Esophagogastroduodenoscopy findings that do no not explain dysphagia are associated with underutilization of high-resolution manometry

In patients with dysphagia that is not explained by upper endoscopy, high-resolution esophageal manometry (HRM) is the next logical step in diagnostic testing. This study investigated predictors of failure to refer for HRM after an upper endoscopy that was performed for but did not explain dysphagia. This was a retrospective cohort study of patients >18 years of age who underwent esophagogastroduodenoscopy (EGD) for dysphagia from 2015 to 2021. Patients with EGD findings that explained dysphagia (e.g. esophageal mass, eosinophilic esophagitis, Schatzki ring, etc.) were excluded from the main analyses. The primary outcome was failure to refer for HRM within 1 year of the index non-diagnostic EGD. We also investigated delayed referral for HRM, defined as HRM performed after the median. Multivariable logistic regression modeling was used to identify risk factors that independently predicted failure to refer for HRM, conditioned on the providing endoscopist. Among 2132 patients who underwent EGD for dysphagia, 1240 (58.2%) did not have findings to explain dysphagia on the index EGD. Of these 1240 patients, 148 (11.9%) underwent HRM within 1 year of index EGD. Endoscopic findings (e.g. hiatal hernia, tortuous esophagus, Barrett's esophagus, surgically altered anatomy not involving the gastroesophageal junction, and esophageal varices) perceived to explain dysphagia were independently associated with failure to refer for HRM (adjusted odds ratio 0.45, 95% confidence interval 0.25-0.80). Of the 148 patients who underwent HRM within 1 year of index EGD, 29.7% were diagnosed with a disorder of esophagogastric junction outflow, 17.6% with a disorder of peristalsis, and 2.0% with both disorders of esophagogastric outflow and peristalsis. The diagnosis made by HRM was similar among those who had incidental EGD findings that were non-diagnostic for dysphagia compared with those who had completely normal EGD findings. Demographic factors including race/ethnicity, insurance type, and income were not associated with failure to refer for HRM or delayed HRM. Patients with dysphagia and endoscopic findings unrelated to dysphagia have a similar prevalence of esophageal motility disorders to those with normal endoscopic examinations, yet these patients are less likely to undergo HRM. Provider education is indicated to increase HRM referral in these patients.

Obesity is not associated with adverse outcomes among hospitalized patients with Clostridioides difficile infection

Background

Obesity is associated with increased risk for death in most infections but has not been studied as a risk factor for mortality in Clostridioides difficile infection (CDI). This study tested obesity as a risk factor for death in patients hospitalized with CDI. This was a three-center retrospective study that included hospitalized adults with CDI at Columbia University Irving Medical Center, Brigham and Women’s Hospital, and NYU Langone from 2010 to 2018. Multivariate logistic regression was used to assess the relationship between obesity, measured by body mass index, and death from any cause within 30 days after the index CDI test.

Results

Data for 3851 patients were analyzed, including 373 (9.7%) who died within 30 days following a diagnosis of CDI. After adjusting for other factors, BMI was not associated with increased risk for death in any BMI category [adjusted OR (aOR) 0.96, 95% CI 0.69 to 1.34 for BMI > 30 vs BMI 20–30; aOR 1.02, 95% CI 0.53 to 1.87 for BMI > 40 vs BMI 20–30]. After stratifying into three groups by age, there were trends towards increased mortality with obesity in the middle-aged (56–75 vs ≤ 55 years old) yet decreased mortality with obesity in the old (> 75 vs ≤ 55) (p = NS for all). Advanced age and low albumin were the factors most strongly associated with death.

Conclusions

We found no association between obesity and death among patients with CDI, in contrast to most other infections. Obesity is not likely to be useful for risk-stratifying hospitalized patients with CDI.

Characteristics and Outcomes of Endoscopies before and during the COVID-19 Pandemic in New York

INTRODUCTION

The COVID-19 pandemic drastically changed hospital workflows. This study aimed to characterize differences in gastrointestinal endoscopies in the New York metropolitan region before, during, and after the first wave of the pandemic.

METHODS

Across 3 hospitals, we compared demographics, indications, and yield of endoscopies before and after March 16, 2020, the date on which elective procedures were canceled, as well as a recovery period for 5 months after they were resumed.

RESULTS

A total of 9,401 procedures before and 332 procedures during the first wave were performed. Females comprised 57 and 44% of patients (p < 0.01), respectively. There was a decline in the proportion of Black (15 vs. 7%, p < 0.02) and Hispanic patients (29 vs. 16%, p < 0.02) undergoing outpatient procedures. There was a significant rise in urgent indications such as bleeding and jaundice. There was an increase in the diagnostic yield of all esophagogastroduodenoscopies for bleeding (p < 0.01) and of outpatient endoscopic ultrasounds for malignancy (p = 0.01), but no increase in yield of inpatient colonoscopy for bleeding. A review of 7,475 procedures during the recovery period showed a return to many nonurgent indications, but still showed decreased proportions of Hispanic and male patients compared to the prepandemic period.

DISCUSSION/CONCLUSION

Lower proportions of Black and Hispanic patients underwent outpatient endoscopies during and after the first wave. The proportion of procedures done for emergent indications and their diagnostic yield increased during the pandemic, suggesting a higher threshold to perform endoscopy. In resource-sparing conditions, clinicians should pay attention to thresholds to perform colonoscopy for bleeding and to racial disparities in outpatient healthcare access.

Body Mass Index and Risk for Intubation or Death in SARS-CoV-2 Infection : A Retrospective Cohort Study

BACKGROUND

Obesity is a risk factor for pneumonia and acute respiratory distress syndrome.

OBJECTIVE

To determine whether obesity is associated with intubation or death, inflammation, cardiac injury, or fibrinolysis in coronavirus disease 2019 (COVID-19).

DESIGN

Retrospective cohort study.

SETTING

A quaternary academic medical center and community hospital in New York City.

PARTICIPANTS

2466 adults hospitalized with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection over a 45-day period with at least 47 days of in-hospital observation.

MEASUREMENTS

Body mass index (BMI), admission biomarkers of inflammation (C-reactive protein [CRP] level and erythrocyte sedimentation rate [ESR]), cardiac injury (troponin level), and fibrinolysis (D-dimer level). The primary end point was a composite of intubation or death in time-to-event analysis.

RESULTS

Over a median hospital length of stay of 7 days (interquartile range, 3 to 14 days), 533 patients (22%) were intubated, 627 (25%) died, and 59 (2%) remained hospitalized. Compared with overweight patients, patients with obesity had higher risk for intubation or death, with the highest risk among those with class 3 obesity (hazard ratio, 1.6 [95% CI, 1.1 to 2.1]). This association was primarily observed among patients younger than 65 years and not in older patients (P for interaction by age = 0.042). Body mass index was not associated with admission levels of biomarkers of inflammation, cardiac injury, or fibrinolysis.

LIMITATIONS

Body mass index was missing for 28% of patients. The primary analyses were conducted with multiple imputation for missing BMI. Upper bounding factor analysis suggested that the results are robust to possible selection bias.

CONCLUSION

Obesity is associated with increased risk for intubation or death from COVID-19 in adults younger than 65 years, but not in adults aged 65 years or older.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Dose addition of intravenous metronidazole to oral vancomycin improve outcomes in Clostridioides difficile infection?

Background

Guidelines recommend adding intravenous (IV) metronidazole to oral vancomycin for fulminant Clostridioides difficile infection (CDI). This study compared dual therapy with IV metronidazole and oral vancomycin versus vancomycin monotherapy. It assessed prevalence of use and effectiveness of dual therapy in non-fulminant and fulminant CDI.

Methods

This was a two-center retrospective study conducted from 2010 to 2018. Adult inpatients were included if they had a positive C. difficile PCR performed on an unformed stool and received oral vancomycin within two days (either before or after) of testing. Patients were classified as having received dual therapy if IV metronidazole was given within the same time window, and otherwise as having received vancomycin monotherapy. The primary outcome was  death or colectomy within 90 days after the index test. Logistic regression modeling was used to adjust for CDI severity and other established predictors of CDI outcomes. CDI recurrence was examined as a secondary outcome, adjusting for death as a competing risk.

Results

The study included 2,114 patients (dual therapy: 993; monotherapy: 1,121) of whom 23% met the primary outcome. There was no association between dual therapy and the primary outcome (adjusted OR (aOR) 1.07, 95% CI 0.79-1.45) which remained true when the analysis was restricted to patients with fulminant CDI (aOR 1.17, 95% CI 0.65-2.10). There was also no association between dual therapy and CDI recurrence.

Conclusions

Dual therapy with IV metronidazole and oral vancomycin was common for non-fulminant and fulminant CDI, but was not associated with improved outcomes compared to vancomycin alone.

1772. Vancomycin-Resistant Enterococcus Alters the Gastrointestinal Microbiome in Critically Ill Patients

Background

Methods

Results

Conclusion

Disclosures

1259. The Local Hospital Milieu and Healthcare-Associated VRE Acquisition

Background

The relationship between the local hospital environment and VRE acquisition is not fully understood. The objective of this study was to identify risk factors for healthcare-associated VRE acquisition related to the local hospital milieu.

Methods

This retrospective cohort study included patients admitted to six ICUs at an academic medical center from January 1, 2012 to December 31, 2016 with negative rectal VRE cultures on admission. VRE acquisition was defined as a positive subsequent surveillance swab performed at any time after the initial negative surveillance swab during the index hospitalization. VRE colonization pressure was defined to encapsulate the circulating VRE burden during the at-risk patient’s ICU stay (patient-days of VRE exposure based on concurrently colonized patients on the unit, divided by time at risk). VRE importation pressure was defined to encapsulate the VRE burden at the time of ICU admission (patient-days of VRE exposure on the unit during the preceding 30 days, divided by total patient-days). Multivariable Cox proportional hazards modeling was used, with patients followed until VRE acquisition, death, or for up to 30 days.

Results

There were 161 patients who acquired VRE among 8,485 patients with negative VRE cultures upon admission, including 1,131 patients who had repeat VRE cultures during the index hospitalization. On univariate analysis, patients with VRE acquisition were more likely to have received vancomycin, have had a neighboring patient who received vancomycin, have high VRE importation pressure, or have high VRE colonization pressure. On multivariable analysis, among these factors only high VRE colonization pressure was an independent predictor of VRE acquisition (aHR 1.79, 95% CI 1.19–2.70).

Conclusion

VRE colonization pressure was the most important risk factor for healthcare-associated VRE acquisition in this ICU population, regardless of VRE importation pressure or local use of vancomycin. Interventions seeking to reduce healthcare-associated VRE acquisition may wish to focus on ways to minimize transmission of VRE between patients with known VRE and the local hospital environment.

Disclosures

All authors: No reported disclosures.

Beholders' sensorimotor engagement enhances aesthetic rating of pictorial facial expressions of pain

The present study addresses a novel issue by investigating whether beholders' sensorimotor engagement with the emotional content of works of art contributes to the formation of their objective aesthetic judgment of beauty. To this purpose, participants' sensorimotor engagement was modulated by asking them to overtly contract the Corrugator Supercilii facial muscles or to refrain from any voluntary facial movement while judging the aesthetic value of painful and neutral facial expressions in select examples of Renaissance and Baroque paintings. Results demonstrated a specific increase in the aesthetic rating of paintings showing painful facial expressions during the congruent activation of the Corrugator Supercilii muscles. Furthermore, participants' empathetic traits and expertise in art were found to correlate directly with the amplitude of the motor enactment effect on aesthetic judgments. For the first time, we show the role of bottom-up bodily driven sensorimotor processes in the objective aesthetic evaluation of works of art.

Biological activities of melanotropic peptide fatty acid conjugates

Four fatty acids (FA, palmitic, myristic, decanoic, hexanoic) were individually conjugated to the N-terminus of the alpha-MSH fragment analog, H-Asp5-His6-D-Phe7-Arg8-Trp9-Lys10-NH2. This resulted in enhanced potency of the conjugates (compared to the unconjugated melanotropin analog) as determined in the lizard skin bioassay and in the mouse melanoma cell tyrosinase bioassay. The shorter conjugates of hexanoic and decanoic acid were at least equipotent to alpha-MSH in the lizard skin bioassay, whereas the longer myristoyl and palmitoyl analogs were 100 times less active. The myristoyl and palmitoyl conjugates exhibited a "creeping" potency in the lizard skin bioassay-that is, potency of the peptides increased with time in contact with the skins. These observations may be related to the more lipid nature of these FA-conjugates. In the tyrosinase assay, the conjugates were 10-100 times more active than alpha-MSH or the unconjugated analog. Each of the FA-melanotropic peptide conjugates exhibited prolonged (residual) melanotropic activity in both the lizard skin and melanoma cell bioassays. In other words, after removal of the melanotropin conjugates from contact with the skins or cells, responses were still manifested for hours or days thereafter. As little as 1 hr of contact with melanoma cells resulted in enhanced enzyme activity as measured 48 hr later. Since the conjugates, but not H-[Asp5, D-Phe7, Lys10]alpha-MSH5-10-NH2, exhibited prolonged activity, the conversion of reversible agonists to irreversible agonists was demonstrated.