKI) was defined by the RIFLE (Risk of renal dysfunction, Injury to the kidney, Failure of function, Loss of function and End-stage kidney disease) consensus criteria using the maximal change in serum creatinine (Scr) and eGFR during the TAC treatment compared with baseline value before treatment. Results: The mean duration of TAC administration was 210 days. At 12weeks, TAC produced a clinical response in 54 patients (76.1%) and remission was achieved in 29 of those 54 (40.8%). The AKI rate during TAC treatment was 46.5% (33 of 71 patients). RIFLE class R (Scr increase > 1.5 times or eGFR decrease > 25%) accounted for 27 patients (38.0%), and RIFLE class I (Scr increase > 2 times or eGFR decrease > 50%) for six (8.5%). The AKI rate was 76.8% (10/13) in patients who had been administrated TAC for more than 1 year and 37.5% (18/48) in patients with TAC treatment within 6 months (p=0.006). After withdrawal of TAC, renal function impairment (eGFR decrease > 25%) was still observed in 10 patients (14.1%). Conclusions: Oral TAC therapy appears to be effective for patients with refractory UC. However, renal function impairment was frequently observed during this treatment. Thus, careful monitoring of renal function must be required to avoid irreversible chronic renal damage during long-term administration of TAC.