GI Illness Research Articles

Somatostatin in Treatment of Acute Recurrent Pancreatitis and Role of Endoscopic Ultrasonography in The Diagnostic Workup

The pancreas is an elongated, soft, flat, lobulated, and yellowish gland located on the posterior abdominal wall in a transverse orientation. The structure is located in the retroperitoneum and has a thin capsule. An abrupt response to pancreatic injury is known as acute pancreatitis (AP). Chronic pancreatitis can lead to enduring harm to the composition and the pancreas' endocrine and exocrine functions. The term idiopathic RAP (IRAP) is employed when the reason cannot be readily identified by the assessment of physical examination, medical history, basic laboratory tests (calcium and serum triglyceride levels, for example), and diagnostic imaging studies (e.g., CT scans and transabdominal ultrasounds). With endoscopic ultrasonography (EUS), you may see the inside of your digestive tract and any surrounding tissues in high resolution and real time. When it comes to evaluating a wide variety of benign and malignant GI illnesses, this technique is both efficient and cost-effective. Somatostatin inhibits the release and manufacture of certain enzymes, which in turn decreases the pancreas' ability to absorb amino acids. The release of somatostatin from the pancreatic islets is stimulated by high glucose concentration.

Adults with FPIES may face delayed diagnoses

BackgroundFood protein-induced enterocolitis (FPIES) is a non-IgE-mediated food allergy that is becoming increasingly recognized in adults. The time between age at symptom onset (ASO) and age at diagnosis (AD) along with factors impacting this gap have not been fully studied. ObjectiveWe sought to investigate the latency between ASO and AD in adults with FPIES. We also sought to evaluate whether those with symptom onset in earlier years and those with comorbid gastrointestinal disease had greater mean latency. MethodsWe conducted a retrospective chart review for FPIES patients seen in the University of Michigan Allergy and Immunology clinic from 2015 to 2022. Patients 18 years and older diagnosed with FPIES by an allergist were included (N=19). Data including characteristics of patients’ prior FPIES reactions and past medical history were collected. ResultsThe median FPIES ASO was 26 years and median AD was 35 years. The median difference between ASO and AD was 10 years and statistically significant via paired t-test (p=0.003). There was a negative correlation of -0.99 between year of symptom onset and latency between ASO and AD (p<0.0001). Those with previously diagnosed GI conditions had higher mean latency between ASO and AD than those without (p=0.124). ConclusionsWe noted a gap between ASO and AD in adults with FPIES. This may be due to under recognition of adult FPIES in the past given the negative correlation with mean latency between ASO and AD. Furthermore, co-morbid GI illnesses may be masking FPIES symptoms in adults and delaying diagnosis.

Unilateral acute posterior multifocal placoid pigment epitheliopathy (APMPPE) with delayed contralateral eye involvement

BackgroundAcute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a rare presumed inflammatory chorioretinopathy characterized by creamy, yellow-white placoid lesions at the level of the retinal pigment epithelium (RPE). Unilateral cases often have fellow eye involvement within days to a few weeks. This report details a rare case of delayed contralateral APMPPE, in which unilateral lesion resolution was followed by contralateral eye involvement 31 months later.Case presentationA 38-year-old woman presented with three days of blurry vision and photopsias in the right eye (OD). She endorsed a viral GI illness one month prior. Visual acuity was 20/25 -2 OD and 20/20 -1 in the left eye (OS). Examination revealed creamy, yellow-white placoid lesions in the posterior pole. Fluorescein angiography (FA) was notable for early hypofluorescence and late hyperfluorescence of the lesions, consistent with APMPPE. MRI and MRA brain were negative for cerebral vasculitis. She was treated with oral prednisone with complete resolution of her symptoms, vision, and lesion regression. She then presented 31 months later, with blurry vision OS and similar new creamy, yellow-white placoid lesions in the posterior pole OS. She endorsed receiving an influenza vaccine one month prior. FA again was notable for early hypofluorescence. She was diagnosed with APMPPE, this time involving the left eye, and was once again started on oral steroids with complete resolution. She denied any neurologic symptoms.ConclusionsAPMPPE is an inflammatory vasculitis of the choroid, leading to hypoperfusion and ischemic injury of the RPE with subsequent lesion formation. APMPPE may be preceded by a viral prodrome or vaccination, both of which were seen in this case. Choroidal inflammation seen in APMPPE is therefore thought to stem from immune-mediated processes. Unilateral cases often have fellow eye involvement within days to a few weeks. Single eye involvement with delayed contralateral presentation, as seen in our patient, is rare. This case demonstrates that lesion resolution in one eye can be followed by contralateral eye involvement up to 31 months later, highlighting the importance of routine ophthalmic monitoring for patients with unilateral APMPPE.

Seroprevalence of Campylobacter jejuni infection in common subtypes of Guillain–Barre syndrome in Kashmiri population

BackgroundGuillain–Barre Syndrome (GBS) is a common differential diagnosis of acute-onset flaccid quadriparesis with or without bulbar involvement. Various illnesses precede GBS, respiratory illness being the most common. Campylobacter jejuni is the single most common organism found associated with GBS. The aim of the present study was to determine the prevalence of Campylobacter jejuni positivity in different subtypes of GBS.MethodsSixty patients of GBS were tested for serological evidence of Campylobacter jejuni and compared with 60 age and sex matched controls.ResultsMean age of cases was 39.58 (± 14.76 years) and that of controls was 35 (± 12.31 years). Preceding illness was present in 38% cases. Respiratory tract illness was present in 9 (15%) cases, while as GI illness was present in 8 (13%) cases. AIDP was the most common variant accounting for 65% of cases, followed by AMAN (18.3%). Among cases, 24 (40%) tested positive for Campylobacter jejuni antibody whereas only 12 (20%) tested positive for antibody among controls. The difference was statistically significant between cases and controls (p value = 0.003). There was no statistically significant difference in antibody positivity and preceding illness among different variants of GBS (p value = 1.0).ConclusionCampylobacter jejuni infection is a frequent preceding illness in GBS patients, although it may be asymptomatic. There is however no relation between different subtypes of GBS and C. jejuni infection.

S2474 Insult to Injury: HUS After a GI Illness on Vacation

S2474 Insult to Injury: HUS After a GI Illness on Vacation

Detection and Classification of Gastrointestinal Diseases by using Machine Learning: A Review

Currently, gastrointestinal diseases claim the lives of up to two million people worldwide. GI disease treatment can be challenging, time-consuming, and expensive. One of the most recent advancements in medical imaging is the use of video endoscopy to diagnose gastrointestinal illnesses such stomach ulcers, bleeding, and polyps. Doctors require a lot of time to review all the images produced by medical video endoscopy since there are so many of them. This makes manual diagnosis difficult and has encouraged research into computer-aided approaches to diagnose all of the generated images quickly and accurately. The innovative aspect of the suggested methodology is the creation of a system for the diagnosis of digestive disorders. Machine learning techniques have the potential to significantly lower the cost of examination procedures while increasing the accuracy and speed of diagnosis. This paper describes a method for classifying GI illnesses using machine learning techniques.

Burden of Gastroduodenal Diseases from the Global Perspective.

We reviewed the recent medical literature to show global burden of gastroduodenal disease, potential strategies, and further perspectives. Gastrointestinal and liver diseases are growing health problems, and cause more than 8 million deaths per year worldwide; encompass a range of long-term health conditions, such as digestive cancers, gastroesophageal reflux disease, Helicobacter pylori infection, peptic ulcer disease, liver diseases, inflammatory bowel disease, coeliac disease, and functional gastrointestinal disorders. Scientific knowledge demonstrates that the noncommunicable disease burden can be greatly reduced if cost-effective preventive and curative actions, along with interventions for prevention and control of noncommunicable diseases already available, are implemented in an effective and balanced manner. Future research will have to elaborate on simple methods for preselection of patients at high risk to allow their implementation in strategies and respect all demand of cost-effectiveness. Understanding trends in GI illnesses could be helpful to meet the needs of patients and decrease the disease burden.

P009 FINANCIAL VOLATILITY OF INFLAMMATORY BOWEL DISEASES VS OTHER CHRONIC GASTROINTESTINAL DISEASES - USING THE BETA COEFFICIENT TO CATEGORIZE GI DISORDERS

Abstract Symptomatic chronic diseases differ in their propensity for serious costly morbidity. Reliable and predictable deterioration presentations can be associated with very narrow margins between symptoms and the onset of serious complications. The inflammatory bowel diseases (IBD): Crohn’s Disease and Ulcerative Colitis are examples of this. As a result, they have high cost per capita with significant variation in that cost. Reliable metrics for assessing the relative volatility of chronic diseases are lacking. In finance, the volatility of a stock is measured using the beta coefficient, a measure of the relative volatility of an individual stock in relation to the that of an index.[i] By definition, the specific index has a beta of 1.0, and individual stocks are ranked according to how much they deviate from the market based on their beta coefficient. A stock that demonstrates more volatility than the market over time has a beta above 1.0. We postulated that chronic gastrointestinal diseases can be profiled using a similar measurement of volatility based on cost. Using a data set of 40,523 members obtained from Health Care Service Corporation, which included professional, facility and pharmacy claims for calendar year 2017, we calculated an index and beta rating for the major gastrointestinal disorders: gastroesophageal reflux disease (GERD), Peptic Ulcer disease (PUD), Gastritis, Celiac disease, Pancreatitis, Irritable Bowel Syndrome (IBS), Crohn’s disease (CD), Ulcerative colitis (UC), Colon Polyps and Diverticulitis: Method: The Total Disease Specific Cost (TDSC) was calculated from claims data for each condition using ICD - Codes.A GI Disease index (GIDI) was created by calculating the TDSC of all of the above conditions. The GIDI TDSC was then segregated into deciles.The cost/decile was then analyzed for each condition and compared against the GI IndexA beta rating (Beta) was calculated using Standard Deviations of the relative cost/decile (SDCD) as follows: Beta = SDCD (Illness)/SDCD (Index) Results: Using this methodology, the GI Index and individual beta ratings are numerically and graphically shown in the figures. Whereas CD and UC have strongly positive Beta scores, the remainder of the GI illnesses do not as compared to the GI Index. Figure 1. Major Gastrointestinal illnesses’ Beta Rating with respect to GI Index Table 1. Summary of major Gastrointestinal illnesses’ cost by decile and Beta Rating Conclusions: Gastrointestinal disorders can be categorized, based on their volatility, into a beta rating[ii]. Disorders associated with high cost and high variability in cost have a high-beta rating compared to the GI disorder index. This is a critical finding as high-beta conditions are those toward which management payments should be focused as they benefit most from patient engagement, care coordination and care managment programs to improve outcomes and control costs. [i] Sharpe W. Portfolio theory and capital markets. New York: McGraw Hill, 1970.[ii] Kosinski L, Brill J; Clinical Gastroenterology and Hepatology Vol. 14, No. 12, P1751-1752

What is the qualitative evidence concerning the risks, diagnosis, management and consequences of gastrointestinal infections in the community in the United Kingdom? A systematic review and meta-ethnography.

BackgroundGastrointestinal (GI) infections cause a significant public health burden worldwide and in the UK with evidence pointing to socio-economic inequalities, particularly among children. Qualitative studies can help us understand why inequalities occur and contribute to developing more effective interventions. This study had two aims: 1. Conduct a systematic review to determine the extent and nature of UK qualitative evidence on gastrointestinal infections; 2. Use meta-ethnography to examine the influences of the differing social contexts in which people live.MethodsMEDLINE, Scopus, Web of science, CINAHL and JSTOR were searched for UK qualitative studies engaging with the risk, diagnosis, management or consequences of gastrointestinal infections from 1980 to July 2019. Five reviewers were involved in applying inclusion and exclusion criteria, extracting and synthesising data (PROSPERO CRD 42017055157).ResultsSearches identified 4080 studies, 18 met the inclusion criteria. The majority (n = 16) contained data relating to the risk of gastrointestinal infection and these made up the main synthesis. The tenets of meta-ethnography were used to glean new understandings of the role of social and environmental contexts in shaping the risk of gastrointestinal infection, specifically with respect to foodborne GI illness. Three main explanations concerning risk emerged from the data: explanations of risk in the community were underpinned by understandings of ‘bugs’, dirt and where food comes from; risks were negotiated in households alongside diverse processes of decision making around food; and resources available to households shaped food practices.ConclusionThis systematic review highlights the scarcity of UK qualitative evidence examining gastrointestinal infections. Apart from risk, questions around diagnosis, management and consequences of illness were largely untouched. No studies investigated patterning by socio-economic status. Nevertheless, the meta-ethnography yielded wider contextual theories and explanations as to why people might not follow food hygiene guidance, giving pointers to the types of qualitative enquiry needed to develop more effective interventions.

464 The Burden of Chronic Gastrointestinal Diseases Among the Uninsured: A Free Clinic Study

INTRODUCTION: Uninsured and under-insured patients with high comorbidity burden are associated with high costs and high needs. GI diseases make up a significant portion of comorbidity burden and annual health expenditures. There is limited data on GI illnesses among the uninsured. The objective of this study is to do a preliminary evaluation of the burden of chronic GI illness in the uninsured community of Tampa Bay, Florida. METHODS: A retrospective query of an IRB approved database of 5076 patients seen across nine free clinics in the Tampa Bay area in 2017 revealed 760 patients with GI illness. Demographics, substance abuse, prevalence of GI illnesses including GERD, metabolic syndrome, irritable bowel syndrome, inflammatory bowel disease, ulcers, hemorrhoids, hepatitis, chronic liver disease, gallstones, and pancreatitis, were analyzed. Statistical analysis was performed with R 3.5.3. RESULTS: GI patients had a preponderance to be female (62.5%) and Hispanic (57.0%). GERD was the most prevalent condition (13.5%) followed by chronic liver disease (3.6%), GI ulcer (3.2%), hemorrhoids (2.2%), hepatitis C (1.6%), metabolic syndrome (1.5%), gallstones (1.2%), inflammatory bowel syndrome (1.0%), pancreatitis (0.6%), hepatitis B (0.4%), Crohn's disease (0.1%), and hepatitis A (0.1%). Most patients with GI illness have had a history of smoking (34.4% vs. 21.9%, P &lt; .001) or alcohol consumption (30.2% vs. 24.1%, P &lt; .001). Patients with chronic GI illness had more average visits per year than those who did not have chronic GI illness (3.7 vs 2.2 visits per year, P &lt; 0.001). Compared to patients without GI illness, patients with GI illness were older (Mean: 48.7 vs. 39.8 years, SD: 13.1 vs. 17.1, P &lt; .001). CONCLUSION: Patients with chronic GI illness tended have more clinic visits, were more likely to have a comorbid history of smoking and alcohol consumption, and were older than those without GI illness. More education and preventative resources should be directed toward the most common GI illnesses such as GERD, chronic liver disease, and ulcers. Further evaluation of the low-income community is required to identify community level solutions and management strategies for chronic GI illness.

Epidemiological investigation of food poisoning outbreak among hajj pilgrims from Sudan at hotel in Jeddah, KSA in August 2017

Objective: An investigation of the outbreak was initiated because of the number of cases of gastroenteritis among Sudanese population reporting to a general hospital Jeddah during the pilgrimage to Makkah (HAJJ). This cases control study was conducted to identify the source of the outbreak, assess its magnitude, and make recommendations to prevent similar outbreaks in the future. Materials and Methods: A case was defined as any individual who developed. A case was defined as anyone who stayed at the hotel on 23rdAugust 2017 and developed GI illness (nausea, vomiting, abdominal pain or diarrhea) diarrhea with or without abdominal pain after eating at the hotel on 24th August 2017. Laboratory tests included stool cultures of all diarrhea patients, and rectal swabs from all food handlers were cultured for enteric pathogens and result were negative. Results: A total of 141 cases hajj pilgrims Sudanese living in hotel were interviewed. Out of these, 83% had developed nausea, 80% abdominal pain and 75% diarrhoea most commonly and the mean incubation period was 2.16(±0.98) hours and the epidemic curve suggested a common point source outbreak. Out of three food items, chicken was found a statistically significant association with illness (p=0.033) food leftovers were found for sampling. All results of stool cultures of all diarrhea patients, and rectal swabs from all food handlers were inconclusive. Conclusions: This outbreak was most likely caused by eating contaminated chicken served at lunch on 23rd august 2017. The most likely organisms were Bacillus cereus, and/or Clostridium perfringens. Consuming food that was kept at an unsafe temperature poor level of food hygiene among food handler probable important factor leading to this outbreak. Keywords: Foodborne outbreak, Saudi Arabia, Hajj, Sudanese.

An assessment of household water quality among Peace Corps volunteers in Guatemala

BackgroundGastrointestinal (GI) illness is the most commonly reported health concern among Peace Corps Volunteers (PCVs) serving in Guatemala. This project identified water types and treatment and storage practices used by PCVs and measured select water quality parameters in their household water.MethodsA survey about water types and practices was conducted of PCVs in Guatemala. The water type most frequently consumed in the household (“primary drinking water”) and other water types present in the household (“secondary water”) were tested for free chlorine residual (FCR) and for the presence of Escherichia coli and total coliforms. A negative binomial regression model was used to analyze data on incidence of self-reported GI illness.ResultsTambo (commercially purified water in a 5-gal bottle) was the water type most frequently (64%) reported as primary drinking water in 39 PCV households. Most (74%) PCVs reported drinking water other than primary drinking water ≥1 day per week; the incidence rate of GI illness per PCV per month was significantly lower among PCVs who reported never consuming water other than primary drinking water compared to those who did (0.4 and 1.6 GI illnesses per PCV per month, respectively) (p < 0.05). E. coli was not detected in any primary drinking water sample, but was detected in 35% of secondary water samples. Total coliforms were detected in more than two-thirds of primary drinking water and secondary water samples. Nearly all water samples had an FCR of < 0.2 mg/L.ConclusionsConsuming primary drinking water exclusively likely contributes to reducing the rate of GI illness among PCVs. However, most PCVs reported drinking multiple water types, which may include contaminated secondary water types in the household. All water intended for consumption, including secondary sources within and outside the household, should be properly treated and safely stored.

Gastroparesis syndromes: Response to electrical stimulation

Factors underlying gastroparesis are not well defined, nor is the mechanism of action of gastric electrical stimulation (GES). We hypothesized that GES acts via several mechanisms related to underlying disordered pathophysiology. We studied 43 consecutive eligible patients with gastroparetic symptoms, previously evaluated by two methods in each of five core areas: inflammatory, autonomic, enteric, electrophysiologic, and hormonal; and also categorized by GI symptoms, metabolic status, illness quantification, and gastric physiology. We then studied 41 patients who underwent temporary GES for 5-7days. Thirty-six of those patients were implanted and 30 were followed up at 6months after permanent GES. In previous but separately reported work, patients had similar GI symptoms regardless of baseline gastric emptying or diabetic/idiopathic status and all patients demonstrated abnormalities in each of the five areas studied. After GES, patients showed early and late effects of electrical stimulation with changes noted in multiple areas, categorized by improvement status. Patients with symptoms of gastroparesis have multiple abnormalities, including systemic inflammation and disordered hormonal status. GES affects many of these abnormalities. We conclude electrical stimulation improves symptoms and physiology with (a) an early and sustained anti-emetic effect; (b) an early and durable gastric prokinetic effect in delayed emptying patients; (c) an early anti-arrhythmic effect that continues over time; (d) a late autonomic effect; (e) a late hormonal effect; (f) an early anti-inflammatory effect that persists; and (g) an early and sustained improvement in health-related quality of life. This study is registered with Clinicaltrials.gov under study # NCT03178370 (https://clinicaltrials.gov/ct2/show/NCT03178370).

Review of water quality criteria for water reuse and risk-based implications for irrigated produce under the FDA Food Safety Modernization Act, produce safety rule

Questions related to the safety of alternative water sources, such as recycled water or reclaimed water (including grey water, produced water, return flows, and recycled wastewater), for produce production have been largely un-explored at the detail warranted for protection of public health. Additionally, recent outbreaks of Escherichia coli (E. coli) in fresh produce, in which agricultural water was suspected as the source, coupled with heightened media coverage, have elevated fruit and vegetable safety into the forefront of public attention. Exacerbating these concerns, new Federal regulations released by the U.S. Food and Drug Administration (FDA) as part of implementation of the FDA Food Safety Modernization Act (FSMA), require testing of agricultural water quality for generic E. coli. Here, we present a review of water quality criteria – including surface water, groundwater recreational water, and water reuse – in an attempt to better understand implications of new FDA regulations on irrigated produce. In addition, a Quantitative Microbial Risk Assessment (QMRA) was conducted to estimate risks from pathogen contamination of food crops eaten fresh under the context of FDA regulations to provide perspective on current water reuse regulations across the country. Results indicate that irrigation water containing 126 CFU/100 mL of E. coli correspond to a risk of GI illness (diarrhea) of 9 cases in 100,000,000 persons (a 0.000009% risk) for subsurface irrigation, 1.1 cases in 100,000 persons (a 0.0011% risk) for furrow irrigation, and 1.1 cases in 1000 persons (a 0.11% risk) for sprinkler irrigation of lettuce. In comparison to metrics in states that currently regulate the use of recycled water for irrigation of food crops eaten fresh, the FDA FSMA water quality metrics are less stringent and therefore the use of recycled water presents a reduced risk to consumers than the FDA regulations. These findings, while limited to a one-time exposure event of lettuce irrigated with water meeting FSMA water quality regulations, highlight the need for additional assessments to determine if the scientific-basis of the regulation is protective of public health.

Clinical and Laboratory Benefits of Early Initiation of Hydroxyurea with Pharmacokinetic Guided Dosing for Young Children with Sickle Cell Anemia

Background: Hydroxyurea is now the standard of care for children with sickle cell anemia (SCA). Results from the BABY HUG study and recommendations from the 2014 NHLBI Guidelines have led to early initiation (increasingly before 1 year of age) of hydroxyurea for many patients. Given the known variability in hydroxyurea pharmacokinetics (PK), treatment response (HbF%), and maximum tolerated dose (MTD), we hypothesized that individualized dosing would provide the optimal treatment approach.Methods: The Therapeutic Response Evaluation and Adherence Trial (TREAT, ClinicalTrials.gov NCT02286154) is a prospective study of a personalized, PK-guided dosing model of hydroxyurea for children with SCA. Using population PK model-based Bayesian estimation, each participant's PK data are used to generate an individualized starting hydroxyurea dose that targets an area under the curve associated with actual MTD. Clinical follow-up and subsequent dose adjustments target MTD, usually defined by ANC<3.0x109/L. We analyzed clinical and laboratory data for TREAT participants who started hydroxyurea before 2 years of age, to allow for comparison to published results from BABY HUG, which included a similar young cohort but with conservative weight-based dosing of 20 mg/kg/day. TREAT participants had ongoing clinical and research evaluations of organ function, including transcranial doppler (TCD) studies, RBC pit counts, and cystatin C measurements.Results:The analysis of children starting hydroxyurea before 2 years of age included 33 participants (of 47 total TREAT enrollments), who contributed a total of 59.5 patient-years of hydroxyurea therapy. The mean age (±SD) at hydroxyurea initiation was 1.0±0.4 years of age. The average PK-guided, individualized starting dose was 27.8±5.3 mg/kg/day, higher than conventional and BABY HUG initial dosing (20 mg/kg/day). For children who have completed 12 months of therapy (n=24), effects in hematologic laboratory data are remarkable with average 35.9±8.9% HbF and hemoglobin concentration of 10.2±1.1 g/dL after 12 months of therapy (compared to 29.3±8.8% and 9.2±1.3 g/dL at baseline). The majority (70%) of these participants have HbF>30% and almost half achieved HbF>40% after 12 months of hydroxyurea. This hematological response is more robust than what was observed in BABY HUG (HbF=22.4%, Hb=9.1 g/dL after two years of therapy, Wang WC et al. Lancet 2011). In the TREAT cohort, there were no episodes of dactylitis, acute splenic sequestration, or stroke. There were 111 emergency room or sick outpatient clinic visits for this young cohort; 107 ED/clinic visits (without subsequent hospitalization) were for fever, URI symptoms, GI illness, or other non-specific complaints unrelated to SCA, while only 4 (3.6%) visits were for pain. There were 38 hospitalizations in 17 participants, mostly for routine evaluation of fever (66%), but no positive blood cultures and no admissions for febrile neutropenia. The average length of hospitalization was 2.8±2.4 days with 81% of participants discharged within 72 hours of admission. There were 3 episodes of acute chest syndrome in 2 patients, two of whom required PRBC transfusion. Including all types of visits, there were only 6 pain events, equivalent to 10.1 pain events per 100 patient-years, which is much lower than the published 94 events per 100 patient-years in the hydroxyurea treatment arm of BABY HUG (Thornburg CD et al. Blood 2012). There were 37 TCD exams performed in 16 participants, all normal except for one patient with conditional velocities that normalized with hydroxyurea. There were no significant differences from baseline to month 12 in either RBC pit counts or cystatin C values.Conclusions: Hydroxyurea initiation at an early age using PK-guided dosing provides significant clinical benefits for young children with sickle cell anemia. These TREAT study data suggest that initiating hydroxyurea around one year of life using a personalized dosing strategy can provide better clinical and laboratory benefits than starting at the conventional 20 mg/kg/day weight-based dose. Very high HbF levels are observed at modest and well-tolerated doses of hydroxyurea, perhaps because treatment was initiated before the process of HbF inactivation is complete. Continued long-term follow-up of these patients will determine whether these will be sustained and able to prevent both short- and long-term complications of SCA. DisclosuresMalik:CSL Behring: Patents & Royalties. Quinn:Silver Lake Research Corporation: Research Funding; Global Blood Therapeutics: Research Funding; Amgen: Research Funding. Ware:Biomedomics: Research Funding; Nova Laboratories: Consultancy; Bristol Myers Squibb: Research Funding; Addmedica: Research Funding; Global Blood Therapeutics: Other: advisory board; Agios: Other: advisory board; Novartis: Membership on an entity's Board of Directors or advisory committees.

1091. Algorithmic Release of Clostridium difficile PCR Results From a Multiplex Gastrointestinal (GI) Panel in Children &amp;lt;3 Years Old

BackgroundInfants have a high rate of asymptomatic Clostridium difficile (CD) colonization, up to 37%. Given this, our laboratory does not release CD+ results from the BioFire FilmArray Gastrointestinal Panel (FGP) in patients <3 years, unless requested by a physician. We sought to validate this model by comparing results from FGP to semi-quantitative CD PCRs for toxin B and glutamate dehydrogenase (GDH), enzyme immunoassay (EIA) for toxin A/B/GDH, and physician requests for CD results.MethodsRetrospective analysis of children <3 years with GI illness and FGP CD+ results between September 2016 and April 2018. CD PCRs for toxin B and GDH, CD EIA for toxin A/B/GDH were performed on convenience samples of frozen aliquots in Cary Blair. Physician request for release of CD results was used as a surrogate of possible role of CD on GI illness.ResultsOf 5,990 FGP, 2,267 (38%) were in children <3 years: 619 (27%) were CD+. Of these 619, 602 (97%) were not reported per algorithm. 62% (386/619) of CD+ samples had copathogens detected; enteropathogenic Escherichia coli and norovirus most frequently. For CD PCRs and EIA performed in subset of 49 CD+, mean cycle threshold values (Cts) for toxin B were evaluated (Table 1). Of 48 samples with detectable CD by toxin B PCR, 14 (29%) had both GDH and toxin B detected, 24 (51%) had only GDH detected, and 9 (19%) had neither GDH nor toxin B detected.ConclusionOnly 3% of FGP CD results in children <3 years were released per physician request, suggesting limited clinical significance. A copathogen was detected in 62% of CD+ samples that may explain illness. Among evaluable samples, only 28.6% of CD+ had both GDH and toxin detected by EIA, possibly indicating low specificity of CD PCR. Ongoing testing and prospective studies are warranted to determine the validity of our algorithm and if semi-quantitative PCR or EIA can be useful to identify when CD detection by FGP in children <3 years is clinically significant.Table 1: CD Toxin B PCR Ct Values Compared with FGP Result Release, Co-Pathogen Detection, and EIA ResultsMedian CtMedian Ct P-valueFGP-CD+ result released (n = 1)20.64FGP-CD+ result not released (n = 47)28.77NSFGP-CD+ only(n = 24)26.83Co-pathogen(n = 24)29.34NSEIA toxin+(n = 14)23.23EIA toxin−(n = 34)31.110.0005Disclosures A. Leber, Nationwide Children’s Hospital: Research Contractor, Research support.

Common Complaints Masking a Rare Disease: Abdominal Pain and Diarrhea as the Presenting Signs of Lupus Enteritis

Systemic Lupus Erythematosus (SLE) is an autoimmune condition characterized by joint pains, rash, and other systemic manifestations. Herein we describe a patient who presented with GI complaints and was later discovered to have lupus enteritis (LE), a rare complication of SLE. A 28-year-old Asian woman with family history of Crohn's disease presented for abdominal pain, watery diarrhea, and bilious emesis. Initial labs were unremarkable with a negative pregnancy test. CT scan revealed mild ascites, mild diffuse enteritis, and sigmoid colitis. Stool cultures, O & P and C. diff toxin were all negative. She was treated with ciprofloxacin and metronidazole with improvement of symptoms and then discharged. She returned for recurrence of symptoms and repeat CT showed mild ascites, rapidly progressing enteritis with severe involvement of the ileum and descending colon. Again, labs were grossly normal including CMP, CBC, ESR, CRP, C. diff., and stool cultures. Colonoscopy was consistent with acute enterocolitis without mucosal changes or evidence of Ulcerative colitits or Crohn's disease. Terminal ileum biopsies were unremarkable. At this point, a rheumatological workup was initiated and she was started on steroids for presumed autoimmune etiology. Her symptoms subsided and ANA returned at 1:320 speckled pattern, complement C3 and C4 were low. She was diagnosed with LE and discharged on oral prednisone. LE is a rare manifestation of SLE that is not fully understood. Given its overlapping symptoms with common GI illnesses, the diagnosis is challenging and easily missed. Common symptoms of LE include abdominal pain (97%), vomiting, diarrhea, and fever. Laboratory features include low complement levels (88%), anemia, leukopenia, lymphopenia, and thrombocytopenia. Median CRP level is 2.0 mg/dL. Imaging findings include bowel wall edema with target sign, ascites, hydronephrosis, mesenteric abnormalities and bowel dilation. If left untreated, LE can progress to intestinal necrosis and perforation. In this case, the family history of Crohn's disease initially led us to an inflammatory cause. Only after common etiologies were ruled out, was an autoimmune etiology explored. LE can be considered in patients with prior diagnosis of an autoimmune disorder who present with recurrent and intractable abdominal pain, diarrhea and emesis. LE has an excellent response to steroids. If promptly treated, symptoms and disease processes are reversible.1560 Figure 1. Abdominal CT images of bowel-wall thickening and enhancement known as the “target sign” (blue/red arrows). The abnormalities are non-specific and can also be seen in patients with Inflammatory Bowel Disease and other gastrointestinal conditions.

103 - Enhancing Breastfeeding Rates Using Cross-Sectional Data, Surveys, and a Population-Based Need Intervention: a Quality Improvement Project

Background: Breastfeeding is recognized as the superior form of infant feeding by both the AAP and WHO. It has been linked to reduction in rates of otitis media, URI, GI illness, obesity and diabetes. Current national and local breastfeeding rates, including rates in our resident clinic, fall below goal according to Healthy People 2020 objectives. A variety of factors are possible causes of this, including lack of knowledge about breastfeeding benefits, lactation technique difficulties, insufficient family and social support, and inadequate physician knowledge and support.

Surveillance for Prevention &amp; Identification of GI Illness Outbreaks Associated with Swimming Pools

ObjectiveTo prevent and identify gastrointestinal outbreaks due to swimming pools using a two-part surveillance system i) Model Aquatic Health Code (MAHC) Guideline Survey and ii) syndromic surveillanceIntroductionSwimming in contaminated pools can cause gastroenteritis from water contaminated by viruses, bacteria, or parasites. Germs that cause gastroenteritis are shed in feces of infected persons, and easily spread to uninfected persons swimming in pools. Symptoms of gastrointestinal illness can include nausea, vomiting, watery or bloody diarrhea, and weight loss. Common causes of swimming-related gastroenteritis included viruses (norovirus), parasites (giardia, cryptosporidium), and bacteria (Escherichia coli, Shigella). Cryptosporidium is most common agent associated with swimming pool outbreaks. In 2011-2012, public health officials from 32 States reported 90 swimming-pool associated outbreaks to CDC’s Waterborne Disease and Outbreak Surveillance System (WBDOSS). These 90 outbreaks resulted in 1,788 cases, 95 hospitalizations, 1 death. 52% of these outbreaks were caused by Cryptosporidium.MethodsLiterature search was conducted using published peer-reviewed articles via PubMed and Internet websites including, CDC and U.S. consumer product safety commission, Agency for toxic substance and disease registry. Statistical data on GI illness outbreaks associated with swimming pools prevalence and outcomes were also reviewed. Current surveillance methods used for detecting prevalence of waterborne disease outbreaks are based on examples from Ohio and Nebraska to determine approaches and effectiveness of the systems.ResultsSurvey and Education Packet - Distribute a survey with questions about current MAHC guideline adherence and MAHC educational packets that include the incident response guidelines and the water contamination response logStrengths: Low cost, simple, and acceptableLimitations: Not timely event reportingEvent Reporting - Develop a website for reporting contamination events based on the water contamination response logStrengths: Timely reportingLimitations: Complex to setup and maintain, moderate cost, and may not be acceptablePool Inspections - Require pools to undergo periodic inspections to monitor adherence to MAHC guidelinesStrengths: Complete and representativeLimitations: Complex, expensive, not timely event reportingThe current system is based on state reporting to the CDC through the paper-based reporting waterborne disease outbreaks surveillance system (WBDOSS), and the National Outbreak Reporting System (NORS), an electronic reporting system in place since 2009CDC uses waterborne disease outbreak surveillance data too identify the types of etiologic agents, and settings associated with outbreakso evaluate the adequacy of regulations to promote healthy and safe swimmingo establish priorities to improve prevention, guidelines, and regulations at the local, state, and federal levelsThe WBDOSS is not sufficient to capture early detection and reporting of AGI outbreaks. We recommend the these surveillance approaches:Syndromic surveillance of WBD outbreaks to capture early outbreaks of diarrheal, and as many suspected cases as possible in a timely mannerSentinel surveillance at specific healthcare facilities in the proximity of swimming pools where outbreaks can occurActive Lab-based surveillance would offer more robust and complete analysis of the prevalence and incidence of acute GI illness outbreaks in the StateConclusionsOur study concluded that state health department should begin a two-part surveillance system: i) distributing MAHC guideline surveys &amp; education packet; ii) syndromic surveillance system for outbreaks. MAHC Guideline Survey and Education Packet would be cost effective to educate pool operators on current MAHC guidelines and gather baseline data on adherence to MAHC guidelines for responding to contamination events. Afterwards, once baseline data is gathered and awareness of the MAHC guidelines is established, the state health department can determine if event reporting or pool inspections are necessary to increase either the timeliness or representativeness of the surveillance system. Syndromic surveillance would be the most timely and sensitive surveillance system. This is important to achieve health department's goal of early outbreak detection. Both predictive value and data quality are limitations of syndromic surveillance system. Acute gastrointestinal illness is also caused by sources other than pool contamination which can cause false positives.References1-CDC. Protracted Outbreaks of Cryptosporidiosis Associated With Swimming Pool Use --- Ohio and Nebraska, 2000 MMWR 2001; 50(20); 406-410.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5020a3.htm2-CDC. Outbreaks of Illness Associated with 2-Recreational Water — United States, 2011–2012 MMWR. 64(24); 668-672. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6424a4.htm?s_cid=mm6424a4_w3-CDC. The Model Aquatic Health Code. August 2015. http://www.cdc.gov/mahc/index.htm4-CDC. (n.d.) Decoding the MAHC: The Model Aquatic Health Code. Retrieved from https://www.cdc.gov/healthywater/pdf/swimming/pools/mahc/decoding-the-mahc.pdf5-CDC. (2016). Fecal Incident Response Recommendations for Aquatic Staff. Retrieved from https://www.cdc.gov/healthywater/swimming/pdf/fecal-incident-response-guidelines.pdf6-CDC. (n.d.) Water Contamination Response Log. Retrieved from https://www.cdc.gov/healthywater/pdf/swimming/pools/water-contamination-response-log.pdf7-CDC. (2016). Model Aquatic Health Code Aquatic Facility Inspection Report. Retrieved from https://www.cdc.gov/mahc/pdf/mahc-aquatic-facility-inspection-report.pdf

A235 EXPLORING PATIENT FACTORS FOR CANCELLED OR MISSED APPOINTMENTS TO AN URGENT GASTROENTEROLOGY OUTPATIENT CLINIC.

The Canadian Association of Gastroenterology reports that wait times to see a gastroenterologist are too long, even for urgent problems. Cancellations and no-shows compound this problem and lead to poor services utilization. A weekly urgent GI clinic started at St Joseph’s Healthcare Hamilton in March 2014 to improve timely access for patients. The clinic accepted referrals from the emergency room (ER) and urgent care with a capacity of 6 patients per week booked within 3 weeks of referral. The cancellation and absence rate from the clinic was 25% in the first 6 months despite patients receiving mail and phone reminder. Studies in no-show predictors focus on primary care, pediatric population and routine outpatient appointments. Published studies on absence rate in urgent clinic settings are very limited. The present study explores patient factors for the high absence rate at our urgent GI clinic. Retrospective review of patients booked to the urgent GI clinic between March and September 2014 that were absent at their appointment. The patient demographics, reasons for referrals, duration of symptoms were reviewed from the chart. The patients were contacted to explain why they missed their appointment and were offered to be rebooked. Between March and October 2014, 37 patients (25%) were absent for their appointment to the urgent GI clinic. The average age of patients was 51 years, and 43% were females. The mean duration of symptoms was 28.2 weeks, but 56% of patients had more acute symptoms for 1 week or less when presenting to ER or urgent care. The reasons for referrals included lower GI bleeding (24%), upper GI bleeding (22%), abdominal pain (16%), dysphagia (8%), anemia (5%) and inflammatory bowel disease (5%). Several attempts were made to contact patients, and 22/37 (59%) were reached. Of the 22 patients, 10 elected to cancel without rebooking, 3 were seen as inpatients, and 3 were seen by another outpatient gastroenterologist. Only 6/22 (27%) were rebooked to another urgent clinic appointment. The urgent GI clinic is a useful means for seeing patients with subacute GI illness but has an unacceptably high rate of missed appointments. Of the patients we contacted, only 27% were rebooked back to the urgent clinic. Almost half elected not to rebook suggesting that an urgent referral may not have been appropriate. On the other hand, 3 patients were admitted, suggesting that outpatient management may not have been suitable either, and 3 patients decided to follow up with their established gastroenterologist. The urgent GI clinic now screens all referrals for appropriateness, and does not see patients seen within the past year by another gastroenterologist. Follow-up data will hopefully demonstrate reduction in absence rate with this new strategy. None