While it is commonly known that patients with rheumatologic diseases can have esophageal dysfunction, this association is insufficiently understood. The aim is to determine the prevalence and characteristics of esophageal motility disorders in patients with rheumatic diseases. This is a single-center retrospective study of adults with rheumatologic disease who underwent high-resolution esophageal manometry (HREM). Those with and without a motility disorder (defined per Chicago classification CCv3.0 criteria, given the timing of the prior studies) were compared and multivariable logistic regression was used to determine odds of motility disorder by rheumatic disease. Of 289 patients, the mean age was 60.5 +/- 13.8 years. Rheumatic diseases included Raynaud's (42%), rheumatoid arthritis (RA) (39%), Sjogren's (21%), systemic lupus erythematous (19%), systemic sclerosis (17%), and mixed connective tissue disease (13%). On HREM, 58% had an esophageal motility disorder: achalasia (5%), EGJ outflow obstruction (20%), jackhammer (8%), diffuse esophageal spasm (1%), ineffective esophageal motility (28%), and fragmented peristalsis (2%). Of note, 50% of the sample with a normal barium swallow had an esophageal dysmotility disorder on HREM. Those with psoriatic arthritis were less likely to have esophageal dysmotility (73% vs. 27%; P = 0.04). There was decreased odds of esophageal hypocontractility in those with RA (OR [95%CI]: 0.27 [0.12-0.58]) and increased odds (OR [95%CI]: 3.13 [1.16-8.41]) of esophageal hypocontractility among those with scleroderma. Esophageal motor disorders were found in more than half of patients with rheumatologic diseases who underwent HREM. HREM should be considered in patients with rheumatic conditions presenting with esophageal symptoms.

INTRODUCTION:Differences in eosinophilic esophagitis (EoE) presentation and outcomes by ethnicity or race remain understudied. We aimed to determine whether EoE patients of Hispanic/Latinx ethnicity or non-White race have differences in presentation at diagnosis or response to topical corticosteroid (tCS) treatment. METHODS:This retrospective cohort study included subjects of any age with a new diagnosis of EoE and documentation of ethnicity or race. For those who had treatment with tCS and follow-up endoscopy/biopsy, we assessed histologic response (<15 eosinophils/hpf), global symptom response, and endoscopic response. Hispanic EoE patients were compared with non-Hispanics at baseline and before and after treatment. The same analyses were repeated for White vs non-Whites. RESULTS:Of 1,026 EoE patients with ethnicity data, just 23 (2%) were Hispanic. Most clinical features at presentation were similar to non-Hispanic EoE patients but histologic response to tCS was numerically lower (38% vs 57%). Non-White EoE patients (13%) were younger at diagnosis and had less insurance, lower zip code-level income, shorter symptom duration, more vomiting, less dysphagia and food impaction, fewer typical endoscopic features, and less dilation. Of 475 patients with race data treated with tCS, non-Whites had a significantly lower histologic response rate (41% vs 59%; P = 0.01), and odds of histologic response remained lower after controlling for potential confounders (adjusted odds ratio 0.40, 95% confidence intervals: 0.19-0.87). DISCUSSION:Few EoE patients at our center were Hispanic, and they had similar clinical presentations as non-Hispanics. The non-White EoE group was larger, and presentation was less dysphagia-specific. Non-White patients were also less than half as likely to respond to tCS.

BACKGROUND:Patients with eosinophilic esophagitis (EoE) typically have concomitant atopic conditions, but whether there are differences in presentation or treatment response by the number of atopic diseases is unknown. OBJECTIVE:To determine whether patients with EoE having multiple atopic conditions have differences in presentation or response to topical corticosteroid (TCS) treatment. METHODS:We performed a retrospective cohort study of adults and children with newly diagnosed EoE. The total number of atopic comorbidities (allergic rhinitis, asthma, eczema, food allergy) was calculated. Patients with at least 2 atopic conditions other than allergic rhinitis were defined as having multiple atopic conditions and their baseline characteristics were compared with those with less than 2 atopic conditions. Histologic, symptom, and endoscopic responses to TCS treatment were also compared with bivariable and multivariable analyses. RESULTS:Of the 1020 patients with EoE having atopic disease information, 235 (23%) had 1 atopic comorbidity, 211 (21%) had 2, 113 (11%) had 3, and 34 (3%) had 4. At baseline, the 180 (18%) patients with 2 or more atopic diseases were younger and had more vomiting, less abdominal pain, more exudates and edema on endoscopy, and higher peak eosinophil counts. Among those treated with TCS, there was a trend toward better global symptom response in patients with less than 2 atopic conditions, but there was no difference in histologic or endoscopic response compared with those with 2 or more atopic conditions. CONCLUSION:There were differences in the initial presentation of EoE between those with and without multiple atopic conditions, but there were no major differences in histologic treatment response to corticosteroids by atopic status.

Purpose: In spring 2020, Coronavirus Disease 2019 (COVID-19) "stay-at-home" orders may have led to later, more acute disease presentations of emergent conditions such as gastrointestinal bleeding (GIB). In this retrospective cohort study, we compared incidence and severity of GIB during the strictest COVID shutdown to pre-COVID periods. Patients and methods: We compared weekly counts of emergency department (ED) visits for GIB between March 27 and May 7, 2020 (COVID period) and pre-COVID periods in 2019 and 2020 in a US statewide network of hospitals. We compared the severity of GIB presentations using incident rate ratios (IRR) of "severe" GIB (requiring >= 4 units of blood, endoscopic therapy, interventional radiology or surgical procedure), intensive care (ICU) admission and shock. We also looked for effect modification of demographic covariates on associations between year and GIB outcomes. Results: Fewer patients presented to ED for GIB during COVID than during the same dates in 2019 (534 versus 904; IRR 0.59, 95% CI 0.53-0.66). A greater proportion of COVID-period ED visits required inpatient admission (73.6% vs 67.8%, p = 0.02) and had severe GIB (19.3% vs 14.9%, p = 0.03). Proportion of patients requiring transfusion (p < 0.001), with shock (p < 0.01), or with critical hemoglobin (p = 0.003) or lactate (p = 0.02) were worse during COVID. Non-white patients experienced disproportionately worse outcomes during COVID than in 2019, with greater absolute counts of shock (65 vs 62, p = 0.01 for interaction) or ICU admission (40 vs 35, p = 0.01 for interaction). Conclusion: Fewer acute GIB presented during the pandemic period compared to the year prior. The severity of pandemic presentations was greater, driven by disproportionately worse outcomes in minorities.

Eosinophilic esophagitis (EoE) is a clinicopathologic condition that is characterized by chronic inflammation with variable manifestations.1Dellon E.S. et al.Gastroenterology. 2018; 154: 319-332.e3Abstract Full Text Full Text PDF PubMed Scopus (368) Google Scholar Esophageal strictures are one of the fibrotic remodeling features of EoE and are more commonly seen with diagnostic delay.2Schoepfer A.M. et al.Gastroenterology. 2013; 145: 1230-1236.e1-e2Abstract Full Text Full Text PDF PubMed Scopus (503) Google Scholar Recognition of strictures is important given their role in complications of EoE, such as food impactions, and because dilation of strictures can safely provide significant symptomatic benefit.3Schoepfer A.M. et al.Am J Gastroenterol. 2010; 105: 1062-1070Crossref PubMed Scopus (259) Google Scholar,4Greenberg S. et al.Endoscopy. 2022; 54: 243-250Crossref PubMed Scopus (6) Google Scholar While it has been frequently demonstrated that the incidence and prevalence of EoE have been increasing, it is unknown if the prevalence of strictures in EoE patients has changed over time. We aimed to determine whether the prevalence of strictures and the performance of dilation have changed over the prior 2 decades in a large population of EoE patients. We conducted a retrospective cohort study utilizing the University of North Carolina EoE clinicopathologic database from inception (2001) through the end of 2020. The development and characteristics of the database have been previously reported.4Greenberg S. et al.Endoscopy. 2022; 54: 243-250Crossref PubMed Scopus (6) Google Scholar,5Eluri S. et al.Dis Esophagus. 2020; 33: doz088Crossref PubMed Scopus (9) Google Scholar Subjects in the study were adults and children with an incident diagnosis of EoE per consensus guidelines at the time of diagnosis, including symptoms of esophageal dysfunction, > 15 eosinophils per high-power field (eos/hpf), and exclusion of competing causes of eosinophilia; all had active EoE. Patient demographics, clinical characteristics, report of symptoms, and procedural data were extracted from medical records, including duration of symptoms before diagnosis, the presence or absence of esophageal strictures or narrowing (defined by the performing endoscopist’s visual assessment), and whether dilation was performed during the diagnostic endoscopy; subsequent endoscopic exams, even if they had dilations, were not assessed for this study. Given that this was an observational study, dilations were performed at the discretion of the endoscopist as clinically indicated. Endoscopic severity was calculated using the EoE Endoscopic Reference Score (EREFS), when this was available, and using an Endoscopic Severity Score, which was available for all patients. The Endoscopic Severity Score is the sum of the presence or absence of the same endoscopic findings in EREFS (exudates, rings, edema, furrows, and stricture) and ranges from 0 to 5, with higher scores being more severe. The prevalence of strictures, narrowing, or dilation was calculated by the year of diagnosis. Diagnostic timeframe was also categorized by 5-year intervals and by time intervals related to diagnostic guideline publications (2001–2007; 2007–2017; 2018–2020). Patient characteristics were compared across the 5-year time intervals using analysis of variance for continuous variables and chi-squared for categorical variables. Multivariate logistic regression was performed to assess for overall trends in the odds of esophageal stricture while accounting for changes in patient age and symptom length prior to diagnosis over time. We analyzed 1064 EoE patients, with a mean age of 29.4 years, 36% children < 18 years, 86% white, 68% male, 59% with at least one atopic condition, and mean symptom length prior to diagnosis of 7.5 ± 8.3 years. When assessing patient baseline characteristics for each 5-year period over the last 20 years (Table), age increased steadily with time (from 17.9 years at diagnosis for 2001–2005 to 33.8 years in 2016–2020; P < .001), as did frequency of dysphagia (from 61% to 83%; P < .001) and food impaction (from 27% to 40%; P = .01); frequency of abdominal pain decreased (from 26% to 12%; P < .001).TableComparison of Clinical Characteristics Across Each of the 5-year Intervals (n = 1064)2001–2005 (n = 49)2006–2010 (n = 262)2011–2015 (n = 331)2016–2020 (n = 422)PbMeans compared with ANOVA; proportions compared with chi-squared.Age at diagnosis (mean years ± SD)17.9 ± 15.126.4 ± 19.527.9 ± 17.933.8 ± 20.2<.001Male (n, %)44 (90)185 (71)212 (64)283 (67).003White (n, %)39 (80)215 (82)287 (89)367 (88).05Any atopic condition (n, %)27 (73)120 (53)196 (60)254 (61).07Symptom length prior to diagnosis (mean years ± SD)3.9 ± 4.96.7 ± 8.48.2 ± 9.07.6 ± 7.9.03Symptoms (n, %) Dysphagia30 (61)158 (62)255 (77)350 (83)<.001 Food impaction12 (27)68 (28)107 (32)168 (40).01 Heartburn19 (44)90 (37)136 (41)135 (32).05 Chest pain1 (2)26 (11)42 (13)38 (9).12 Abdominal pain11 (26)55 (22)73 (22)50 (12)<.001Endoscopic findings (n, %) Exudates6 (12)58 (22)152 (46)209 (50)<.001 Rings12 (24)108 (41)171 (52)248 (59)<.001 Edema3 (6)34 (13)146 (44)220 (52)<.001 Furrows4 (8)109 (42)245 (74)334 (79)<.001 Stricture10 (20)44 (17)75 (23)171 (41)<.001 Narrowing4 (8)28 (11)61 (18)75 (18).02 Dilation11 (22)50 (19)77 (23)177 (42)<.001 Total EREFS (mean ± SD)aEREFS data available for n = 466; ESS, endoscopic severity score, for which all data available.n/an/a3.5 ± 2.23.9 ± 1.8.16 Total ESS (mean ± SD)aEREFS data available for n = 466; ESS, endoscopic severity score, for which all data available.0.7 ± 0.71.3 ± 1.22.4 ± 1.52.8 ± 1.5<.001Peak eosinophil count (mean eos/hpf ± SD)72.2 ± 69.763.4 ± 37.566.1 ± 47.664.8 ± 44.0.81EREFS, Endoscopic Reference Score; SD, standard deviation.a EREFS data available for n = 466; ESS, endoscopic severity score, for which all data available.b Means compared with ANOVA; proportions compared with chi-squared. Open table in a new tab EREFS, Endoscopic Reference Score; SD, standard deviation. Overall, stricture prevalence and dilation frequency significantly increased over time, from 8% for each in 2004 to as high as 54% and 59%, respectively, in 2019 (P < .001). On multivariate analysis with the year as a continuous variable, the odds of stricture increased by 18% annually even after accounting for changes in patient age and symptom length prior to diagnosis (adjusted odds ratio [aOR] 1.18, 95% confidence interval [CI]: 1.12–1.23). When evaluating 5-year intervals, there was a significant increase in the prevalence of strictures, narrowing, and dilation (Figure A ). Within these intervals, after accounting for changes in age and symptom length, the odds of stricture doubled for each interval (aOR 2.11, 95% CI 1.69–2.65). Similar results were noted for EoE guideline intervals (Figure B). Compared to pre-guidelines time period, there were increased odds of stricture for both the second period (aOR 2.75, 95% CI 1.29–5.83) and the most recent time-period (aOR 6.80, 95% CI 3.12–14.8), after controlling for age and symptom length prior to diagnosis. We found that the prevalence of esophageal strictures in newly diagnosed EoE patients has markedly increased over the past 2 decades, with an associated increase in dilation. This doubling of stricture prevalence persists after accounting for changing demographic and disease factors, including age at diagnosis and symptom duration prior to diagnosis, which are associated with a higher likelihood of fibrostenotic phenotype.2Schoepfer A.M. et al.Gastroenterology. 2013; 145: 1230-1236.e1-e2Abstract Full Text Full Text PDF PubMed Scopus (503) Google Scholar Potential explanations for our findings could include increasing recognition of strictures, a changing phenotype, or a combination of both, though the exact reason is difficult to determine with our study design. While there is a broader recognition of EoE over the past 20 years, the incidence of EoE continues to outpace the rate of biopsies for the condition.6Dellon E.S. et al.Aliment Pharmacol Ther. 2015; 41: 662-670Crossref PubMed Scopus (122) Google Scholar Additionally, studies have demonstrated that our ability to endoscopically detect strictures has been limited, particularly when compared to other diagnostic modalities such as barium esophagram.7Gentile N. et al.Aliment Pharmacol Ther. 2014; 40: 1333-1340Crossref PubMed Scopus (98) Google Scholar,8Menard-Katcher C. et al.J Pediatr Gastroenterol Nutr. 2015; 61: 541-546Crossref PubMed Scopus (47) Google Scholar This may be due to EoE causing more subtle or diffuse strictures as compared to other more focal forms of stricturing such as in peptic disease.8Menard-Katcher C. et al.J Pediatr Gastroenterol Nutr. 2015; 61: 541-546Crossref PubMed Scopus (47) Google Scholar Because it is possible for endoscopists to maximize their detection of strictures with a focused and thorough endoscopic exam9Dellon E.S. Clin Gastroenterol Hepatol. 2021; 19: 2489-2492.e1Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar and for even severe strictures to be successfully treated,10Kim J.P. et al.Gastrointest Endosc. 2020; 92: 44-53Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar enhanced stricture detection is likely a major reason for our observed increase. However, improved ways to assess fibrostenosis in routine practice (such as standard use of techniques like impedance planimetry) and whether our findings may also represent a shifting phenotype require future research. Limitations of this study, including the single-center retrospective design, lack of ability to prospectively define strictures or narrowing, and potential variability in EREFS reporting over time, are balanced by the large population size, detailed patient characterization, and long study timeframe. In conclusion, the rate of strictures detected at the time of EoE diagnosis has been rising over the past 2 decades, with a concomitant increase in the rate of esophageal dilation.

INTRODUCTION: Despite societal recommendations supporting Barrett's esophagus (BE) screening, it is unknown what proportion of eligible patients is screened in primary care. We assessed the proportion of BE screening- eligible patients evaluated in the primary care setting receiving upper esophagogastroduodenoscopy (EGD) and identified factors associated with undergoing EGD. METHODS: This was a retrospective study of BE screening-eligible patients, as defined by the American College of Gastroenterology's BE guidelines, in a multipractice healthcare network consisting of 64 internal medicine practices and 94 family medicine (FM) practices. The proportion undergoing EGD, prevalence of BE and esophageal adenocarcinoma (EAC) in this group, and patient and provider factors associated with undergoing EGD were assessed. Multivariable logistic regression was performed to identify independent predictors of undergoing EGD. RESULTS: Of 1,127 screening-eligible patients, the mean age was 65.2 ± 8.6 years; 45% were obese; and 61% were smokers. Seventy-three percent were seeing FM; 94% were on proton pump inhibitors; and 44% took ≥1 gastroesophageal reflux disease (GERD) medication. Only 39% of patients (n = 436) had undergone EGD. The overall prevalence of BE or EAC was 9.9%. Of 39 (9%) referred for BE screening as the primary indication, BE/EAC prevalence was 35.1%. Factors associated with increased odds of having EGD were symptomatic GERD despite treatment (odds ratio [OR] 12.1, 95% confidence interval [CI] 9.1‐16.3), being on ≥1 GERD medication (OR 1.4, 95% CI 1.0‐1.9), and being an FM patient (OR 1.5, 95% CI 1.1‐2.1). DISCUSSION: In this large, primary care population, only 39% of screening-eligible patients underwent EGD. Most of the examinations were triggered by refractory symptoms rather than screening referrals, highlighting a need for improved dissemination and implementation of BE screening.

Background and Objectives: Percutaneous transhepatic biliary drainage (PTBD) and EUS-guided choledochoduodenostomy (EUS-CD) are alternate therapies to endoscopic retrograde cholangiopancreatography with stent placement for biliary decompression. The primary outcome of this study is to compare the technical and clinical success of PTBD to EUS-CD in patients with distal biliary obstruction. Secondary outcomes were adverse events (AEs), need for reintervention, and survival. Methods: A multicenter retrospective cohort study from three different centers was performed. Cox regression was used to compare time to reintervention and survival and logistic regression to compare technical and clinical success and AE rates. Subgroup analysis was performed in patients with malignant biliary obstruction (MBO). Results: A total of 86 patients (58 PTBD and 28 EUS-CD) were included. The two groups were similar with respect to age, gender, and cause of biliary obstruction, with malignancy being the most common etiology (80.2%). EUS-CD utilized lumen-apposing metal stents in 15 patients and self-expandable metal biliary stents in 13 patients. Technical success was similar been EUS-CD (100%) and PTBD (96.6%; P = 0.3). EUS-CD was associated with higher clinical success compared to PTBD (84.6% vs. 62.1%; P = 0.04). There was a trend toward lower rates of AEs with EUS-CD 14.3% versus PTBD 29.3%, odds ratio: 0.40 (95% confidence interval [CI]: 0.12-1.33, P = 0.14). The need for reintervention was significantly lower among patients who underwent EUS-CD (10.7%) compared to PTBD (77.6%) (hazard ratio: 0.07, 95% CI: 0.02-0.24; P < 0.001). A sensitivity analysis of only patients with MBO demonstrated similar rate of reintervention between the groups in individuals who survived 50 days or less after the biliary decompression. However, reintervention rates were lower for EUS-CD in those with longer survival. Conclusion: EUS-CD is a technically and clinically highly successful procedure with a trend toward lower AEs compared to PTBD. EUS-CD minimizes the need for reintervention, which may enhance end-of-life quality in patients with MBO and expected survival longer than 50 days.

Eosinophilic esophagitis (EoE) has been associated with autoimmune (AI) and connective tissue disorders (CTDs), but clinical correlates and treatment response to topical corticosteroids (tCS) for patients with both conditions are not well known. We aimed to determine the prevalence and clinical features of AI/CTDs in EoE patients, and assess the response to tCS. In this retrospective cohort study of adults and children newly diagnosed with EoE in the University of North Carolina EoE Clinicopathologic database, we extracted clinical characteristics and treatment response data. We compared EoE patients with and without AI/CTDs, identified independently associated factors, and explored treatment responses. Of 1029 EoE patients, 61 (5.9%) had an AI/CTDs. The most common AI/CTDs were psoriasis/psoriatic arthritis (P/PA) (1.7%), Hashimoto's (1.2%), and rheumatoid arthritis (RA) (1%). Compared to those without AI/CTDs, AI/CTDs patients were older (35 vs. 28 years, P = 0.004), more likely to be female (51% vs. 30%, P = 0.001), have insurance (93% vs. 78%, P = 0.004) and a longer symptom duration prior to EoE diagnosis (10 vs. 7 years, P = 0.02). Older age, female sex, having insurance, and having allergic rhinitis were independently associated with AI/CTDs. AI/CTD patients with EoE were less likely to have a symptom response (47% vs. 79%, P = 0.003). Overlap between EoE and AI/CTDs was uncommon, seen in approximately 6%, with P/PA, Hashimoto's, and RA being most frequent. In conclusion, older age, female sex, having insurance, and allergic rhinitis were independently associated with AI/CTDs. EoE patients with AI/CTDs had less symptom response, with trendtowards lower endoscopic and histologic responses, to tCS therapy.

Goals: The goal of this study was to compare the relative safety of administering iron infusions on the same day as intravenous (IV) biological therapy to the administration of these treatments on different days in patients with inflammatory bowel disease (IBD). Background: IV iron therapy is often required in patients with IBD. Many patients with IBD who receive IV iron therapy in the outpatient setting also receive biological infusion therapy for treatment of their IBD. Study: Patients with IBD who received IV iron therapy at a single infusion center were included. We compared documented infusion-related reactions in patients with patients receiving an iron infusion on the same day as their biological infusion to those who received their iron infusion on a different day. Results: Among 481 patients, 129 received an iron infusion on the same day as a biologic infusion. There was no significant difference in the incidence of infusion reaction when comparing patients who received biological infusion therapy in the same session as the iron infusion to those patients who received a biological infusion on a different day (5% vs. 7%, P=0.246) or any IBD-related therapy (5% vs. 8%, P=0.206). Conclusions: The frequency and type of infusion reactions in patients receiving IV iron therapy on the same day after IV therapy with biologics was not increased compared with patients who received a biological infusion on a different day. A sequential infusion of biological therapy followed by IV iron therapy may be a safe and cost-effective approach.

Background: There are few data assessing treatment response in older eosinophilic esophagitis (EoE) patients and we evaluated treatment outcomes to topical corticosteroids (tCS) in this older population.Methods: This retrospective cohort study of the UNC EoE Clinicopathologic database included subjects with a new diagnosis of EoE treated with tCS. Histologic responses, global symptom response, and en-doscopic changes were recorded. Older EoE patients ( >65 years) were compared to younger EoE patients ( < 65). Results: We identified 467 EoE patients treated with tCS, 12 (3%) of whom were >65 years. Compared to those < 65 years, patients >65 had longer symptom duration and worse endoscopy scores, but most clinical features were similar. Post-treatment peak eosinophil counts trended higher in the < 65 group (25.0 vs 5.5; p = 0.07). Histological response was greater in the >65 population at < 15 eos/hpf (92% vs 57%; p = 0.02), <6 eos/hpf (83% vs 50%; p = 0.02), and < 1 eos/hpf (58% vs 29%; p = 0.03). Older age was independently associated with increased odds of histologic response (adjusted OR 8.48, 95% CI: 1.08-66.4).Conclusions: EoE patients >65 years had a higher likelihood of responding to tCS therapy, suggesting they should be studied more closely and included in future trials.(c) 2021 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

BACKGROUND & AIMS:Understanding which eosinophilic esophagitis (EoE) patients will respond to treatment with topical corticosteroids (tCS) remains challenging, and it is unknown whether obesity impacts treatment response. This study aimed to determine whether treatment outcomes to tCS in EoE patients vary by body mass index (BMI). METHODS:This retrospective cohort study of the University of North Carolina EoE Clinicopathologic database assessed subjects age 14 years or older with a new diagnosis of EoE. Their BMI was calculated and histologic, symptom, and endoscopic responses were recorded after tCS treatment. The treatment response of obese (BMI, ≥30 kg/m2) and nonobese EoE status was compared using bivariate and multivariate analyses. RESULTS:We identified 296 EoE patients treated with tCS. Baseline characteristics were similar, although obese EoE patients had more heartburn and hiatal hernias. Histologic response was higher for those who were nonobese compared with obese at fewer than 15 (61% vs 47%; P = .049) and 6 or fewer (54% vs 38%; P = .02) eosinophils per high-power field, respectively. In addition, nonobese patients had significantly greater endoscopic and symptomatic responses. On multivariate analysis, increasing BMI was associated independently with decreased histologic response after accounting for age, heartburn, dilation, and hiatal hernia whether BMI was assessed as a continuous variable (adjusted odds ratio [aOR], 0.93; 95% CI, 0.89-0.98), as nonobese vs obese (aOR, 0.38; 95% CI, 0.21-0.68), or in 4 categories (overweight vs normal [aOR, 0.46; 95% CI, 0.26-0.84] or obese vs normal [aOR, 0.26; 95% CI, 0.13-0.51]). CONCLUSIONS:As BMI increases in EoE patients, the odds of histologic, symptomatic, and endoscopic responses to tCS decreases, with obese patients having an approximately 40% decrease in odds of response.

BACKGROUND:There is conflicting evidence about the association between eosinophilic esophagitis (EoE) and esophageal motility disorders. The aim of this study was to evaluate esophageal manometry findings in EoE.METHODS:We conducted a systematic review using PubMed, EMBASE, and Web of Science. All articles from 1990 to 2021 with EoE patients who underwent esophageal manometry were eligible. We also included pertinent abstracts from national conferences from 2015 to 2020. The primary outcomes were the prevalence of specific Chicago 3 Classification (CCv3) diagnoses in EoE, as well as broader categories of non-relaxing lower esophageal sphincter, and major and minor peristaltic disorders. When multiple studies reported a specific outcome, we performed random effects meta-analysis to obtain pooled prevalence of each outcome. To reduce heterogeneity, we restricted meta-analysis to high-resolution manometry (HRM) studies only.KEY RESULTS:Of 763 publications identified, 27 original studies met criteria for inclusion, encompassing 706 EoE patients; 14 studies (425 patients) had HRM and underwent meta-analysis. The pooled prevalence of any motility abnormality was 53% (95% CI: 43%-63%), largely comprised of minor motility disorders such as ineffective esophageal motility and fragmented peristalsis. Major motility disorders, classified by CCv3, were less common in EoE, with pooled prevalence of 2% (0%-7%), 10% (5%-16%), and 1% (0%-3%), for achalasia, esophagogastric-junction outflow obstruction, and hypercontractile disorders, respectively.CONCLUSION AND INFERENCES:Non-specific motility disorders were common in patients with EoE, but major motility disorders were rare. Further studies are needed to determine the relationship between eosinophilic infiltration and the clinical relevance of abnormal esophageal motility findings in this population.

Despite societal recommendations for Barrett’s esophagus (BE) screening, it is unknown what proportion of eligible patients are screened in a primary care setting.

Introduction: There is conflicting evidence about the association between eosinophilic esophagitis (EoE) and esophageal motility disorders, as well as whether dysmotility impacts clinical manifestations and treatment. The aim of this study is to evaluate esophageal manometry findings and esophageal dysmotility disorders in patients with EoE. Methods: We conducted a systematic review using PubMed, EMBASE, and Web of Science. Articles with EoE patients who underwent esophageal manometry were eligible for inclusion. We also included pertinent abstracts from national conferences from 2015-2020. Review articles, editorials, and commentaries were excluded. Clinical, endoscopic, and manometry findings as well as EoE treatment type and response, were extracted. Weighted averages for the proportion of EoE patients with different manometric findings were calculated. An assessment of risk of bias was completed using NIH/NHLBI quality assessment tools. Results: We identified 755 articles, of which 31 met inclusion criteria (Figure 1A). There were 18 retrospective studies, 8 prospective cohorts, 4 case control studies, and 1 case series, representing a total of 808 patients. A majority of patients with EoE were male and ∼33% (range 7-86%) had atopic conditions. Conventional manometry was used in 11 articles, and high-resolution esophageal manometry (HREM) in 20 articles. A total of 7 different esophageal motility disorders were identified (Figure 1B). Ineffective esophageal motility and achalasia were the most common in EoE patients, with weighted averages of 28.3% and 13.9%, respectively. The remaining dysmotility disorders and their weighted averages were fragmented peristalsis (11.7%), EJGOO (6.8%), jackhammer (4.2%), nutcracker (4.1%), distal esophageal spasm (DES) (3.8%), and absent contractility (2.9%). In terms of treatment response, 5/15 articles noted a positive symptom and/or endoscopic response to a PPI trial. Nine out of fourteen studies that used fluticasone for EoE treatment, saw improvement of symptoms and/or endoscopic findings, and 2 studies noted significant improvement in histologic findings. Conclusion: Discrete esophageal motility disorders were present in a significant percentage of patients with EoE who underwent HREM. Clinical symptoms of EoE may be related to esophageal dysmotility and manometry should be considered for evaluation, particularly in EoE patients with ongoing disease manifestations and symptoms despite treatment.Figure 1.: Flowchart for systematic review and prevalence of motility disorders in EoE

Introduction:The COVID-19 pandemic has altered the delivery of all health care.In spring of 2020, efforts made to minimize disease transmission including "stay-at-home" orders and the deferral of elective outpatient encounters may have led to later, more acute disease presentations.Aim: Assess the impact of the COVID healthcare shutdown on patients presenting to hospital with gastrointestinal bleeding (GIB).Methods: We compared weekly counts of ED visits and inpatient admissions for GIB between the time periods of March 27-May 7, 2020 (COVID period) and March 27-May 7, 2019 (pre-COVID period) in a large health system comprising academic and community hospitals.We also compared the severity of GIB presentations between periods, using incident rate (IRR) and odds ratios (OR) of "severe" GIB (requiring >4 units of red blood cells, endoscopic therapy, interventional radiology or surgical procedure), ICU admission, or shock, as well as multiple secondary clinical outcomes based on automated extraction of ICD-10 diagnoses as well as manual chart review.Lastly, we looked for effect modification of demographic covariates on any association between year and GIB outcomes.Results: The number of ED visits for GIB was significantly lower in 2020 (534 ED visits) compared to 2019 (904 in 2019; IRR 0.59, 95%CI 0.53-0.66, Figure 1).A greater proportion of ED visits for GIB required an inpatient stay in 2020 (73.6% vs 67.8%, p=0.02).Although the absolute number of inpatient and ICU admissions for GIB in 2020 were fewer, the percentage of visits categorized as severe GIB was significantly higher in 2020 (19.3% vs 14.9%, p=0.03).Average transfusion requirement, the first or extreme values for hemoglobin and lactate, and the proportion diagnosed with shock were statistically worse in the 2020 group.While higher frequency variables (e.g.number of endoscopic procedures with hemostasis intervention, total units of red cells, hospital/ICU lengths of stay) were higher in 2019, those for lower frequency variables of more severe disease, including vasopressor support, intubations, renal replacement therapy and inpatient deaths, were similar.There was a significant interaction between year and race, with non-white patients experiencing greater proportions of severe GIB, and greater absolute counts of shock or ICU admission in 2020 than 2019 (Figure 3). Conclusion:A significantly lower number of ER visits and hospitalizations GIB occurred during the pandemic period compared to the same period the year prior.The severity of pandemic presentations was greater, driven by disproportionately worse outcomes in minorities.During the rest of COVID-19 and future pandemics, it is critical to maintain standards of care for non-COVID conditions, with a particularly eye to racial equity.Differences in ED visits for GI bleed during a 6-week period of COVID lockdown and the corresponding period from 2019

Back to table of contents Previous article Frontline ReportsFull AccessCapacity-Building in the Peer Workforce: A Systems-Level ApproachSumana B. Reddy, M.D. M.P.H., Jessica Wolf, Ph.D., Louis D. Brown, Ph.D.Sumana B. Reddy, M.D. M.P.H., Jessica Wolf, Ph.D., Louis D. Brown, Ph.D.Published Online:14 Jan 2020https://doi.org/10.1176/appi.ps.71301AboutSectionsView articleView PDFView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articlePeer providers deliver services in behavioral health settings, drawing from their own recovery experiences and the skills obtained from formal peer provider training. Although peer services are becoming increasingly common, barriers persist in fully integrating peer support workers into behavioral health systems, including unclear peer roles and difficulties in placing peers on care teams.To address these problems, the California Office of Statewide Health Planning and Development funded SHARE!, the Self-Help and Recovery Exchange, to develop the Supervision of the Peer Workforce project. SHARE! seeks to maximize the efficacy of both peer workers and their supervisors, thereby improving outcomes for individuals receiving mental health and substance use services. Training was provided by nationally recognized leaders with decades of experience with peer workforce development to more than 200 peer workers and their supervisors from 38 program sites in the Los Angeles County public mental health system from December 2018 through June 2019.The program included four training courses. The Strategies for an Effective Peer Workforce course addressed the core peer worker role. Training covered best practices in peer services, including peer listening and disclosing recovery planning, use of self-help support groups, peer bridging; and evoking the helper therapy principle. Learning objectives included demonstrating knowledge of evidence-based practices for referring people to self-help groups and understanding differences in the responsibilities of peer workers and clinicians. Also included were strategies to help peer providers and supervisors reduce stress, improve life satisfaction, and create a plan to improve self-care. This training assisted peer workers in fulfilling the objectives while demonstrating cultural competence in applying peer practices and services.Becoming an Ally addressed hardships related to discrimination that can cause isolation and alienation within agencies and community. Having allies allows people to move away from stigma, discrimination, and "othering" and support people in speaking for themselves and setting and attaining personal goals. To develop cultural competency and inclusion, the training focused on exercises and tools that cultivate dialogue, a practice that aligns people with a shared vision in becoming an ally with people who are stigmatized or the targets of discrimination. It emphasizes mutual respect, learning, and balancing inquiry and advocacy. This training includes discussion, group activities, and tools to become an ally, tolerate differences, reduce prejudice, and support others in using their voice.The Trauma-Informed Developmental Model of Supervision taught supervisors and peer providers to use trauma-informed practical tips and strategies, with emphasis on forging alliances with supervisors to improve outcomes. Effective supervisory relationships require peers and supervisors to understand how their trauma experience is connected to their mental health and how to implement trauma-informed care as well as trauma-informed supervision. This training encouraged self-awareness, motivation, and autonomy. With an effective context and structure for supervision in place, peers and their supervisors developed a joint trauma-informed developmental model of supervision for their specific work.The Anti-Stigma Workshop, the fourth course, is evidence-based training delivered by On Our Own of Maryland, a peer-run organization. Public stigma refers to a set of negative attitudes and beliefs that motivate individuals to fear, reject, avoid, and discriminate against people with mental illness. This training helped participants recognize impediments of stigma. By recognizing stigma within and around them, participants explored changing behavior to reduce stigma in the workplace.On completion of training, each interested agency was encouraged to create its own implementation team by utilizing supervisors, peer workers, and other staff members to develop and implement sustainable peer services action plans. In early 2020, participants and other stakeholders will convene to share lessons learned from the project and work toward further implementation of best practices with peer support workforces.SHARE! has helped supervisors and peer providers recognize and address barriers to successful inclusion of peer workers in the public mental health system. Although evaluation results are pending, participants' high satisfaction ratings suggest positive project impact so far. By addressing the competencies of peer workers and supervisors through robust training within a context of agency leadership and support, the mental health system can strengthen workforce capacity to improve quality of life and recovery of those served.School of Public Health in El Paso, University of Texas Health Sciences Center at Houston (Reddy, Brown); Decision Solutions, Stratford, and Department of Psychiatry, Yale University, New Haven, Connecticut (Wolf). Francine Cournos, M.D., and Stephen M. Goldfinger, M.D., are editors of this column.Send correspondence to Dr. Reddy ([email protected]). FiguresReferencesCited byDetailsCited ByNone Volume 71Issue 3 March 01, 2020Pages 307-307 Metrics History Published online 14 January 2020 Published in print 1 March 2020