Assessment of the clinical and allergy profiles of PPI responsive and non-responsive eosinophilic esophagitis.

A subset of patients with eosinophilic esophagitis (EoE) respond to proton-pump inhibitor (PPI) therapy, however they cannot be distinguished prior to PPI trial and the mechanism of PPI response remains unclear. Improved understanding of the distinct patient phenotypes in PPI-responsive EoE (PPI-r-EoE), PPI-non-responsive EoE (PPI-nr-EoE) and erosive esophagitis (EE) may help guide management. The aim of this paper is to compare the clinical and allergy profiles of PPI-r-EoE versus PPI-nr-EoE and EE. This was a retrospective case-control study of EoE patients (>15 eos/hpf on esophageal biopsies) at a tertiary center. EE controls were identified from the pathology database. EoE patients were classified as PPI-r-EoE or PPI-nr-EoE based on histologic response to twice-daily PPI for ≥8 weeks. Patient demographics, comorbidities, symptoms, allergy history and endoscopic findings were recorded. Univariate analyses were performed using the Fisher-exact test or t-test. Multivariable analyses were performed using logistic regression. In all, 104 EoE (57 PPI-r-EoE/47 PPI-nr-EoE) and 80 EE subjects were included. On multivariable analyses, allergic conditions (aOR 20.1, P < 0.0001) and rings (aOR 108.3, P = 0.001) were independent predictors for PPI-r-EoE versus EE, whereas allergic conditions (aOR 4.8, P = 0.03), rings (aOR 27.5, P = 0.002) and furrows (aOR 17.1, P = 0.04) were independent predictors for PPI-nr-EoE versus EE. Esophageal rings was the only significant predictor found in PPI-nr-EoE versus PPI-r-EoE (OR 2.5, P = 0.03). Allergic conditions and esophageal rings are significantly more prevalent in PPI-r-EoE and PPI-nr-EoE compared with EE. PPI-r-EoE appears clinically similar to PPI-nr-EoE and significantly different from EE. Further studies are needed to delineate the underlying pathophysiology of PPI-r-EoE versus PPI-nr-EoE.

Endoscopic Features and Eosinophil Density Are Associated with Food Impaction in Adults with Esophageal Eosinophilia.

BACKGROUND AND AIMS: Food impaction has been described in both eosinophilic esophagitis and proton pump inhibitor-responsive esophageal eosinophilia. The association between endoscopic/histologic features of esophageal eosinophilia and food impaction remains unclear. We aimed to identify clinical, endoscopic, and histologic findings associated with a history of food impaction in esophageal eosinophilia. METHODS: This was a retrospective cohort study of adult esophageal eosinophilia patients at a tertiary center in 6/2005-10/2014. Only patients with ≥15 eosinophils/high-power field on mucosal biopsies were included. Demographics, comorbidities, symptoms, endoscopic/histologic findings on initial endoscopy, and history of food impaction were reviewed. Statistical analyses were performed using Fisher's exact test (univariate) and forward stepwise logistic regression (multivariate). RESULTS: 400 patients (42 ± 14 years, 61 % male) were included, with 78 (20 %) having food impaction history. On univariate analyses, rings (62 vs 42 %, p = 0.003), erosions (12 vs 5 %, p = 0.03), eosinophil density on biopsy (40 [IQR = 30-50] vs 30 [IQR = 15-50], p = 0.004), and dysphagia (88 vs 62 %, p < 0.0001) were more prevalent among patients with food impaction history, while heartburn (10 vs 33 %, p < 0.0001) and abdominal pain (1 vs 12 %, p = 0.002) were less common. On multivariate analysis, rings (OR 2.6, p = 0.002), erosions (OR 3.2, p = 0.02), and eosinophil density (ß-coefficient = 0.01, p = 0.04) remained associated with food impaction. CONCLUSIONS: Findings of rings and erosions on endoscopy and increased eosinophil density on histology were independently associated with a history of food impaction in adult esophageal eosinophilia patients. Food impaction may result from both active inflammation (erosions and increased eosinophil density) and chronic fibrostenotic changes (rings).

Predicting Non-Adherence with Outpatient Colonoscopy Using a Novel Electronic Tool that Measures Prior Non-Adherence.

BACKGROUND: Accurately predicting the risk of no-show for a scheduled colonoscopy can help target interventions to improve compliance with colonoscopy, and thereby reduce the disease burden of colorectal cancer and enhance the utilization of resources within endoscopy units. OBJECTIVES: We aimed to utilize information available in an electronic medical record (EMR) and endoscopy scheduling system to create a predictive model for no-show risk, and to simultaneously evaluate the role for natural language processing (NLP) in developing such a model. DESIGN: This was a retrospective observational study using discovery and validation phases to design a colonoscopy non-adherence prediction model. An NLP-derived variable called the Non-Adherence Ratio ("NAR") was developed, validated, and included in the model. PARTICIPANTS: Patients scheduled for outpatient colonoscopy at an Academic Medical Center (AMC) that is part of a multi-hospital health system, 2009 to 2011, were included in the study. MAIN MEASURES: Odds ratios for non-adherence were calculated for all variables in the discovery cohort, and an Area Under the Receiver Operating Curve (AUC) was calculated for the final non-adherence prediction model. KEY RESULTS: The non-adherence model included six variables: 1) gender; 2) history of psychiatric illness, 3) NAR; 4) wait time in months; 5) number of prior missed endoscopies; and 6) education level. The model achieved discrimination in the validation cohort (AUC= =70.2 %). At a threshold non-adherence score of 0.46, the model's sensitivity and specificity were 33 % and 92 %, respectively. Removing the NAR from the model significantly reduced its predictive power (AUC = 64.3 %, difference = 5.9 %, p < 0.001). CONCLUSIONS: A six-variable model using readily available clinical and demographic information demonstrated accuracy for predicting colonoscopy non-adherence. The NAR, a novel variable developed using NLP technology, significantly strengthened this model's predictive power.

Risk factors for inadequate colonoscopy bowel preparations in African Americans and whites at an urban medical center.

OBJECTIVES: Poor bowel preparation leads to inadequate examinations and shorter surveillance intervals for colorectal cancer screening. Previous studies regarding risk factors for inadequate preparation have not included large numbers of African Americans. Our aim was to determine the prevalence of inadequate bowel preparation on initial and follow-up colonoscopy in a large, racially diverse patient population. METHODS: Colonoscopies performed during a 1-year period were analyzed retrospectively. Factors including age, sex, race, and start time were recorded. Patient ZIP codes were linked to census data to estimate education and income. For examinations with inadequate bowel preparations, we collected data on recommendations and the preparation quality of follow-up procedures. RESULTS: We included 3741 patients (40.2% African American). Of these, 66.9% had adequate bowel preparation and 33.1% had inadequate bowel preparation. African Americans had the highest prevalence of inadequate preparations at 43.0%. African American race was a predictor of inadequate bowel preparation, despite controlling for education and income. Age, male sex, and procedure taking place after 12 pm also were risk factors for inadequate preparation. Receipt of specific preparation instructions on the endoscopy report did not affect preparation quality on follow-up examination. Our study found a high rate (33.1%) of inadequate bowel preparations, and African American race was found to be an independent risk factor for inadequate preparation. We validated previously reported risk factors including age, male sex, and later procedure time. Finally, we noted high rates of inadequate preparation on follow-up examinations. CONCLUSIONS: Improving the quality of colonoscopy bowel preparation is important for colorectal cancer prevention, especially in high-risk populations such as African Americans.