FL Background Research Articles

Large-area ReS2 monolayer films on flexible substrate for SERS based molecular sensing with strong fluorescence quenching

Two-dimensional (2D) transition metal dichalcogenides materials have recently been explored as possible substrates for surface-enhanced Raman spectroscopy (SERS). However, in comparison to the conventional noble-metal-based counterpart, most of the 2D materials have very small area for SERS measurement, which is a big limitation toward practical applications. Herein, we presented our study of SERS using substrate-scale continuous ReS2 monolayer films on flexible mica substrate. We demonstrated that the charge transfer between the target molecules and the atomically thin ReS2 can be modulated by the underlying substrate of ReS2, resulting in greatly different suppressing level of FL background. Kelvin probe force microscopy revealed a large difference of surface potential between ReS2/SiO2 and ReS2/mica, suggesting that the strong FL quenching of molecular on ReS2/mica might be attributed to the inert surface of layered mica. The large-area ReS2 monolayer films on mica show a detection limit of R6G molecule around 10−7 M and a robust SERS performance after an exposure in air for one month and repeated bending for 1000 times. Our work explores the practical application of 2D ReS2 for molecular detection via SERS technique.

47) The epidemiology and outcomes of hospitalized children with rhabdomyolysis in the United States during 2012

TITLE: The epidemiology and outcomes of hospitalized children with rhabdomyolysis in the United States during 2012 Alejandro Martinez Herrada, Jessica Barreto, Paul Madera, Balagangadhar Totapally Division of Critical Care Medicine, Nicklaus Children's Hospital, Miami, FL BACKGROUND: Large multi-institutional studies in children with rhabdomyolysis are lacking. OBJECTIVE: To characterize pediatric inpatient admissions with rhabdomyolysis in the United States and identify etiology and variables associated with complications and mortality. METHODS: A retrospective study using the Healthcare Cost and Utilization Project 2012 Kids’ Inpatient Database was performed. Rhabdomyolysis in …

Mo1496 Endoscopic Ultrasound Guided (EUS) Fiducial Marker Placement Without Fluoroscopy - Safety and Technical Feasibility

Mo1496 Endoscopic Ultrasound Guided (EUS) Fiducial Marker Placement Without Fluoroscopy - Safety and Technical Feasibility

Mo1604 Recurrent Overt Obscure GI Bleed - Does Therapeutic Enteroscopy Change the Disease Course of Patients With Acquired Von Willebrand Factor (Vwf) Deficiency (Heyde's Syndrome)?

Mo1604 Recurrent Overt Obscure GI Bleed Does Therapeutic Enteroscopy Change the Disease Course of Patients With Acquired Von Willebrand Factor (Vwf) Deficiency (Heyde’s Syndrome)? Bhaumik Brahmbhatt*, Frank Lukens, Joseph L. Blackshear, Carlos R. Simons Linares, Paul T. Kroner, Abhishek Bhurwal, Mark E. Stark, Michael J. Bartel Gastroenterology, Mayo Clinic, Jacksonville, FL; Cardiology, Mayo Clinic, Jacksonville, FL Background: Patients with recurrent overt obscure GI bleed (OGIB) frequently undergo repetitive therapeutic enteroscopies. In this context, acquired vWF deficiency (Heyde’s syndrome) predisposes both AVM formation and hypocoagulability. Patients at risk for acquired vWF deficiency are those with underlying vascular pathology causing turbulent blood flow, especially aortic valve disease and hypertrophic obstructive cardiomyopathy (HOCM), which all result in destruction of vWF polymers. Aim: Investigate our outcome of patients who underwent therapeutic double balloon enteroscopy (DBE) for overt OGIB stratified by the presence or absence of acquired vWF deficiency or risk factors for acquired vWF deficiency. Methods: 1296 patients underwent 1747 double DBE between 2/2009 and 9/2013 at a single tertiary center. Of those, 243 patients underwent DBE for overt OGIB. Of which, 118 patients were tested for vWF polymers and/or underwent transthoracic echocardiogram (TTE). All patients with abnormal vWF level consistent with Heyde’s syndrome and/or very high likelihood for acquired vWF deficiency on TTE (Rmoderate aortic stenosis or regurgitation, Rmoderate mitral regurgitation, HOCM) are in cohort A. All other patients (normal vWF level and no high risk features on TTE) formed cohort B. The main outcome was the rate of recurrent OGIB. Results: 118 patients who met inclusion criteria (mean age 71.7years, SD 10, 44% female), underwent therapeutic DBE for overt OGIB. 8 patients had abnormal vWF level consistent with Heyde’s syndrome and 31 patients had normal vWF level. An additional 40 patients had TTE findings with very high likelihood for acquired vWF deficiency. No significant differences in age, gender, duration of bleed, transfusion requirement, number of transfusion, NSAID use, and anticoagulation were found between both cohorts. Also the DBE intubation depth (upper DBE 201cm vs 192cm; lower DBE 144cm vs 130cm), rate of total enteroscopy (70% vs 67%), DBE procedure time (118min vs 127min) and diagnostic yield (73% vs 73%) did not differ significantly between the cohorts. The findings on DBE did not differ significantly in both cohorts with the majority being AVMs. Median follow up was 180 days (range 1-2120 days, SEM 69). 39.5% of patients re-bled, 46% in cohort A and 38% in cohort B (NS). When considering only patients with a minimal follow up of 30 days, or stratifying by patients with only abnormal TTE or only abnormal vWF level, similar results were achieved. Conclusion: Patients with documented acquired vWF deficiency (Heyde’s syndrome) and patients with very high likelihood for acquired vWF deficiency based on TTE findings have a non-significant higher rebleeding risk following therapeutic DBE for overt OGIB. Based on our results, those patients should be considered for enteroscopy similarly to patients with normal vWF levels.

Su1649 Algorithmic Approach Including Bile Aspiration to Decrease ERCP Associated Adverse Events in Primary Sclerosing Cholangitis

Su1646 Endoscopic Treatment of Dominant Biliary Strictures in Primary Sclerosing Cholangitis Patients: Comparison of Adverse Events Associated With Balloon Dilation With and Without Stenting Udayakumar Navaneethan, Ramprasad Jegadeesan*, Jeffrey Hammel, Madhusudhan R. Sanaka, John J. Vargo, Mansour A. Parsi Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH; Cleveland2Center for Interventional Endoscopy, Florida Hospital Institute for Minimally Invasive Therapy, Orlando, FL Background: Dominant biliary strictures occur commonly in patients with primary sclerosing cholangitis (PSC). The optimal endoscopic management of dominant strictures remains unclear and the comparative risk of adverse events associated with balloon dilation alone versus balloon dilation and short term stenting remains unknown. Aim: Our aim was to compare the rate of adverse events associated with balloon dilation alone versus balloon dilation followed by short term stenting (! 7 days) in PSC patients with dominant strictures. Methods: In this retrospective study, 298 patients with PSC were evaluated. Among these, patients who had undergone biliary balloon dilation and/or short term stent placement (! 7 days) for endoscopic treatment of dominant strictures were identified. Adverse events associated with endoscopic biliary balloon dilatation with and without short term stenting for management of dominant strictures were determined. Results: A total of 72 PSC patients (median age 52.6 years; interquartile range 42.5-64) with dominant strictures were identified. Fifteen patients (20.8%) were treated with endoscopic balloon dilation alone and 57 patients (79.2%) were treated with balloon dilation and stent placement. Both groups had comparable baseline characteristics such as age, symptoms, bilirubin levels and severity of PSC as determined by the Mayo PSC risk score. The median duration of follow-up after intervention was similar in both groups (49 months). The overall risk of adverse events with endoscopic retrograde cholangiopancreatography (ERCP) was 15.3% (nZ11). Six patients developed cholangitis which was the most common adverse event. None of the patients in the balloon dilation alone group developed adverse events in contrast to 19.3% of patients (nZ11) who had undergone balloon dilation and short term stenting. (p! 0.01) On multivariate analysis, only stent placement increased the risk of adverse event development. (Hazard ratio 1.86; 95% confidence interval [1.3-2.2], pZ0.02). Conclusions: In this study, even short term stenting after balloon dilation appeared to increase the overall risk of adverse events associated with treatment of dominant strictures in PSC patients. Randomized controlled trials are required to clarify the appropriate management of dominant strictures in PSC patients.

Su1646 Endoscopic Treatment of Dominant Biliary Strictures in Primary Sclerosing Cholangitis Patients: Comparison of Adverse Events Associated With Balloon Dilation With and Without Stenting

Su1646 Endoscopic Treatment of Dominant Biliary Strictures in Primary Sclerosing Cholangitis Patients: Comparison of Adverse Events Associated With Balloon Dilation With and Without Stenting Udayakumar Navaneethan, Ramprasad Jegadeesan*, Jeffrey Hammel, Madhusudhan R. Sanaka, John J. Vargo, Mansour A. Parsi Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH; Cleveland2Center for Interventional Endoscopy, Florida Hospital Institute for Minimally Invasive Therapy, Orlando, FL Background: Dominant biliary strictures occur commonly in patients with primary sclerosing cholangitis (PSC). The optimal endoscopic management of dominant strictures remains unclear and the comparative risk of adverse events associated with balloon dilation alone versus balloon dilation and short term stenting remains unknown. Aim: Our aim was to compare the rate of adverse events associated with balloon dilation alone versus balloon dilation followed by short term stenting (! 7 days) in PSC patients with dominant strictures. Methods: In this retrospective study, 298 patients with PSC were evaluated. Among these, patients who had undergone biliary balloon dilation and/or short term stent placement (! 7 days) for endoscopic treatment of dominant strictures were identified. Adverse events associated with endoscopic biliary balloon dilatation with and without short term stenting for management of dominant strictures were determined. Results: A total of 72 PSC patients (median age 52.6 years; interquartile range 42.5-64) with dominant strictures were identified. Fifteen patients (20.8%) were treated with endoscopic balloon dilation alone and 57 patients (79.2%) were treated with balloon dilation and stent placement. Both groups had comparable baseline characteristics such as age, symptoms, bilirubin levels and severity of PSC as determined by the Mayo PSC risk score. The median duration of follow-up after intervention was similar in both groups (49 months). The overall risk of adverse events with endoscopic retrograde cholangiopancreatography (ERCP) was 15.3% (nZ11). Six patients developed cholangitis which was the most common adverse event. None of the patients in the balloon dilation alone group developed adverse events in contrast to 19.3% of patients (nZ11) who had undergone balloon dilation and short term stenting. (p! 0.01) On multivariate analysis, only stent placement increased the risk of adverse event development. (Hazard ratio 1.86; 95% confidence interval [1.3-2.2], pZ0.02). Conclusions: In this study, even short term stenting after balloon dilation appeared to increase the overall risk of adverse events associated with treatment of dominant strictures in PSC patients. Randomized controlled trials are required to clarify the appropriate management of dominant strictures in PSC patients.

Mo1412 The 25G FNA Needle: Good for Onsite but Poor for Offsite Evaluation? Results of a Randomized Trial

Mo1412 The 25G FNA Needle: Good for Onsite but Poor for Offsite Evaluation? Results of a Randomized Trial

Mo1255 Management of Duodenal Perforations After Upper Endoscopic Procedures: Is a Non-Surgical Approach Tenable?

Management of Duodenal Perforations After Upper Endoscopic Procedures: Is a Non-Surgical Approach Tenable? Alejandro L. Suarez*, Dennis Collins, Anand Gupte, Shailendra S. Chauhan, Peter V. Draganov, Christopher E. Forsmark, Mihir S. Wagh Division of Gastroenterology, University of Florida, Gainesville, FL Background: Duodenal perforation is a rare but serious endoscopic complication. Management of duodenal perforations is not standardized and surgical intervention has been the traditional approach. Aim: To review the incidence, management and outcomes of duodenal perforations after upper endoscopic procedures. Methods: A retrospective review of our electronic endoscopic complications database and medical records was performed to identify patients with duodenal perforations after upper endoscopic procedures (EGD/ enteroscopy, EUS, ERCP) from 1/2000 8/2011. The study was approved by the IRB at the University of Florida. Medical records were reviewed to collect data on incidence, management and outcomes after duodenal perforation. Data collected included procedure indication, type of endoscopic procedure, time of diagnosis, radiologic test results, management via surgery or conservative measures, length of hospital stay and mortality. Results: 43,572 upper endoscopic procedures were performed during this period [30,038 EGDs (69%), 7,761 ERCPs (18%), 5,773 EUS (13%) ] leading to 18 duodenal perforations (0.04%). 6/18 (33%) perforations resulted from diagnostic procedures while 12/18 (67%) were from therapeutic endoscopies including duodenal EMR/polypectomy, dilation, EUS-FNA, sphincterotomy and stent placement. 8/18 (44%) were identified during endoscopy, 5/18 (28%) within 24 hours and 5/18 (28%) after 24 hours after endoscopy. 16/18 (88%) had radiographic imaging (15 CT scans and 1 abdominal X-ray) while 2 went straight to surgery. Overall, 12/18 (67%) underwent surgery with a mean length of stay of 28 days while 6/18 (33%) were treated conservatively with a mean length of stay of 10 days. Intraperitoneal free air was seen in 73% and retroperitoneal air was seen in 27%. Abdominal CT scan with oral contrast was used to detect duodenal extravasation and leak. Contrast extravasation was seen in 4/15 (27%) with all 4 patients (100%) undergoing surgery (2/4, 50% survived with a mean length of stay 13.5 days). Extravasation of contrast was not seen on CT in 11/15 (73%). Only 5/11 (45%) had surgery (all 5 survived with a mean length of stay 14 days) while 6/11 (55%) were treated conservatively (NPO, NG tube, IV fluids, antibiotics, percutaneous drain if needed), of which all 6 (100%) survived with a mean length of stay 10.3 days. Complications were seen in 4/18 (22%) patients (1 with fever that resolved with antibiotics, 1 sepsis, 1 post-ERCP pancreatitis and 1 abdominal abscess drained percutaneously). Overall, 2/18 (11%) patients died after duodenal perforation (both patients had contrast extravasation requiring surgery). Conclusion: Though limited by small numbers, our data suggests that patients with duodenal perforation without duodenal contrast extravasation on CT scan may be effectively managed conservatively without surgery.

Tu1609 Diagnostic Yield of Spiral Enteroscopy Compared to Balloon Enteroscopy

Diagnostic Yield of Spiral Enteroscopy Compared to Balloon Enteroscopy Daniel Heller, Chakradhar M. Reddy, Henrique Fernandez, David Kerman, Javier Parra Department of Medicine, Mount Sinai Medical Center, Miami Beach, FL; Division of Gastroenterology, Miller School of Medicine, University of Miami, Miami, FL; Division of Gastroenterology, St. Mary-Corwin Medical Center, Pueblo, CO; Division of Gastroenterology, Gastroenterology Care Center, Miami, FL Background: Small bowel enteroscopy with double balloon enteroscopy (DBE) and single balloon enteroscopy (SBE) allows for diagnostic and therapeutic management of small bowel pathology. Spiral enteroscopy (SE) is a new technique which utilizes an overtube, twisting and pleating the small bowel allowing for advancement of the endoscope.Aim:The aim of the study is to compare spiral enteroscopy with balloon enteroscopy (DBE and SBE), and determine the utility in terms of diagnostic yield, interventions, depth of insertion, procedure time, and complications.Patients and Methods:All cases of small bowel enteroscopy done by the authors over a two year period were retrospectively analyzed. Results: 140 procedures were performed in 112 patients, mean age was 59.7 years (20 89), 48% were males. Obscure gastrointestinal (GI) bleeding was the most common indication (51%). 69 patients underwent 87 SBE/DBE (67 antegrade, 20 retrograde), and 43 patients underwent 53 SE (37 antegrade, 16 retrograde). The diagnostic yield of SBE/DBE was 82%, while SE was 70%. The most common finding of SBE/DBE was inflammation/ ulceration (46.5%), angioectasias (26.8%), strictures (12.7%), and neoplasia (8.5%). The most common finding of SE was inflammation/ ulceration (43.2%), angioectasias (35%), strictures (8%), and neoplasia (5.4%). 70% of SBE/ DBE procedures required an intervention, the most common were biopsy (53.3%), hemostasis (45%); 44% of these were bipolar coagulation, and stricture dilation (8%). 53% of SE required an intervention, the most common were biopsy (22%), hemostasis (22%); 71% of these were bipolar coagulation, intestinal stricture dilation (5%), and polypectomy (2%). The mean depth of insertion in the SBE/ DBE group was the proximal ileum, the cecum was reached in one case of antegrade enteroscopy. Six patients in the SBE/ DBE group underwent concurrent antegrade and retrograde endoscopy, and the entire GI tract was visualized in two patients. The mean depth of insertion in the SE group was the proximal ileum, the terminal ileum was reached in two cases of antegrade enteroscopy. In the SE group five patients underwent concurrent antegrade and retrograde endoscopy, the entire GI tract was visualized in one patient. 21 patients (16 SBE/ DBE, 5 SE) had previously undergone gastric bypass with Roux-en-Y reconstruction, the extruded stomach was reached in all 21 patients (100%). Common adverse events included sore throat, swallowing discomfort, abdominal bloating, transient hypoxia (2%), and cardiac arrhythmias (0.7%). There were no serious complications such as perforation or death. Conclusion: Spiral enteroscopy is an effective method for evaluation of the small bowel. The diagnostic yield, depth of insertion, and procedure time appear comparable to other deep small bowel enteroscopic (DBE, SBE) techniques.

Su1493 Comparison Between Video and Mosaic Viewing Mode of Confocal Laser Endomicroscopy (pCLE) in Patients With Barrett's Esophagus

Comparison Between Video and Mosaic Viewing Mode of Confocal Laser Endomicroscopy (pCLE) in Patients With Barrett’s Esophagus Emanuele Dabizzi, Muhammad W. Shahid, Bashar Qumseya, Mohamed O. Othman, Michael B. Wallace Mayo Clinic Jacksonville, Florida, Jacksonville, FL Background: Probe-based confocal laser endomicroscopy (pCLE) allows in vivo histologic assessment of the mucosal layer during endoscopy. Currently, there are two available viewing modes of pCLE. The most widely used mode is the Video mode which has significant limitations, including a small field of view as well as movement artifacts. Mosaic mode is analgorythm-based software, creating , static images, from video captures, and also automatically eliminated noninformative images. Currently active attempts are underway to improve the accuracy of pCLE system, including availability of mosaic-view mode. However, the improvement of the accuracy level of mosaic-view mode is yet to be determined. Aim: We conducted the study to assess the diagnostic yield of mosaics mode in comparison with the traditional video viewing mode, in detection of esophageal mucosal dysplasia, evaluating the accuracy, the time to achieve the diagnosis and the agreement between the two modalities. Methods: A total of 29 patients (19 males, mean age 59 yo), with Barrett’s esophagus, were randomly selected from our previously described database. For each patient, a video clip and a series of mosaics were created off-line. The video-clip series and mosaics series were decoded and reviewed separately and independently by an expert endoscopist, blinded to the other image pair and the histological diagnosis, assumed as gold standard. The endoscopist rated the mucosa as benign or dysplastic, according to Miami Classification criteria. Results: The sensitivity and specificity of video mode in achieving the correct diagnosis was 71% and 68%, respectively, compared to 57% and 68% of the mosaics mode. The accuracy of video mode was 69%, compared to 66% in the mosaics mode. The McNemar’s Test between the accuracy of the two modalities has a non-significant p value (p 1.0). The average time needed to achieve the diagnosis was significantly longer in the video mode (mean: 48.03 35.38 sec) vs 17.06 7.11 sec for mosaics, with a p 0.0001. The observed Kappa for the agreement in the diagnosis of dysplasia between the two modalities was moderat (0.50; 95% CI 0.17-0.82). Conclusions: Mosaic-view mode seems to have the same accuracy of the video-mode, with a significantly less viewing time, in order to achieve the diagnosis.