The relationship between off-site inpatient gastroenterology consultations and timeliness of care delivery

Corresponding author: Gregory Cote, Oregon Health and Science UniversityIntroduction: Gastroenterologists are increasingly responsible for providing inpatient care at multiple facilities. Here, we hypothesized that a single gastroenterology team covering two facilities impacts care delivery outcomes such as length of stay (LOS). Materials and Methods: This retrospective cohort study included inpatient GI consultations over a three-year period performed at two hospitals within a single academic health system. One site, where complete endoscopic services are provided, was considered the “primary,” and the other a "satellite." These facilities are located approximately 10 minutes apart in walking time. Patients admitted to non-medical services were excluded. Outcomes included LOS, time from admission to consultation, use of inpatient endoscopy, and time from endoscopy to discharge. Results: Of 1,952 admissions with GI consultation, 700 (36%) occurred at the satellite. The median LOS was longer for patients admitted to the satellite (4.9 vs. 4.2 days, p[less than]0.001), primarily because there was a significantly longer time from admission to GI consultation (0.3 vs. 0.01 days, p[less than]0.001); however, median time from consultation to discharge was similar between facilities (p = 0.80). Patients admitted to the primary facility were more likely to undergo inpatient endoscopy (62% vs. 55%, p=0.003). After adjusting for potential confounders, including consult indication, there was a significant positive correlation between admission to satellite and increased LOS (beta coefficient 3.72, p[less than]0.001). Conclusions: Inpatient GI consults at satellite facilities are associated with longer LOS and lower use of inpatient endoscopy. Health systems should monitor the timeliness of inpatient subspecialty care at satellites and consider interventions to minimize delays.Charles V. Welden IV (MD, Department of Medicine, Division of Gastroenterology and Hepatology, Medical University of South Carolina), B. Joseph Elmunzer (MD, MS, Department of Medicine, Division of Gastroenterology and Hepatology, Medical University of South Carolina), Donald C. Rockey (MD, Department of Medicine, Division of Gastroenterology and Hepatology, Medical University of South Carolina), Gregory A. Cote, (MD, MS, Department of Medicine, Division of Gastroenterology and Hepatology, Medical University of South Carolina, Department of Medicine, Division of Gastroenterology and Hepatology, Oregon Health and Science University)Includes bibliographical reference

31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016) : part two

Background The immunological escape of tumors represents one of the main ob- stacles to the treatment of malignancies. The blockade of PD-1 or CTLA-4 receptors represented a milestone in the history of immunotherapy. However, immune checkpoint inhibitors seem to be effective in specific cohorts of patients. It has been proposed that their efficacy relies on the presence of an immunological response. Thus, we hypothesized that disruption of the PD-L1/PD-1 axis would synergize with our oncolytic vaccine platform PeptiCRAd. Methods We used murine B16OVA in vivo tumor models and flow cytometry analysis to investigate the immunological background. Results First, we found that high-burden B16OVA tumors were refractory to combination immunotherapy. However, with a more aggressive schedule, tumors with a lower burden were more susceptible to the combination of PeptiCRAd and PD-L1 blockade. The therapy signifi- cantly increased the median survival of mice (Fig. 7). Interestingly, the reduced growth of contralaterally injected B16F10 cells sug- gested the presence of a long lasting immunological memory also against non-targeted antigens. Concerning the functional state of tumor infiltrating lymphocytes (TILs), we found that all the immune therapies would enhance the percentage of activated (PD-1pos TIM- 3neg) T lymphocytes and reduce the amount of exhausted (PD-1pos TIM-3pos) cells compared to placebo. As expected, we found that PeptiCRAd monotherapy could increase the number of antigen spe- cific CD8+ T cells compared to other treatments. However, only the combination with PD-L1 blockade could significantly increase the ra- tio between activated and exhausted pentamer positive cells (p= 0.0058), suggesting that by disrupting the PD-1/PD-L1 axis we could decrease the amount of dysfunctional antigen specific T cells. We ob- served that the anatomical location deeply influenced the state of CD4+ and CD8+ T lymphocytes. In fact, TIM-3 expression was in- creased by 2 fold on TILs compared to splenic and lymphoid T cells. In the CD8+ compartment, the expression of PD-1 on the surface seemed to be restricted to the tumor micro-environment, while CD4 + T cells had a high expression of PD-1 also in lymphoid organs. Interestingly, we found that the levels of PD-1 were significantly higher on CD8+ T cells than on CD4+ T cells into the tumor micro- environment (p < 0.0001). Conclusions In conclusion, we demonstrated that the efficacy of immune check- point inhibitors might be strongly enhanced by their combination with cancer vaccines. PeptiCRAd was able to increase the number of antigen-specific T cells and PD-L1 blockade prevented their exhaus- tion, resulting in long-lasting immunological memory and increased median survival

Case Series Regarding Parastomal Variceal Bleeding: Presentation and Management

Parastomal variceal bleeding (PVB) is a serious complication occurring in up to 27% of patients with an ostomy and concurrent cirrhosis and portal hypertension. The management of PVB is difficult and there are no clear guidelines on this matter. Transjugular intrahepatic portosystemic shunt (TIPS), sclerotherapy, and /or coil embolization are all therapies that have been shown to successfully manage PVB. We present a case series with five different patients who had a PVB at our institution. The aim of this case series is to report our experience on the management of this infrequently reported but serious condition. We also conducted a systemic literature review focusing on the treatment modalities of 163 patients with parastomal variceal bleeds. In our series, patient 1 had embolization and sclerotherapy without control of bleed and expired on the day of intervention due to hemorrhagic shock. Patient 2 had TIPS in conjunction with embolization and sclerotherapy and had no instance of rebleed 441 days after therapy. Patient 3 did not undergo any intervention due to high risk for morbidity and mortality, the bleed self-resolved and there was no further rebleed, this same patient died of sepsis 73 days later. Patient 4 had embolization and sclerotherapy and had no instance of rebleed 290 days after therapy. Patient 5 had TIPS procedure and was discharged five days post procedure without rebleed, patient has since been lost to follow-up