bluuebunny/crossref_metadata_2025 huggingface dataset:
Employees’ opinions on critical success factors and performance criteria in disaster and emergency management
Authors: Şahinöz Saime , Yaprak Ünal , Şahinöz Turgut
Published: October 2019

Objective: To evaluate the critical success factors at disaster and emergency management and to analyse their impact on performance to guide the managers and decision makers.

Methods: This was a cross-sectional study. It included all staff working in the fire brigade, 112 Emergency, Disaster and Emergency Management Authority and Red Crescent institutions serving in emergency situations in five provinces (Rize, Artvin, Trabzon, Gümüşhane, Bayburt) in the Eastern Black Sea region of Turkey. One province (Gümüşhane) was selected by cluster sampling method. Questionnaire which is the data collection method in the study was applied between 08/01/2016 - 02/02/2016 to all of the staff working in the fire brigade, 112 Emergency, Disaster and Emergency Management Authority and Red Crescent institutions serving in emergency situations in Gümüşhane province.

Results: It has been found out that there is a significant and positive relationship between all of the critical success factors, planning, response and recovery criteria, and performance variance.

Conclusions: The presence of well-planned emergency aid systems in the institutions or organizations involved in this area is an element of success. For this reason, this factor should be given more importance.

doi: https://doi.org/10.12669/pjms.35.6.778

How to cite this:Sahinoz S, Yaprak U, Sahinoz T. Employees’ opinions on critical success factors and performance criteria in disaster and emergency management. Pak J Med Sci. 2019;35(6):1636-1641. doi: https://doi.org/10.12669/pjms.35.6.778

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Evidence-based Clinical Decision Support Systems for the prediction and detection of three disease states in critical care: A systematic literature review
Authors: Medic Goran , Kosaner Kließ Melodi , Atallah Louis , Weichert Jochen , Panda Saswat , Postma Maarten , EL-Kerdi Amer
Published: October 2019

Background:Clinical decision support (CDS) systems have emerged as tools providing intelligent decision making to address challenges of critical care. CDS systems can be based on existing guidelines or best practices; and can also utilize machine learning to provide a diagnosis, recommendation, or therapy course.

Methods:This research aimed to identify evidence-based study designs and outcome measures to determine the clinical effectiveness of clinical decision support systems in the detection and prediction of hemodynamic instability, respiratory distress, and infection within critical care settings. PubMed, ClinicalTrials.gov and Cochrane Database of Systematic Reviews were systematically searched to identify primary research published in English between 2013 and 2018. Studies conducted in the USA, Canada, UK, Germany and France with more than 10 participants per arm were included.

Results:In studies on hemodynamic instability, the prediction and management of septic shock were the most researched topics followed by the early prediction of heart failure. For respiratory distress, the most popular topics were pneumonia detection and prediction followed by pulmonary embolisms. Given the importance of imaging and clinical notes, this area combined Machine Learning with image analysis and natural language processing. In studies on infection, the most researched areas were the detection, prediction, and management of sepsis, surgical site infections, as well as acute kidney injury. Overall, a variety of Machine Learning algorithms were utilized frequently, particularly support vector machines, boosting techniques, random forest classifiers and neural networks. Sensitivity, specificity, and ROC AUC were the most frequently reported performance measures.

Conclusion:This review showed an increasing use of Machine Learning for CDS in all three areas. Large datasets are required for training these algorithms; making it imperative to appropriately address, challenges such as class imbalance, correct labelling of data and missing data. Recommendations are formulated for the development and successful adoption of CDS systems.
In Search of the University Landscape
Authors: Asmer Kadri , Maiste Juhan
Published: October 2019

In Search of the University Landscape
The Archiginnasio, the Seat of the University of Bologna in Modern Times
Authors: Negruzzo Simona
Published: October 2019

The Archiginnasio, the Seat of the University of Bologna in Modern Times
Next steps for student supervision and assessment
Authors: Heath Shaun
Published: October 2019

Student nurses are the future of the profession. Shaun Heath explains how changes to the Nursing and Midwifery Council's education standards will effect those currently acting as mentors and how all practice nurses can get involved and contribute to student placement experiences

This article explores the Nursing and Midwifery Council's 2018 education standards and how these will affect the role of general practice nurses in primary care settings. The differing roles found in the standards will be discussed, alongside how primary care and the emerging Primary Care Networks can support learners in general practice through communities of practice.
The journey to becoming a newly qualified nurse in general practice
Authors: Bell Victoria
Published: October 2019

Practice Nursing is keen to encourage more students to get excited about a career in general practice. Victoria Bell kindly shares her experience of placements and job hunting in the hope that more students will see that working in general practice is an option them
Small Intestinal Bacterial Overgrowth (SIBO): An Interview with Preet Khangura, ND
Authors: Sutherland Elizabeth
Published: October 2019

Liz Sutherland, ND, Editor-in-Chief of the Journalof Restorative Medicine, recently spoke with PreetKhangura, ND, who practices in Victoria, BC,Canada. Dr. Khangura is an expert in the diagnosisand treatment of small intestinal bacterial overgrowth(SIBO). He has developed treatment and preventionprotocols for this condition, and offers consultationsand educational seminars on the topic to healthcareproviders.
Potential of medicinal plants to treat dengue
Authors: Neelawala Dulanjalee , Rajapakse Sanjaya , Kumbukgolla Wikum Widuranga
Published: October 2019

Dengue is a major public health challenge worldwide, particularly in tropical areas. Nearly 390 million infections and 22,000 deaths occur every year. At present, there are no specific therapeutics available to treat dengue; however, possible treatment procedures are explained in the traditional medical systems (TMSs), such as Sri Lankan TMS, Indian Ayurvedic, Unani, and Siddha TMS. In these TMSs, medicinal plants have been used in several ways against dengue, such as virocides, larvicides, and mosquito repellents. Therefore, medicinal plants inherit biologically active compounds/lead compounds that are yet to be identified chemically and physiologically. Herein, we discuss the possible applications of crude plant extracts and isolated phytochemicals from medicinal plants such as quercetin, sulfated galactomannans, flavonoids, and glabranine in controlling dengue. Moreover, medicinal plant-based therapeutics can be safer, cost-effective, and non-toxic. Therefore, this paper reviews the medicinal plants that are used in TMSs to manage dengue, the phytochemicals they contain, and mode of action of these phytochemicals such as virocides, larvicides, and mosquito repellents.
KONDISI PLANKTON PADA TAMBAK UDANG WINDU (Penaeus monodon FABRICIUS) DENGAN SUBSTRAT BERBEDA
Authors: Hendrajat Erfan Andi , Sahrijanna Andi
Published: October 2019

Plankton is one of water microorganisms that plays an important role as natural food for fish and shrimp and as an stability indicator of water or aquatic environment.The purpose of this study was to determine the composition and abundance of plankton in tiger shrimp ponds using concrete ponds without substrate, concrete ponds using sand substrate and ponds. Sampling of plankton and water quality was carried out from March to July 2016 at PunagaTakalar Experimental Pond at 6 ponds consisted of concrete ponds without 2 subplot of sand (pond A) and concrete pond with 2 subplate sand subplate (pond B) respectively measuring 1,000 m2 and a 2-square-meter plot of 2,500–3,000 m2 (pond C). The results showed that plankton abundance in pond A ranged from 37–349 individuals/L, pond B ranged from 35–1,399 individuals/L and pond C ranged from 54–999 individuals/L. The most common phytoplankton genera in this study was Oscillatoria while for zooplankton is of  Acartia.  The diversity of plankton in ponds A, B and C is included in the community of unstable to moderate biota. In general, the diversity of plankton in pond B is included in the community of moderate biota. The plankton uniformity index in pond A, pond B and pond C is generally close to 1 this indicates that the existence of plankton species in the three ponds is relatively even.
BUDIDAYA UDANG GALAH (Macrobrachium rosenbergii (de Man, 1879)) SISTEM AKUAPONIK BERBASIS POLIKULTUR DENGAN IKAN TAMBAKAN (Helostoma temminckii Cuvier, 1829)
Authors: Setijaningsih Lies , Gunadi Bambang , Supriyono Eddy
Published: October 2019

This experiment aimed to find out the optimum density combinations of prawn (M. rossenbergii (de Man, 1879) and fish of kissing gouramy (Helostoma temminckii Cuvier, 1829) in the polyculture based aquaponic fish culture system. There are four treatments and three replications applied in the Completely Randomized Design experiment. The treatments were the combination of giant freshwater prawn (U) and kissing gouramy (T) densities for one square meter (m2), namely (A) 30 prawns and 100 gouramy (U30T100); (B) 20 prawns and 50 gouramy (U20T50); (C) 30 prawns and 50 gouramy (U30T50) and (D) 20 prawns and 100 gouramy (U20T100). An equal density of aquatic plant of water spinach Ipomoea reptans Poir was planted in each treatment units. The results from 60 days experiment showed that the highest growth of prawn were achieved in treatment C i.e 9,355 ± 1,096 g and survival rates of 75.02±0.67%. The highest growth of kissing gouramy were achieved at treatment D i.e 13,688 ± 1,382 g and survival rates of 86.66±0.83%. The water spinach was able to reduce ammonia, nitrite and nitrate. The lowest reduction was achieved at treatment A, i.e., amonia 6.54 %, nitrite 1,33% and nitrate 5,90%. While the highest reduction of ammonia is 11.72% found at treatment D, 3,52% for nitrite at treatment C and 11,72% for nitrate at treatment D. The highest reduction of Total N dan Total P by water spinach were found at the treatment C i.e. 32.54% and D i.e. 47.62%. According to the dominance and abundance index of plankton, Chlorophyceae and Cyanophyceae were recognized as the dominant class in all treatments.
PERSPEKTIF GENDER SUKU OSING DI BANYUWANGI DALAM PENILAIAN KEMANFAATAN TANAMAN
Authors: Prasetyo Budi , Chikmawati Tatik , Walujo Eko Baroto , Zuhud Ervizal A.M
Published: October 2019

The different roles and responsibilities of male and female of the Osing tribe influence the knowledge of the use of plants. The aims of research is to analyze the values of the benefits of plants based on gender perception. The research used a qualitative and quantitative methods. Data collection for the value of plant species utilization were carried out  using Pebble Distribution Method (PDM) and analysis used Index of Cultural Significance (ICS). The Osing community recognised 86 plant species that were grouped in to eight beneficial groups. The male in three villages have a better understanding of ethnobotanical knowledge and practice than female on crops as staple foods, medicines, fruits, and firewood, while understanding of ornamental plants are relatively the same for both male and female. Female have a broader and more detailed understanding on vegetables, plant species used as building construction, and traditional rituals. The high PDM value in eight beneficial groups was supported by the high value of each ICS.
Karakteristik Infeksi Sitomegalovirus pada Anak dengan Infeksi HIV di RSUPN Cipto Mangunkusumo
Authors: Muktiarti Dina , Amalia Rizqi , Kurniati Nia , Karyanti Mulya Rahma
Published: October 2019

Latar belakang. Infeksi sitomegalovirus (CMV) adalah infeksi oportunistik virus yang tersering pada anak dengan infeksi HIV. Setelah era penggunaan terapi ARV prevalensi infeksi sitomegalovirus pada anak dengan infeksi HIV di negara berkembang belum mengalami penurunan bermakna. Tujuan. Mengetahui prevalensi , karakteristik demografi, manifestasi klinis, terapi, dan luaran infeksi sitomegalovirus pada anak ≤18 tahun dengan infeksi HIV di RSUPN Cipto Mangunkusumo tahun 2003-2018. Metode. Studi retrospektif deskriptif dilakukan terhadap seluruh anak ≤18 tahun dengan infeksi HIV di RSUPN Cipto Mangunkusumo pada tahun 2003-2018. Evaluasi infeksi sitomegalovirus dilakukan terhadap subyek yang memiliki manifestasi klinis sugestif infeksi sitomegalovirus. Hasil. Prevalensi infeksi sitomegalovirus pada anak dengan HIV di RSUPN Cipto Mengunkusumo tahun 2018 adalah 6%, meningkat 5 kali dibandingkan dengan tahun 2007. Total anak yang mengalami ko-infeksi HIV-CMV adalah 36 orang. Sebagian besar subyek adalah lelaki, berusia 49 bulan (rentang 2-191 bulan), belum menggunakan ARV, dengan rerata CD4 382 sel/μL (11%). Manifetasi klinis tersering adalah demam ≥2 minggu, peningkatan enzim transaminase, dan diare kronik. Titer IgM dan IgG reaktif didapatkan pada 22 dan 32 subyek. Materi DNA sitomegalovirus terdeteksi pada 25 subyek. Infeksi sitomegalovirus terbanyak terjadi dalam bentuk sindrom sitomegalovirus (15/36), korioretinitis (9/36), dan hepatitis (6/36). Immune reconstitution syndrome didapatkan pada empat subyek. Seluruh subyek mendapatkan terapi inisial dengan gansiklovir, valgansiklovir, atau kombinasi keduanya. Tidak ada subyek yang meninggal saat terapi inisial, tetapi 11 subyek memiliki morbiditas permanen dengan 9 subyek di antaranya mengalami low vision atau kebutaan. Kesimpulan. Prevalensi infeksi sitomegalovirus pada anak dengan infeksi HIV sebesar 6%. Infeksi sitomegalovirus perlu diwaspadai pada anak HIV dalam keadaan imunosupresi berat yang mengalami demam ≥2 minggu disertai manifestai klinis terkait organ target.
Peran delta neutrophil index sebagai prediktor sepsis pada anak
Authors: Natasukma Lucky Yogasatria , Pudjiastuti Pudjiastuti , Martuti Sri
Published: October 2019

Latar belakang. Sepsis adalah disfungsi organ yang mengancam kehidupan yang disebabkan oleh disregulasi imun terhadap infeksi. Dalam keadaan stres atau infeksi, neutrofil imatur dilepas ke sirkulasi. Delta Neutrophil Index (DNI) dapat mencerminkan jumlah granulosit imatur di sirkulasi. Di Indonesia, belum ada penelitian manfaat DNI pada populasi anak.Tujuan. Untuk mengetahui peran DNI sebagai prediktor sepsis pada anak.Metode. Penelitian observasional analitik dengan menggunakan studi potong lintang. Subjek penelitian adalah anak usia 1 bulan-18 tahun yang dirawat di PICU dan HCU anak, RSUD Dr. Moewardi, Surakarta, dengan kecurigaan infeksi antara bulan Januari sampai November 2018. Setiap subjek diukur kadar DNI dan dikategorikan sepsis atau tidak sepsis. Kemampuan diagnosis DNI dinyatakan sebagai sensitivitas, spesifisitas, nilai duga positif, nilai duga negatif, rasio kemungkinan positif, rasio kemungkinan negatif, akurasi dan post-test probabilityHasil. Cut-off DNI ≥2,7% didapatkan peningkatan risiko 33 kali untuk seseorang terkena sepsis, dengan sensitivitas 84,6%, spesifitas 85,7%, nilai duga positif positif 78,6%, nilai duga negatif sebesar 90%, rasio kemungkinan positif 5,9, sedangkan rasio kemungkinan negatif 0,2 serta akurasi 82,3%, dengan post test probability meningkat 26,8%.Kesimpulan. Delta neutrofil indeks dapat digunakan sebagai prediktor sepsis pada anak.
Evaluasi Fungsi Ginjal pada Penyandang Talasemia-β Mayor Anak
Authors: Manurung Berton Juniper , Susanah Susi , Gurnida Dida A.
Published: October 2019

Latar belakang. Informasi keterlibatan ginjal pada penyandang talasemia-β mayor anak masih sedikit. Disfungsi ginjal dipengaruhi berbagai faktor seperti anemia kronis, hipoksia kronis, dan hemosiderosis. Neutrophil gelatinase associated lipocaline urin (NGALu) merupakan penanda biologis dini yang sensitif dan spesifik terhadap gangguan ginjal. Tujuan. Menilai disfungsi ginjal pada penyandang talasemia-β mayor anak menggunakan NGALu.Metode. Penelitian dengan rancang potong lintang dilaksanakan Oktober–November 2018. Subjek adalah penyandang talasemia β mayor anak di RS. Hasan Sadikin yang menggunakan kelasi besi deferiprondan dipilih secara consecutive sampling. Heteroanamnesis pada orang tua mengenai riwayat penyakit dan frekuensi transfusi. Terhadap subjek penelitian dilakukan pemeriksaan feritin serum, kreatinin serum, dan NGALu. Uji statistik menggunakan uji korelasi rank Spearman dengan nilai kemaknaan p<0,05.Hasil. Sebanyak 71 subjek yang memenuhi kriteria penelitian, terdiri dari 46 laki-laki dan 25 perempuan. Kadar rerata kreatinin serum 0,38±0,08 mg/dL, median feritin 2897,1 ng/mL, median NGALu 13,8 ng/mL. Peningkatan kadar NGALu ditemukan 11 (15%) subjek. Didapatkan korelasi negatif antara frekuensi transfusi dan kadar NGALu (r= -0,294, p=0,006). Tidak terdapat korelasi baik antara feritin serum dengan kreatinin serum maupun feritin serum dan NGALuKesimpulan. Disfungsi ginjal sudah terindikasi terjadi pada penyandang talasemia-β mayor anak.
3 Comparison of Normal Saline and Plasmalyte in the Management of Acute Pancreatitis
Authors: Iqbal Umair , Makar Michael , Shah Ruchit N. , Berger Andrea , Khara Harshit S.
Published: October 2019

INTRODUCTION:

Acute pancreatitis (AP) is one of the most common causes of hospitalization in the United States. Intravenous (IV) hydration with normal saline (NS) is the most commonly used fluid for resuscitation. Recent studies have shown better outcomes with use of more pH balanced fluid like ringer's lactate and Plasmalyte (PL). We conducted a retrospective review to evaluate differences in outcomes of AP in patients who received NS compared to PL.

METHODS:

All patients >18 years of age admitted to our hospital with the diagnosis of AP from November 2016 to October 2018. Primary outcomes were persistent SIRS at 48 hours and mortality. Secondary outcomes were readmission within 30 days and length of stay (LOS). Categorical characteristics of NS and PL patients were compared using Pearson's chi-square or Fisher's exact tests and continuous ones were compared using Student's t-tests or Wilcoxon rank-sum tests. Odds ratios (OR) and their 95% confidence intervals (CI) were estimated using a multivariable logistic regression model for 30 days readmission. The model adjusted for age, sex, SIRS at 48 hours, and LOS. A multivariable linear regression model on a natural log transformation of LOS was used to estimate the effect of fluid type on LOS for NS and PL patients. Statistical analysis was conducted using SAS 9.4.

RESULTS:

343 patients met our inclusion criteria. 192 patients received NS and 151 received PL for IV hydration. There were no differences in the baseline demographics including age, sex, BMI and comorbidities as calculated by Charlson comorbidity index. Persistent SIRS at 48 hours was significantly higher in patients who received NS compared to PL (26.8% vs 7.7%; P = <0.0001). LOS was significantly higher in patients who received NS (4.7 days vs 3.7 days, P = 0.0039). 30 days readmission was also significantly higher in NS group (22.8% vs 12.8%; P = 0.0195). Mortality although trended lower in PL group, was not significantly different (7.3% NS group vs 2.6% PL group, P = 0.0556). In multivariable analysis use of PL is associated with lower odds of 30 days readmission [OR = 0.515 (CI: 0.280–0.950); P = 0.0338] and shorter LOS [%decrease = 16.6% (CI: −26.4%, −5.5%); P = 0.0045].

CONCLUSION:

Our study revealed that use of PL in AP is associated with lower rate of persistent SIRS at 48 hours, shorter LOS, and 30 days readmission rate. Larger randomized controlled trials are needed to further strengthen the association of PL for outcomes in AP.
4 Optimizing Inpatient Management of Acute Pancreatitis: A Single Center Quality Improvement Project
Authors: Koul Abhinav , Mills Ashley , Singh Sital , Johl Hershan , Zhang Hao , La Force Jessica , Tejaswi Sooraj
Published: October 2019

INTRODUCTION:

The management of acute pancreatitis has evolved over the last decade with emphasis on early adequate fluid resuscitation, early nutrition, and cholecystectomy prior to hospital discharge in gallstone pancreatitis. Adherence to these metrics reduces mortality, hospital length of stay (LOS), and overall healthcare utilization. We evaluated our institution's current performance and subsequently devised a strategy to improve adherence to quality metrics.

METHODS:

Patients hospitalized with acute pancreatitis between January, 2017 and October, 2018 were reviewed. Patient demographics, etiology and severity of pancreatitis, rate and type of IV fluid resuscitation, time to initiating nutrition, hospital LOS, ICU LOS, and hospital re-admission rates were examined. An EMR order set for inpatient management of acute pancreatitis was then designed and launched in December, 2018. Follow up data was collected until May, 2019.

RESULTS:

Our baseline data included 240 hospitalizations for acute pancreatitis of varying etiologies (Figure 1) and severity (Figure 2). The average patient age was 54.3 years and the average BMI was 28.3 (Figure 3). The mean hospital LOS was 6 days. ICU care was needed in 17% of cases. Mean ICU LOS was 4 days. The 30-day hospital re-admission rate was 14%. Adequate IV fluid resuscitation was given in only 25% of cases, with 20% receiving Lactated Ringer's (LR) solution. The average time to starting nutrition was 3 days. Cholecystectomy was performed prior to hospital discharge in 87% of mild gallstone pancreatitis cases. After launch, the EMR order set was used in 19 of 70 hospitalizations for acute pancreatitis (usage rate 27%). Among these patients, 79% received adequate fluid resuscitation, with 84% receiving LR. The average time to starting nutrition was 1.4 days. The mean hospital LOS was 4.4 days. No patients required ICU level care.

CONCLUSION:

Our baseline data revealed non-adherence to guideline recommendations of adequate fluid resuscitation with LR and early enteral feeding. By designing a customized EMR order set, we improved adequate fluid resuscitation from 25% to 79%, while reducing time to nutrition from 3 days to 1.4 days. Our average hospital LOS decreased from 6 days to 4.4 days, below the national average of 4.7 days. The advent of our EMR order set for acute pancreatitis has helped standardize management and improve outcomes thus far. Further work is needed to increase EMR order set utilization and continue data collection on patient outcomes.
6 A Novel EUS-Guided Intratumoral Delivery of Submicron Particle Paclitaxel (SPP) for the Treatment of Locally Advanced Pancreatic Cancer (LA-PAC): A Prospective Safety, Tolerability and Preliminary Efficiency Study
Authors: Lo Simon , Hendifar Andrew , Sharma Neil , Othman Mohamed , Mendoza-Ladd Antonio , Verco Shelagh , Verco James , diZerega Gere
Published: October 2019

INTRODUCTION:

PAC is an aggressive malignancy with a 5-year survival rate of < 8%. LA-PAC poses a particularly difficult therapeutic challenge. The aim of this study is to assess safety and preliminary efficacy of direct injection of submicron paclitaxel particles (SPP), which have been shown to reside at the delivery site for up to at least 100 days in a prior study, for control of PAC disease activity.

METHODS:

LA-PAC subjects were enrolled to receive EUS-guided intratumoral SPP delivery of 6, 10, or 15 mg/mL concentrations, ≤20% of the tumor volume, in a standard “3+3” dose-escalation protocol. The highest dose with an acceptable safety and tolerability profile, 15 mg/mL, is evaluated in the second study phase, which is ongoing, designed to enroll 12 subjects to receive two equal-dose injections 4 weeks apart. All subjects are followed for 6 months (m) to monitor their clinical parameters. Tumor responses are being assessed at 3- and 6 m post-initial injection.

RESULTS:

Seventeen subjects have been enrolled to date, comprising 10 subjects in the dose escalation group and 7 in the second phase. Of the 10 dose escalation subjects, seven have completed the 6 m study; one died just prior to the 6 m visit; 2 withdrew with disease progression. Of the 7 in the second phase, 5 have had both injections; 3 have completed 3m follow-up; 2 have withdrawn due to disease progression. Transient mild/moderate abdominal pain was noted in 4 subjects. Bradycardia, nausea, back pain, bloating, nausea and pancytopenia were also recorded. Acute pancreatitis has not been encountered. Plasma paclitaxel levels were detectable through days 1 and 2 at very low levels, returning to baseline in all but 1 subject by wk 4, supporting slow release of SPP from the delivery site. All but 1 subject had a very low plasma level of ≤10 ng/mL. Plasma CA19-9 was normal or stable in half of the subjects and continued to rise in half during first 3 m of treatment. In one subject the injected tumor appeared cyst-like at time of second injection, without signs of infection, and another subject in the second phase was down-staged at wk 16 and underwent surgical resection.

CONCLUSION:

SPP appears to be safe and tolerable when administered by intratumoral PAC injection at up to 15 mg/mL on two occasions 4-wks apart. One subject was down-staged and has undergone surgical resection. These are encouraging results and warrant further investigation of this novel treatment approach.
11 Risk of Pancreatic Cancer in Patients With a Prior History of Acute Pancreatitis: Meta-Analysis of Cohort Studies
Authors: Gonzalez Zorisadday , Roy Neel P. , Kanth Rajan , Roy Praveen K.
Published: October 2019

INTRODUCTION:

Several studies have reported increased risk of pancreatic cancer in patients with chronic pancreatitis. However, the risk of pancreatic cancer in patients with a history of acute pancreatitis (AP) is not well known. Several recent epidemiological studies, especially case-control studies, have reported conflicting results. We conducted a meta-analysis of cohort studies to quantify the risk of pancreatic cancer in patients with history of AP.

METHODS:

A detailed search of several databases (Pubmed, Embase, Google Scholar, Cochrane database and CINAHL) and research scientific meetings of gastroenterology and surgical societies was performed for cohort studies examining the risk of pancreatic cancer in patients with a prior history of acute pancreatitis. Data was extracted using a standard form by 2 reviewers. Data regarding study characteristics, patient characteristics, exposures and outcomes and country of study was extracted. Summary odds ratio was calculated using Comprehensive Meta-analysis software. Random effects model was used for computing effect size. Studies without a matched control group were excluded. Heterogeniety and publication bias were assessed. Quality of studies was assessed using the Newscastle-Ottawa scale. There were no language restrictions.

RESULTS:

Five cohort studies met the inclusion criteria. Studies were performed in UK, Sweden, USA and Taiwan. The most common etiology of AP was gall stone pancreatitis in all the studies. Patients with chronic pancreatitis and alcohol related acute pancreatitis were excluded in all studies. All studies had a matched control group and adjusted for confounders. There were 1162 cases of pancreatic cancer in 103958 patients with a prior history of acute pancreatitis. 2042 cases of pancreatic cancer were seen in 1442158 controls. A higher risk of pancreatic cancer was seen among patients with prior history of AP (OR 7.39: 95% CI 5.03–10.88, P < 0.05). Three studies provided data on risk of pancreatic cancer >2 years after diagnosis of AP. The risk of pancreatic cancer was still elevated after >2 years in patients with prior of history of AP (OR 2.31: 1.61 = 3.30, P < 0.05). Heterogeneity was present and the effect size was computed using random effects model.

CONCLUSION:

Patients with a prior history of AP are at an increased risk of pancreatic cancer. Further cohort studies are needed to confirm these findings.
12 Non-Alcoholic Fatty Liver Disease and Risk for Intrahepatic and Extrahepatic Cholangiocarcinoma: Meta-Analysis of Case Control Studies
Authors: Roy Neel P. , Gonzalez Zorisadday , Kanth Rajan , Roy Praveen K.
Published: October 2019

INTRODUCTION:

The incidence of cholangiocarcinoma is increasing worldwide. Over 8000 cases of both intrahepatic (ICC) and extrahepatic cholangiocarcinoma (ECC) are diagnosed every year in the US. Several recent studies have evaluated the role of non-fatty alcoholic liver disease (NAFLD) as a risk factor for cholangiocarcinoma. We performed a meta-analysis of case-control studies to evaluate the role of NAFLD as a risk factor for intrahepatic and extrahepatic cholangiocarcinoma.

METHODS:

We performed a systematic search of Medline, EMBASE and the Cochrane Library for studies without language restriction for case-control studies evaluating the risk of intra-hepatic and extra-hepatic cholangiocarcinoma in adult patients with NAFLD. We also hand searched grey literature from major gastrointestinal meetings. Standardized forms were used to extract data regarding number of cases of NAFLD and cholangiocarcinoma. Data was extracted by two reviewers independently. Summary odds ratio was calculated using Comprehensive Meta-analysis software. Heterogeneity, quality of studies and publication bias were also assessed. Random effects model was used for calculating the effect size.

RESULTS:

Ten studies met the inclusion criteria. 9 studies reported data on ICC and 5 studies reported data on ECC. Studies were performed in China, Taiwan, Japan, US, Europe and Korea. The period of patient enrollment ranged from 1992 to 2017. The majority of the studies used hospital based controls. The quality of the studies was assessed using Newcastle-Ottawa Scale. NAFLD was associated with a higher risk of ICC (OR 1.78: 95% CI 1.3–2.5, P = 0.001, I2 = 81). On subgroup analysis based on region of study, the increased risk was seen only in the studies reported from the Asian countries (5 studies, OR 1.93; 95% CI, 1.22–3.05, P = 0.005) but not from the Western countries (4 studies, OR 1.58; 95% CI 0.83–3.0, P = 0.17). On pooling all studies, risk of ECC was not increased in patients with NAFLD (OR 1.38; 95% CI 0.67–2.83, P = 0.55, I2 = 95%). However on subgroup analysis, increased risk of ECC was seen in the Western countries (2.42; 95% CI 2.01–2.91, P = 0.0001), but not the Asian countries. No significant publication bias was present.

CONCLUSION:

NAFLD is a risk factor for cholangiocarcinoma. Increased risk of ICC with NAFLD was seen in the Asian countries and ECC in the Western countries. Further studies are needed to confirm these findings.
14 Endoscopic Ultrasound in the Diagnosis and Staging of Pancreatic Cancer: A Comparison With Computer Tomography Imaging
Authors: Moutinho-Ribeiro Pedro , Costa-Moreira Pedro , Morais Rui , Vilas-Boas Filipe , Lopes Susana , Macedo Guilherme
Published: October 2019

INTRODUCTION:

Computed Tomography (CT) and Endoscopic Ultrasound (EUS) with or without tissue acquisition have been widely used for diagnosing and staging pancreatic adenocarcinoma (PDAC). Previous studies showed conflicting results in the pathologic findings and the role of each modality in diagnosis and staging this disease is still mater of discussion. We aimed to compare CT and EUS in terms of mass detection, mass size, vascular and lymph node involvement and metastatic disease detection according to TNM Classification of Malignant Tumors (8th edition).

METHODS:

We included a consecutive sample of patients proposed for EUS for diagnosis/staging of PDAC in which a CT scan was performed in the same institution (within one-month period) between 2016 and 2018, in a tertiary referral center. Concordance between CT and EUS was assessed using a retrospective chart review and statistical analysis with Cohen's κ.

RESULTS:

We evaluated 44 patients with a median age of 66.9 ± 11.6 years, 52% were male. The median follow-up after EUS was 4 (IQR 0–10) months. All cases were submitted to tissue acquisition, with pathologic confirmation of PDAC in 91% (n = 40). Only 5 patients were submitted to surgical resection. EUS and CT agreed in TNM staging in 41% of the cases. The sub analysis for TNM categories revealed a concordance rate in 66% of the cases for T stage, 75% for N stage and 73% for M stage. In the T-stage, the highest non-concordance rate was found for T4: of the 16 cases with involvement of the celiac axis or the superior mesenteric artery identified in CT, only 7 cases (44%) were classified as T4 in EUS staging. Global Cohen's κ between two imaging methods was low: 0.25 (P < 0.01). However, when applied to each TNM category, we found values of 0.58 (T, P < 0.01), 0.36 (N, P < 0.01) and 0.7 (M, P < 0.01).

CONCLUSION:

Between TNM categories, CT and EUS agreed moderately well in the definition of T stage. Discrepancies between the two modalities were more common in those with T4 (unresectable) disease. EUS, with tissue acquisition, has the unique capacity to provide the definite cytohistological diagnosis. Clinicians should consider the role of both methods for proper diagnosis and staging of PDAC.
18 Characteristics and 30-Day Outcomes of Acute Pancreatitis Admissions According to Etiology: A Nationwide Analysis
Authors: Mulki Ramzi , Shah Rushikesh , Qayed Emad
Published: October 2019

INTRODUCTION:

Acute pancreatitis (AP) is a frequent cause of hospitalization in the United States. The major etiologies of AP are alcohol, choledocholithiasis, and drug-induced. We aim to describe demographic, clinical, and admission characteristics of AP hospitalizations according to etiology. In addition, we compared in-hospital and 30 day mortality and readmission outcomes among the three major AP subtypes.

METHODS:

We performed a retrospective analysis of the 2016 National Readmission Database. Hospital admissions of adults (>18 years of age) with the primary or secondary discharge diagnosis of AP. Specific ICD-10 codes were used to classify AP into biliary pancreatitis (K851), alcoholic pancreatitis (K852), and drug-induced pancreatitis (K853). Patients with nonspecific AP codes were classified as biliary pancreatitis if they had a concomitant diagnosis of cholelithiasis and as alcoholic AP if they had a diagnosis of alcohol abuse. Non-specific AP admissions were excluded. Characteristics and 30-day outcomes of the three groups were compared using the X-square test for categorical variables and the one-way analysis of variance (ANOVA) for continuous variables.

RESULTS:

A total of 81,382 admissions met the inclusion criteria: 32,459 had biliary AP, 46,438 alcoholic AP, and 2,485 drug-induced AP. Patients with alcoholic AP were more likely to be male (69.1%) and younger (mean age 46.6) compared to the other groups. Patients with biliary AP were more likely to develop cholangitis (1.8%) compared to the other groups (≤0.2%). HIV was more associated with drug-induced pancreatitis (1.4%) compared to the other groups (≤0.4%). Mean length of stay was longest (5.9 days) and mean costs were highest ($15,367) in biliary AP. These were lowest in drug induced AP (4.2 days and $9413, respectively). In-hospital mortality (0.9%) and 30-day mortality (1.3%) was highest in biliary AP compared to the other groups. Thirty day- readmissions were highest in alcoholic AP (14.3%) compared to drug induced AP (11.5%) and biliary AP (10.1%).

CONCLUSION:

In this large, nationally representative patient sample, drug induced AP had the lowest length of stay and costs, while alcoholic AP had the highest 30-day readmission rates (14.3%). Biliary pancreatitis was associated with the highest in-hospital and 30-day mortality. Knowledge of these findings may allow us to design and target future studies to mitigate the high readmission rates in alcoholic pancreatitis, and the complications and mortality in biliary pancreatitis.
21 Drug-Induced Pancreatitis: A Retrospective Cohort Study on Incidence, Etiology, Presentation and Outcomes
Authors: Salazar Miguel , Mbachi Chimezie , Elkhouly Mohamed A. , Mathew Madhu , Kumapley Rudolf , Paintsil Isaac , Simons-Linares C. Roberto
Published: October 2019

INTRODUCTION:

Drug adverse reactions stands as a rare cause of acute pancreatitis; the incidence is mostly estimated from case reports and case series. Our aim was to determine the incidence, presentation, course, etiology (causative drugs), severity and outcome of drug induced pancreatitis in a 6-year period in a large tertiary hospital.

METHODS:

We conducted a retrospective investigation of all cases of acute pancreatitis at a large tertiary teaching hospital in Chicago, IL from January 2012 to April 2018, Diagnosis and severity of was determined according to the Revised Atlanta Classification. Patients were divided according to etiology. Regarding cases where was stablished, we further subcategorized them using the Naranjo score and Badalov et al 2008 classification to assess and determine the likelihood of drug adverse reaction as a causative factor of drug induced pancreatitis. The revised Atlanta Classification was used to determined severity of AP.

RESULTS:

A total of 531 patients with acute pancreatitis were reviewed, most common etiologies for AP were Biliary 206 (38.79%), Alcohol 179 (33.7%), Hypertriglyceridemia 55 (10.35%), DIP 16 (3.01%), post-ERCP 13 (2.44%), Idiopathic 56 (10.54%), Miscellaneous 6 (1%). DIP ranked fourth in the most common cause for acute pancreatitis. Gender distribution was 9 men (56%) and 7 women (43.7%), The most commonly associated drug was azathioprine 5 cases (31.25%) followed by Bactrim 2 cases (12.5%), all other were reported as single cases (6.25%) including: mesalamine, enalapril, L-asparaginase, isoniazid, diazepam, metformin, hydrochlorothiazide. Diazepam case was reported as an overdose. First exposure adverse reaction occurred in most cases 15 (93.75%).

CONCLUSION:

Drug induced pancreatitis stands as an uncommon cause of acute pancreatitis, diagnosis is often underestimated and made by exclusion of other more common etiologies, or by retrospective evaluation of individual cases, the number of commonly used drugs associated with drug induced pancreatitis is relatively high. The disease seems more common in patients with Crohn's disease on Azathioprine regimen.
22 Association Between Acute Pancreatitis and Cannabis Use—A U.S. Population-Based Study
Authors: Saleem Saad , Then Eric O. , Abu-Heija Ahmad , Weissman Simcha , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Cannabis is the most frequently used illicit drug in the world. Increase use of marijuana had caused higher rates of cannabis-related adverse effects. This study aims to assess the cannabis use as an etiology of acute pancreatitis.

METHODS:

A retrospective analysis was conducted using the de-identified data from the national health database, the Healthcare Cost and Utilization Project (HCUP). We identified the hospital encounters for “cannabis use” using international classification of Diseases (ICD-9) diagnostic codes from 2011 to 2014. We assessed the incidence of acute pancreatitis in cannabis use patients and independent predictors of acute pancreatitis by multivariate analysis. P-values less than 0.05 indicated a statistically significant association. The odds ratio and 95% confidence interval were also calculated. Data were analyzed using SPSS.

RESULTS:

A total of 410385 cannabis use admissions were identified - 5469 (1.3%) acute pancreatitis with history of cannabis use (study group) and 404916 (98.7%) without acute pancreatitis in cannabis use population (control group). Comparing study group with control group, age - mean with standard deviation 39.8 + 11.81 yrs vs. 36.09 + 14.05 (P < 0.001) , sex - male 3901 (71.3%) vs. 252486 (62.4%) (P < 0.0001, Odds ratio [OR] = 1.50, Confidence interval (CI); 1.41–1.59), race - African American 1765 (32.3%) vs. 113524 (28%) (P < 0.0001, OR = 1.22, CI; 1.15–1.30), smoking 3909 (71.5%) vs. 222558 (55%) (P < 0.0001, OR = 2.05, CI; 1.93–2.18), Alcohol 1959 (35.8%) vs. 54876 (13.6%) (P < 0.0001, OR = 3.56, CI; 3.37–3.77), acute pancreatitis 5469 (1.3%) vs. 4334 (0.7%) OR = 1.80 CI 1.73–1.87, P < 0.001). The odds of developing acute pancreatitis among cannabis use patient was significantly higher (P < 0.001, adjusted odds ratio [aOR] = 1.20, CI; 1.14–1.25) (shown in Figure 1).

CONCLUSION:

This study showed that up to 20% increased likelihood of acute pancreatitis among the cannabis use patients. Older age, male sex, African American race, alcohol, smoking and cannabis use showed greater odds of developing acute pancreatitis.
24 A Comparison of EUS and MRCP to Diagnose Choledocholithiasis
Authors: Aamar Ali , Kolli Sree , Aloreidi Khalil , Barakat Mohamed , Ramai Daryl , Shahnazarian Vahe , Ofosu Andrew , Reddy Madhavi , Quintero Eduardo
Published: October 2019

INTRODUCTION:

ASGE recommends EUS or MRCP for patients at intermediate risk for choledocholithiasis. Numerous studies have compared diagnostic yield of EUS and MRCP for choledocholithiasis. Two systematic reviews showed no significant difference in the two modalities. Diagnostic yield of both modalities is high for large stones. However, EUS is more sensitive in diagnosing small stones.

METHODS:

This is a retrospective study that includes the patients who had ERCP for suspected choledocholithiasis. Basic demographics, clinical, laboratory, imaging and endoscopic data was collected. The imaging modalities including abdominal ultrasound, CT, MRCP and EUS were compared using choledocholithiasis on ERCP as the gold standard. Performance characteristics such as sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratio and accuracy were calculated.

RESULTS:

During the study period, a total of 137 patients had ERCP for suspected choledocholithiasis. The mean age (±SD) was 53 ± 21 years. 81 (59%) were female and 78 (56.9%) were African American. 60 (43.8%) had EUS, 50 (36.5%) had MRCP, 74 (54%) had CT abdomen, 120 (87.6%) had abdominal ultrasound. Sensitivity, specificity, PPV, NPV, positive likelihood ratio, negative likelihood ratio and accuracy for EUS vs MRCP were 90 vs 85, 46 vs 78, 88 vs 95, 50 vs 54, 1.65 vs 3.84, 0.22 vs 0.19, 82 vs 84, respectively.

CONCLUSION:

The diagnostic yield of EUS and MRCP is high and comparable. Preference for EUS or MRCP may depend on availability, patient preference and probability of choledocholithiasis. Specificity and NPV of both modalities were low for detecting sludge. ERCP may be helpful in these cases if clinical suspicion for choledocholithiasis remains high.
25 Very High Rates of Pancreatic Fluid Collections in Patients With the Triad of Hypertriglyceridemia-Induced Acute Pancreatitis and Diabetes Ketoacidosis
Authors: Estevez Jaqueline , Simons-Linares Roberto , Stevens Tyler , Chahal Prabhleen
Published: October 2019

INTRODUCTION:

The triad of hypertriglyceridemia (HTG) induced acute pancreatitis (AP) coexisting with diabetes ketoacidosis (DKA) has been reported. Patients with the triad are a special subgroup of AP patients that may need different management due to potential life-threatening conditions presenting all at once. Outcomes of pancreatic fluid collections (PFCs) in this population has not yet been studied. We sought to investigate AP mortality, morbidity and PFC outcomes in patients with the triad.

METHODS:

We perform a cohort study of a prospectively maintained database of patients admitted with AP at a tertiary center in the last 15 years. We strictly included patients who met AP diagnosis by Revised Atlanta Classification. Study groups were: AP-only vs. HTG-AP + DKA, AP + DKA, and HTG-AP. Primary outcome was inpatient mortality, morbidity (SIRS, ICU, AKI, ARDS), severity of AP and complication of AP. Multivariable logistic regression models were constructed using STATA software version 9.4.

RESULTS:

Over two thousand patients were reviewed, of whom 124 patients had the triad (HTG-AP, DKA), 100 had HTG-AP only (triglyceride levels >1,000 mg/dL), 67 had AP + DKA and we included 101 with AP-only (control) for the analysis. Patients with HTG-AP + DKA had higher rates of PFCs 59% compared to AP-only 22%, HTG-AP 29% and AP + DKA 20% (P < 0.001). HTG-AP + DKA were more likely to have acute peripancreatic fluid collections (APFC) 46% compared to AP-only 17%, HTG-AP 19% and AP + DKA 13% (P < 0.001). HTG-AP were more likely to have pseudocysts 11% compared to AP-only 4%, HTG-AP + DKA 4%, and AP + DKA 2% (P = 0.06). No difference in PFC drainage was found (P = 0.97). Patients with AP+DKA were more likely to develop AKI 63% compared to AP-only 8%, HTG-AP + DKA 34% and HTG-AP 33% (P < 0.001). HTG-AP patients were more likely to have ARDS 25% compared to AP-only 2%, AP + DKA 10% and HTG-AP + DKA 17% (P < 0.001). HTG-AP were more likely to require enteral tube feeding and total parenteral nutrition (Table 1). No difference inpatient mortality was found.

CONCLUSION:

Patients with the triad of HTG-AP + DKA have significantly higher rates of pancreatic fluid collections. But PFCs seems to resolve in its own as there was not difference in interventions for the PFCs. Less aggressive strategy for PFCs management in this patient population can be followed.
27 Assessment of the Impact of Hypertriglyceridemia on Organ Failure During Acute Pancreatitis: A Different Perspective
Authors: Estevez Jaqueline , Simons-Linares Roberto , Chahal Prabhleen
Published: October 2019

INTRODUCTION:

Hypertriglyceridemia (HTG) may impact acute pancreatitis (AP) outcomes. This study investigates the effect of different serum triglycerides (TG) thresholds on the development of persistent or multiple organ failures in patients with AP.

METHODS:

Cohort study of a prospectively maintained database of patients admitted with AP at a tertiary center in the last 15 years. We strictly included patients who met AP diagnosis by Revised Atlanta Classification. Severity of HTG was determined by the American Endocrine Society guidelines. Control group: AP (including all common etiologies, except HTG-induced AP). Study groups included other common HTG scenarios: 1) HTG-AP (i.e. HTG-induced AP), 2) HTG-AP + DKA (i.e. Triad), and 3) AP + diabetes ketoacidosis (AP-DKA). We assessed the levels of TG and its impact on organ failure. Multivariable logistic regression models were constructed using STATA software version 9.4.

RESULTS:

2,654 patients were reviewed, of whom 124 patients had the triad (HTG-AP, DKA), 100 had HTG-AP only (triglyceride levels >1,000 mg/dL), 67 had AP + DKA and we included 101 with AP-only as control for the analysis. Overall, any level of hypertriglyceridemia in all of the three study groups (HTG related syndromes) had higher odds for developing organ failure when compared to the control group (Table 1). All study groups had higher odds to develop ARDS, AKI, ileus, and shock. The highest odds ratios for organ failures were: HTG-AP patients with moderate levels of HTG were almost 25 times more likely to develop ARDS. AP-DKA patients with moderate levels of HTG were 32 times more likely to develop AKI. HTG-AP patients with severe HTG levels were 16 times more likely to develop ileus. HTG-AP patients with moderate HTG levels were 7 times more likely to develop shock. Interestingly, all study groups had lower odds to develop SIRS, persistent SIRS at 24 or48 hrs, and myocardial infarction (MI) (Table 1).

CONCLUSION:

Increased TG levels were associated with the development of multiple organ failure among AP patients, particularly in the settings of HTG-induced AP, the Triad of HTG-AP-DKA, and AP-DKA. Interestingly, HTG did not correlate with SIRS (transient or persistent), which one could have expected. It seems that the severe organ failure is driven by direct lipotoxicity from HTG rather than pancreatitis-inflammation (i.e. SIRS).