Victor F. Scott

A Model for Routine Hospital-wide HIV Screening: Lessons Learned and Public Health Implications

BACKGROUND Approximately 232700 (21%) of Americans are unaware of their HIV-seropositive status; this represents a potential for virus transmission. Revised recommendations from the Centers for Disease Control for HIV screening promote routine screening in the health care setting. We describe the implementation of a hospital-wide routine HIV screening program in the District of Columbia. METHODS Rapid HIV testing was conducted at Howard University Hospital on consenting patients at least 18 years of age using the OraSure OraQuick Advance Rapid HIV-1/2 Antibody Test. The study population includes Howard University Hospital patients who were offered HIV screening over a 12-month period at no cost. Screened patients received immediate test results and, for those patients found to be preliminarily reactive, confirmatory testing and linkage to care were offered. RESULTS Of the 12836 patients who were offered testing, 7528 (58.6%) consented. Preliminary reactive test results were identified in 176 patients (2.3%). Overall, 45.5% were confirmed, of which 82.5% were confirmed positive. Screening protocol changes have led to 100% confirmation since implementation. CONCLUSIONS Hospital-wide routine HIV screening is feasible and can be implemented effectively and efficiently. The HIV screening campaign instituted at Howard University Hospital identified a substantial number of HIV-positive individuals and provided critical connection to follow-up testing, counseling, and disease management services.

Effectiveness of ranitidine bismuth citrate, clarithromycin, and metronidazole therapy for treating Helicobacter pylori

OBJECTIVE:There are limited data available from the United States on the effectiveness of ranitidine bismuth citrate (RBC) plus two antibiotics to treat Helicobacter pylori. Therefore, the following study was undertaken to evaluate RBC with two antibiotics, which have been used successfully in combination, to treat H. pylori.METHODS:Adults with and without abdominal symptoms, who had never received H. pylori eradication therapy, were tested for the presence of H. pylori infection either by in-office rapid serology assays or histology. Positive subjects were administered the 13C-urea breath test. Subjects who had a positive urea breath test were then treated with RBC 400 mg b.i.d., clarithromycin 500 mg b.i.d., and metronidazole 500 mg b.i.d. for 10 days. Four to 6 wk after completing antibiotics all subjects were asked to return for a second urea breath test to assess treatment success.RESULTS:Forty-seven of the 50 subjects enrolled into this study completed the antibiotic regimen and returned for a repeat urea breath test. Thirty-seven subjects were negative for H. pylori by urea breath test and 10 were positive, resulting in a 79% eradication rate. Seven subjects (14%) stopped their medication because of side effects. When analysis was performed on the 40 subjects who took ≥ 80% of their medication (per-protocol), the eradication rate was 90%.CONCLUSIONS:The combination of RBC with clarithromycin and metronidazole successfully treated H. pylori infection after only 10 days of therapy. The per-protocol eradication rate from this study was similar to that seen with Food and Drug Administration (FDA)-approved regimens. In conclusion, RBC plus clarithromycin and metronidazole should be considered as a first-line treatment regimen for H. pylori infection, and may only need to be taken for a period of 10 days, as opposed to 14 days for FDA-approved regimens.

Factors associated with attendance to scheduled outpatient endoscopy.

Background Non-attendance of 42% has been reported for outpatient colonoscopy among persons with low socioeconomic status (SES) in an open access system in the USA. Objectives To evaluate attendance to outpatient endoscopy among populations with low SES after inperson consultations with endoscopists prior to scheduling. Methods Retrospectively, we reviewed the endoscopy schedule from September 2009 to August 2010 in an inner city teaching hospital in Washington, DC. We identified patients who came for their procedures. We defined non-attendance as when patients did not notify the facility up to 24 h prior to their scheduled procedures and did not show up. Results A total of 3304 patients were scheduled for outpatient endoscopy (mean age 55.2 years; 59.5% women). Only 36 (1.1%) patients were uninsured. 716 (21.7%) patients did not show up for their procedures. There were no differences in attendance by age, sex and race. Patients seen in a private endoscopists office (OR=1.47; 95% CI 1.07 to 2.04) were more likely to attend when compared with patients seen in trainees’ continuity clinic. Married patients (OR=1.40; 95% CI 1.11 to 1.78) were also more likely to attend. Conversely, Medicaid and uninsured patients were less likely to attend. Restricting our analysis to patients scheduled for only colonoscopy yielded similar results except that patients aged 50 years and older were more likely to attend. Conclusions Our study suggests improved attendance to endoscopy when populations with lower SES undergo prior consultation with an endoscopist. There is a potential to further improve attendance to outpatient endoscopy by directly involving the social support of the patients.

Beverage intake preference and bowel preparation laxative taste preference for colonoscopy.

AIM To examine whether non-alcoholic beverage intake preferences can guide polyethylene glycol (PEG)-based bowel laxative preparation selection for patients. METHODS We conducted eight public taste test sessions using commercially procured (A) unflavored PEG, (B) citrus flavored PEG and (C) PEG with ascorbate (Moviprep). We collected characteristics of volunteers including their beverage intake preferences. The volunteers tasted the laxatives in randomly assigned orders and ranked the laxatives as 1(st), 2(nd), and 3(rd) based on their taste preferences. Our primary outcome is the number of 1(st) place rankings for each preparation. RESULTS A total of 777 volunteers completed the study. Unflavored PEG was ranked as 1(st) by 70 (9.0%), flavored PEG by 534 (68.7%) and PEG with ascorbate by 173 (22.3%) volunteers. Demographic, lifestyle characteristics and beverage intake patterns for coffee, tea, and carbonated drinks did not predict PEG-based laxative preference. CONCLUSION Beverage intake pattern was not a useful guide for PEG-based laxative preference. It is important to develop more tolerable and affordable bowel preparation laxatives for colonoscopy. Also, patients should taste their PEG solution with and without flavoring before flavoring the entire gallon as this may give them more opportunity to pick a pattern that may be more tolerable.

T1656 Helicobacter pylori May Protect African Americans from Reflux Esophagitis, a Hospital Based Study

BACKGROUND AND AIM: Helicobacter pylori (HP) is well known as a major factor in chronic gastritis, peptic ulcer disease, gastric cancer, and gastric MALT lymphoma, however the role of HP in Gastroesophageal reflux disease (GERD) is controversial. During the last two decades the prevalence of HP in African-Americans (AA) in comparison to Caucasians was higher. However in AA, the incidence of GERD and its complications such as erosive esophagitis, Barretts and Adenocarcinoma of the esophagus, in comparison to Caucasians was low. The aim of this study was to determine whether HP can be protective against GERD. METHODS: Retrospectively, we studied 2012 cases with esophagitis, gastritis, both esophagitis and gastritis, and a normal control group. The data set represented patients who visited Howard University Hospital from January 2004 through December 2007.We collected the pathology and upper endoscopy reports of these patients. All patients underwent an esophagogastroduoudenoscopy with esophageal and gastric biopsies to determine HP status and presence of esophagitis and gastritis. The relationship between HP infection and esophagitis was assessed by calculating OR (95% CI) adjusted for age and sex. RESULTS: The data set consisted of 2012 cases and controls, including 57 with esophagitis only, 1553 with gastritis only, 362 with both esophagitis and gastritis, and 40 normal controls. The frequency of males was 53% (30) in esophagitis, 38% (583) in gastritis, 45% (162) in both esophagitis and gastritis, and 45% (18) in normal control group. The mean (SD) age was 54 (17) and 57 (16) in esophagitis and gastritis, respectively. HP data was available for 79% (1611) of the cases. The frequency of HP positivity in gastritis patients was 40% (506), in esophagitis patients was 4% and in normal controls was 34% (11), while HP was positive 34% of the patients with both esophagitis and gastritis patients was 66% (189) . After adjusting for effects of age and sex, Odds Ratio of HP was 0.06 (95% CI=0.01-0.45) for esophagitis group vs. gastritis group. CONCLUSIONS: Our results show that in AA patients, HP has a significant (p<0.001) negative association with esophagitis, this suggests that HP may play a protective role in the pathogenesis of esophagitis. In addition, H. pylori maybe the reason for the decrease in GERD complications in AA, such as Barretts esophagus and adenocarcinoma of the esophagus.

Mo1068 Colorectal Cancer Disparities Between Blacks and Hispanics: Healthcare Utilization Versus Biological Differences

Background: Despite comparable rates of putative risk factors for colorectal cancer including poor access and lower screening uptake, Hispanic Americans have reduced burden of colorectal cancer when compared to Blacks. It is unknown if better healthcare utilization (when access is available) or biological differences are playing a major role in this disparity within minority groups. Aim: To compare the adherence to scheduled out-patient colonoscopy (healthcare utilization) and the findings of neoplasia (biological differences) during colonoscopy performed among compliant patients by race-ethnicity (Blacks versus Hispanics). Method: A total of 2,126 (88.2%) non-Hispanic Black and 284 Hispanic (11.8%) adult patients were scheduled for out-patient colonoscopy from September 2009 to August 2010 in our endoscopy suite at Howard University Hospital, a minority serving tertiary institution in Washington DC. We reviewed their records and abstracted the data in standard fashion. We compared Blacks to Hispanics in their rates of attendance to the scheduled colonoscopy, the quality of colonoscopy performed and the detection of neoplasia. We used logistic regression models to calculate odds ratio (OR) and 95% confidence interval (CI) and adjusted for age, sex, marital status and health insurance. Results: Blacks were slightly older (mean age 56.5 years versus 52.7 years, P<0.001) and were less likely to be married (23% versus 32%, P = 0.001), but there was no difference by sex (P = 0.64). A lower percentage of Blacks were compliant with their procedures (76.9% versus 82%, OR = 0.76; 95%CI: 0.541.06). There was no difference in cecal intubation rate (97.5% versus 97.4%, P = 0.93) and finding of good bowel preparation (73% versus 71.5%, P = 0.13). Blacks were more likely to have polyps (50.8% versus 33.2%, OR = 2.10; 95%CI: 1.54-2.88) and adenoma (26.3% versus 18.8%, OR = 1.53; 95%CI: 1.05-2.23). These differences were mainly from diagnostic procedures (Table). Nine (0.57%) Blacks and one (0.44%) Hispanic had colorectal cancer diagnosed (P = 0.8). Conclusion: Although Blacks were borderline less likely to attend their scheduled colonoscopy, they were significantly more likely to have colorectal neoplasia. This suggests that biological differences may be playing more of a role in the increased burden of CRC among Blacks as compared to Hispanics. Comparison of prevalence of adenoma among blacks and Hispanics by indication of colonoscopy

M1038 Neoplastic Changes in Colonic Mucosa Following Polypectomy, Does Follow Up Make Sense?

Background and Aim: African Americans (AA) are at higher risk for colorectal cancers than general population and the neoplastic changes could be detected if followed properly. The aim of this study was to evaluate the incidence of colon cancer in patients who have previously undergone polypectomy. Method: In a retrospective study, 4793 documented symptomatic (GI bleeding, abdominal pain, weight loss) patients aged 40-90 years with no personal or family history of familial adenomatous polyposis and inflammatory bowel disease who underwent colonoscopy were identified from pathology, surgery and colonoscopy centers of Howard University Hospital over a period of 49 years (1959-2007). Demographic characteristics and histological findings were recorded. The frequency of pathological subtypes (tubular, villous, and tubular-villus and adenomatous polyps) of colorectal polyps was determined. Logistic regression was used to assess the independent risk factor of malignancy in patients with a prior diagnosis of adenoma. Results: Among 4793 patients with colon adenoma (without cancer) diagnosed from 1959-2007. There were 1619 (34%) patients with only right sided adenomas, 2951 (62%) were left sided and 220 (4%) were had adenoma on both sides of colon. Among the adenoma cases 52% (n=74) were 64 years or younger. Half (n=48) of the patients developed cancer before 1999. During the study period colon cancer occurred in 3% of cases previously diagnosed with adenoma. Adjusting for effect of sex and age, tubular adenoma (OR:2.5, 95%CI:1.6-4.1) and right colon location (OR:5.7,95% CI:3.9-8.5) were risk factor for neoplastic changes in cases with adenoma. The median (IQR) duration between diagnosis of adenoma and subsequent colon cancer was 9 (4-15) years. Conclusion: Despite adenoma diagnosis and removal, neoplastic changes is a fairly prevalent outcome in African-American with colorectal adenoma. High risk groups includes right sided and multiple adenoma. Compliance with full colonoscopy after polypectomy will reduce the risk of neoplastic progression in this group.

M1033 Colorectal Neoplasia in Young African Americans, Could Race Be a Risk Factor? a 40 Years Experience in An Inner City Teaching Hospital

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer, and survival in African Americans (AAs) is worse than Caucasians. Some studies suggest that the incidence of CRC is higher in AA patients below the age of 50 when compared to Caucasians. This study aims to confirm the higher prevalence of CRC in an AA population within the age groups of 40-49, and its implications to the screening guidelines. METHOD: In a retrospective study demographic data, indication and outcome of colonoscopy, and biopsy data were collected at Howard University Hospital over a period of 38 years (1970-2007). All of the study patients were (AA), and cases were classified either symptomatic average risk, 692 (91%); or high risk (family history, IBD), 69 (9%). Distribution of variables were studied by mean (standard deviation) or number (%) . RESULTS: A total of 8851 patients who had colonoscopy were analyzed. Female comprise 56%, and the mean (SD) for age was 60.3 (14.9). Out of the total, 965 (11%) were in the age group of 40-49, of which 409 (42%) had adenoma, and 45 (4.8%) had CRC. The location of 86% of the 409 adenomas were obtained. Two-hundred six (59%) adenomas were on the left side, and 144 (41%) were right sided. The histology of the adenomas included, 264 tubular adenomas (64.5%), 83 hyperplastic lesions (0.3%), 44 villous adenomas (10.8%), and 18 other histology (4.4%). When patients from age 40-44 (378) were compared for the prevalence of adenoma and CRC to those age 45-49 (587), the 40-44 age group had 148 (39.2%) adenomas and 18 (4.8%) CRC, vs. the 45-49 age group had 349 (59.4%) adenomas and 28.1(4.8%) CRC. Twenty four (68.5%) cancers were on the left side, and 11(31.5%) were right sided. Females had higher CRC rates 27 (61%), compared to males 18(39%). CONCLUSION: Our data showed a very high burden of colorectal adenoma and CRC in young AAs (<45). CRC rate of (4.8%) was seen for both the age group of 40-44, and 45-49, which indicates cancer in AAs may starts at younger age than predicted (<45). The American College of Gastroenterology recommends to start screening of AAs at age of 45, but this may not cover many high risk people who are younger than 45. Further study is needed on AAs to confirm these findings.