bluuebunny/crossref_metadata_2025 huggingface dataset:
73 Measuring Clinical Response to Lactated Ringer's vs. Normal Saline in Acute Pancreatitis: A Retrospective Study at a Community Hospital
Authors: Beattie Michael , Kopek Nathan
Published: October 2019

INTRODUCTION:

Acute pancreatitis is the most common GI cause of U.S. hospital admissions, and the incidence is rising.1,2 Aggressive IV fluid resuscitation and pain control are the mainstay of therapy; with the therapeutic goal to resume diet as soon as safely possible, especially within the first 48–72 hours.3–6 Several studies and guidelines have suggested LR may provide anti-inflammatory benefits as measured by CRP and SIRS criteria.6–8 Despite an improvement in SIRS criteria, studies have shown no mortality benefit.9 The primary goal of this study was to compare NS vs LR with improved clinical response as the primary endpoint. Clinical response was measured by time to diet initiation upon ED presentation. Secondary goals examined if the timing to initiation of IV fluids led to improved clinical outcome regardless of fluid type, as this has not been examined in previous studies.

METHODS:

Data was abstracted for all adult patients 18 years of age or older with an admitting diagnosis of acute pancreatitis from 1/1/17–12/31/17. Primary fluid type was determined by reviewing medication and IV infusion orders and was calculated by length of time for which the fluid was administered. A subgroup analysis was performed comparing patients within groups based on their BISAP score (0–1, 2, >3). Time to initiation of diet was examined by calculating the difference from time of arrival to the ED to the time that diet was ordered. For the secondary endpoint, patients were compared based on timing of initial fluid administration (<2 hours from arrival versus >4 hours form arrival). To determine if there was a significant difference when comparing time to diet initiation, a student's t-test was utilized.

RESULTS:

Complete data was collected on 200 patients. NS was the primary fluid type in 77% and LR for 21.5%. Time to diet initiation was shorter for patients receiving NS in all subgroups. This finding was significant in patients with a BISAP score of 1 or below (Table 2). The data indicates that when fluids were initiated within two hours as compared to greater than four hours, diet was initiated 7.4 hours sooner (Table 3). Diet initiation was delayed in patients with a BISAP of 3 or greater in both the NS and LR group.

CONCLUSION:

Our study did not demonstrate any clinical difference in disease and symptomatic resolution based on fluid type. Time to fluid initiation may be more important than fluid choice. This should be studied further with larger populations.
74 Pain Modulatory Phenotypes Differentiate Chronic Pancreatitis Patients With Distinct Clinical Pain Profiles
Authors: Faghih Mahya , Philipps Anna E. , Larsen Isabelle M. , Drewes Asbjørn , Singh Vikesh , Yadav Dhiraj , Olesen Søren
Published: October 2019

INTRODUCTION:

Pain is a common problem in patients with chronic pancreatitis (CP) and effective therapy remains a considerable challenge. Methods based on quantitative sensory testing (QST) provide information on pain modulation and have demonstrated promise in predicting future pain status and the efficacy of analgesics. The aims of this study were to evaluate the existence of CP subgroups with different pain modulatory phenotypes and to investigate associations with patients' clinical pain and psychological profiles.

METHODS:

This was a cross-sectional, multicentre study of CP outpatients. Patients fulfilled a number of questionaries' including the Brief Pain Inventory short form, the Hospital Anxiety and Depression Score as well as measures of Conditional and Situational Pain Catastrophising. Using a standardized QST protocol, we recorded pain detection thresholds (PDTs) to static muscle pressure stimulations at the “pancreatic dermatomes” on the upper abdomen and back and at three control areas. The ratio between pancreatic and control PDTs were calculated (PDT-index) to offset interindividual differences in absolute thresholds. The PDT-index was used in conjunction with repetitive pinprick stimulations (temporal summation) applied at the abdominal pancreatic dermatome to obtain a measure of segmental hyperalgesia. A conditioned pain modulation (CPM) paradigm was performed to investigate descending pain modulation. Patients were grouped based on normative QST reference values and questionnaire scores were compared across subgroups to investigate associations between patients' pain modulatory phenotypes and clinical pain and psychological profiles.

RESULTS:

A total of 91 patients were enrolled in the study. The mean age was 53.1 ± 12.7 y, 62% were men, and 65% had toxic etiology. Three distinct pain modulatory phenotypes were found: group 1 (n = 31) had normal pain modulation; group 2 (n = 17) had segmental sensitization; group 3 (n = 43) had widespread sensitization. Patients with widespread sensitization had higher pain score (P < 0.01) and lower QOL (P < 0.05) in comparison to segmental and normal. In contrast, psychological features were comparable across subgroups.

CONCLUSION:

CP patients with widespread sensitization have significantly higher levels of pain and lower QOL. QST characterizes the sensory profiles independently of the patient's psychological status and provides an unbiased proxy of pain processing. This information can be used for prognostication and tailoring of management strategies.
75 Calcifications and Moderate to Marked Ductal Changes Are Only Seen in Patients With Imaging Documented Acute Recurrent Pancreatitis
Authors: Faghih Mahya , Yahyapourjalaly Niloofar , Boortalary Tina , Fan Chris , Makary Martin , Kalloo Anthony , Afghani Elham , Khashab Mouen , Singh Vikesh
Published: October 2019

INTRODUCTION:

Acute pancreatitis (AP) is often diagnosed on the basis of abdominal pain and elevations in pancreatic enzymes without abdominal imaging. However, neither pain nor enzyme elevations are specific for AP and recurrent presentations without confirmatory imaging may lead to a misdiagnosis of acute recurrent pancreatitis (ARP) and/or chronic pancreatitis (CP).

METHODS:

Adult patients with a diagnosis of ARP and/or CP between 2010–2019 were evaluated. All medical records and imaging studies from prior AP admissions were reviewed at our institution. Definite ARP was defined as ≥2 episodes of abdominal pain, elevated serum amylase and/or lipase ≥3X upper limit normal and abdominal imaging(s) showing changes or sequelae of AP. Probable ARP was defined as above but without any evidence of AP on abdominal imaging. Possible ARP was defined as ≥2 episodes of abdominal pain either with serum amylase and/or lipase levels that were normal or <3X ULN without any abdominal imaging showing AP. This was included as a category as referring physicians had diagnosed and managed these patients as ARP. The M-ANNHEIM criteria were used to define definite CP. Any patients with definite CP without a history of ARP were excluded.

RESULTS:

There were a total of 854 patients with ARP and/or CP with a mean age of 51.2 ± 14 years; 54.9% female; 75% white. There were 489 (57.2%) definite ARP, 162 (19%) probable ARP and 202 (23.7%) possible ARP with a similar mean duration of disease of 8.5 ± 7.8, 5.2 ± 4.1 and 6.8 ± 3.4 years, respectively. All patients were followed for a mean of 5.3 ± 2 years. Pancreatic calcification(s) and marked to moderate ductal changes were only seen in definite ARP. There were higher rates of exocrine insufficiency in definite ARP compared to probable and possible ARP (P = 0.005). Chronic opioid use was higher among the probable ARP compared to definite ARP and possible ARP (P < 0.001). All other characteristics including demographics, rates of alcohol use and smoking, diabetes and BMI similar between the 3 groups.

CONCLUSION:

Recurrent presentations of abdominal pain and pancreatic enzyme elevations without confirmatory changes of AP on imaging is problematic for the diagnosis of ARP as none of these patients developed definite changes of CP over the duration of disease and follow-up. This study highlights the nonspecific nature of abdominal pain and enzyme elevations for the diagnosis of AP and suggests that current diagnostic criteria may require revision.
78 What Is the Impact of a Delayed Presentation on Outpatients With Post-ERCP Pancreatitis? An Analysis of Clinical Predictors and Outcomes
Authors: Bick Benjamin L. , Fogel Evan L. , Schmidt Suzette , Elmunzer Badih , Tong Yan , Gromski Mark A. , Sherman Stuart , Lehman Glen , Watkins James L. , Cote Gregory A. , Tarnasky Paul , Kwon Richard , Guda Nalini , Pleskow Douglas , Easler Jeffrey J.
Published: October 2019

INTRODUCTION:

Post-ERCP pancreatitis (PEP) occurs in up to 15% of high risk patients. Symptoms after ERCP are common and usually determine admission. However, discharge of outpatients at risk for PEP is frequent after ERCP. In retrospective studies, discharged PEP patients are at increased risk for severity, possibly due to delays in IV fluid therapy. The aim of this study is to evaluate clinical predictors and outcomes in patients discharged and later admitted with delayed presentation of PEP.

METHODS:

We identified consecutive outpatients with PEP enrolled in a prospective study designed to evaluate the optimal rectal Indomethacin dose for prevention of PEP in high-risk patients. All patients received Indomethacin and were observed for at least 4 hours post-ERCP per protocol. All clinical data except IV fluids, recovery medications, and pain scores were collected prospectively. Diagnosis and severity of PEP was defined by Cotton criteria.

RESULTS:

107/720 (14.9%) developed PEP. 135/720 (18.8%) were directly admitted after ERCP. While the direct admission rate in patients that developed PEP was higher (P < 0.001), 58/107 (54.2%) were discharged and had a delayed presentation of PEP. Median time to presentation was 24 hours (IQR 15–31.75 h). Discharged patients were older (age 47.7 vs 41.1, P = 0.026), more often had a morning procedure (59.2% vs 39.7%, P = 0.044), less often had pancreatic stent placement (82.8% vs 95.9%, P = 0.032), spent less time in recovery (261 vs 312 minutes, P = 0.004), required less IV opioids (6.4 vs 17.3 MME, P < 0.001) and had lower pain scores (2.8 vs 6.5, P < 0.001) (Table 1). On multivariable analysis, an afternoon procedure (OR 4.00, P = 0.016) and pain score >3 (OR 1.37, P = 0.001) were associated with admission. While discharged patients were more likely to present with SIRS on admission (43.1% vs 10.2%, P < 0.001), a delayed presentation was not associated with severe PEP (Table 2).

CONCLUSION:

Delayed presentation of PEP after discharge of high-risk patients is frequent, but not associated with adverse outcomes or severe PEP. Systematic deployment of PEP prophylaxis with rectal Indomethacin, pancreatic stents, and IV fluids may attenuate the impact of delayed presentation on outcomes. Afternoon procedure time and increased pain appear to influence decisions to admit. However, given the frequency of delayed presentation of PEP, accurate and early diagnostic tests for PEP may be of clinical value.
80 Long-Term Follow-Up of Patients With Pancreatic Cystic Lesions Who Had No Significant Changes in the First 5 Years of Diagnosis
Authors: Lee Brian S. , Chang Karen , Nguyen Andrew K. , Tekeste Timnit F. , Girgis Agathon , Adeyemo Mopelola , Hanna Maryam S. , Kwok Karl , Giap Andrew Q. , Chaya Charles , Hunt Gordon C. , Kao Kevin , Attam Rajeev , Ko Albert , Yao Janis F. , Pio Jose R. , Tovar Stephanie , Lim Brian S.
Published: October 2019

INTRODUCTION:

Discontinuation of surveillance after 5 years for pancreatic cystic lesions (PCL) without significant changes remains controversial. Long-term outcomes of patients with PCL with no significant changes in the first 5 years were evaluated.

METHODS:

We performed a retrospective analysis of patients with PCL diagnosis from 2005 to 2011 with follow-up until 2017. Significant changes were defined as the history of pancreatic cancer, pancreatectomy, high risk stigmata (HRS), worrisome features (WF) and worrisome EUS features (WEUS). Details of HRS, WF, WEUS in Table 1.

RESULTS:

Of 1551 patients with the diagnosis of PCL, 984 had no significant changes in the first 5 years. Range of follow-up was 5–13 years (190 patients >10 years). Median (Q1–Q3) cyst size at initial imaging was 12 (9–17) mm; maximum cyst size in first 5 years and post 5 years were 13 (9–18) mm and 15 (10–22) mm, respectively. 4 patients developed pancreatic cancer (0.41%; at 80, 97, 70, and 103 months). 7 (0.71%), 99 (10%), 5 (0.51%) patients developed HRS, WF, WEUS, respectively. Median (Q1–Q3) time to cancer, HRS, WF, and WEUS were 88.7 (75.3–100), 97.2 (66–109.6), 78.2 (72.5–97.9), 77 (68–104) months, respectively. Patients with CSO/clinically significant outcomes (defined as pancreatic cancer, HRS, WF, WEUS) post 5 years had larger maximum cyst size in the first 5 years compared to those without CSO [median (Q1–Q3) 16 (12–23) vs 12 (9–17) mm, P = 0.0001] (Figure 1). 152 patients died post 5 years (3 due to pancreatic cancer). The incidence of pancreatic cancer and CSO at 7 years post 5-year period (12 years from PCL diagnosis) in patients with no significant changes were 0.7% and 12.5%, respectively. The mortality due to pancreatic cancer was 0.45%; mortality due to all causes was 31.7%. Median (range) of Charlson Comorbidity Index (CCI) was 2 (0–16) at 5 years post PCL diagnosis. The mortality rate at 7 years post 5-year period for ACCI (age-adjusted CCI) of ≤3, 4–6, and ≥7 were 3.5%, 28% and 58% (P < 0.0001), respectively (Figure 2).

CONCLUSION:

The incidence of pancreatic cancer in patients with PCL with no significant changes in the first 5 years of diagnosis remains low at 0.7%. The incidence of clinically significant outcomes (CSO) was higher at 12.5%. Maximum cyst size of ≥15 mm in the first 5 years had higher cumulative incidence of CSO in long-term follow-up. These risks should be weighed against patients' overall mortality (based on scoring systems such as CCI) when making surveillance decision of PCL beyond 5 years.
82 A Comparison of Machine Learning and Logistic Regression Performance for the Prediction of In-Hospital Mortality Among Acute Biliary Pancreatitis Patients
Authors: Luthra Anjuli K. , Porter Kyle , Hinton Alice , Krishna Somashekar G.
Published: October 2019

INTRODUCTION:

For population databases, traditional multivariate analysis is accepted standard for predictive modelling of mortality in acute biliary pancreatitis (ABP). Machine Learning (ML) and artificial intelligence (AI) are novel methodologies to analyze databases. The gradient boosting machine (GBM) is a tree-based ML approach. Tree-based algorithms partition the data based on predictors in an attempt to accurately classify the outcome. The gradient boosting approach employs successive trees to improve upon misclassifications of the earlier trees. Alternatively, logistic regression is a statistical approach, in which predicted probabilities are generated based on parameters estimated by maximum likelihood estimation. With the advent of universal electronic medical records, patient databases are more complex, large, and interlinked to multiple institutions. Hence, we sought to compare traditional statistical methods and ML in building prediction models for mortality in ABP.

METHODS:

Using the Nationwide Readmission Database (2010–2014), we identified all patients (age > 18 years) with index admissions for ABP. This data was randomly divided into a training set (70%) and a test set (30%), stratified by outcome in order to get similar event rates in both sets. The same training and test sets were used for GBM learning and logistic regression. The area under the ROC curve (AUROC) was calculated for both GBM and logistic regression modelling for predicting mortality in ABP.

RESULTS:

A total of 97,027 patients were hospitalized for ABP from 2010–2014 in the US. The in-hospital mortality rate was 0.97% (n = 944). Using the same set of predictor variables (demographic, hospital, etiological, comorbidities, severity of acute pancreatitis (AP), procedures, and duration of stay), ML and logistic regression performed similarly in predicting mortality with GBM achieving an AUROC of 0.955 and logistic regression AUROC 0.948 (Figure 1). Key predictors of mortality for AP using logistic regression included: Severe AP, sepsis, increasing age, and failure to perform cholecystectomy. Foremost predictors using GBM included length of stay, age, severe AP and income quartile.

CONCLUSION:

Notwithstanding emergence of novel AI methodologies, traditional logistic regression is comparable to novel ML algorithms in the predictive modelling of hospital outcomes in ABP and can continue to be utilized in large population databases.
92 Management of Pancreaticopleural Fistula in Necrotizing Pancreatitis: A Single Tertiary Care Center Experience
Authors: Dirweesh Ahmed , Choo Christopher , Amateau Stuart , Azeem Nabeel , Mallery Shawn , Freeman Martin , Trikudanathan Guru
Published: October 2019

INTRODUCTION:

Pancreaticopleural fistula (PPF) is a rare sequelae of necrotizing pancreatitis (NP) consequent to pancreatic duct (PD) disruption. Due to low prevalence, experience in the management of this condition remains sparse outside specialized centers and management remains controversial. We report our center experience with PPF. The study aimed to report the demographic and clinical characteristics, management and outcomes of NP patients with radiologically confirmed PPF in our institution.

METHODS:

A retrospective analysis of all 515 NP patients managed at our institution between 2010–2019 was performed from a prospectively maintained database for the occurrence of PPF. Baseline characteristics, clinical presentation, management and outcomes were evaluated.

RESULTS:

Five white patients (three males and two females, median age 51 years [range, 38–63 years]) with PPF were managed in our institution during the study period, with a prevalence of 1%. The etiology of pancreatitis was alcohol in three and idiopathic in two. All patients had documented exudative pleural effusion with amylase content >1,000 U/L. All patients underwent computerized tomography (CT), magnetic resonance imaging (MRI) and/or sinogram studies to delineate the fistula and site of PD disruption. All patients required ERCP with PD stenting and/or chest tube placement. No patient required surgical intervention. Four patients (75%) remain well at a median follow up of 6 months, while one died during the same hospitalization (25%).

CONCLUSION:

Pancreaticopleural fistulae can present a challenging diagnostic dilemma and require a high index of clinical suspicion. Early recognition and a multi-disciplinary approach in centers with specialized experience are vital for successful management of this condition.
96 Impact of the National Opioid Epidemic on Chronic Pancreatitis Related Admissions
Authors: Chatila Ahmed , Bilal Mohammad , Siddiqui Mohamed Tausif , Al-Hanayneh Muhannad , Shah Aun R. , Desai Madhav , Wadhwa Vaibhav , Parupudi Sreeram , Casey Brenna W. , Krishnan Kumar , Hernandez-Barco Yasmin G.
Published: October 2019

INTRODUCTION:

Opioid use disorder (OUD) has become a public health emergency in the United States. Patients with chronic pancreatitis (CP) are at high risk for opioid dependence due to chronic pain associated with the disease process. We aimed to evaluate the prevalence, impact and predictors of OUD in patients hospitalized with CP.

METHODS:

A retrospective cohort study was performed using the national inpatient sample (NIS) database from 2005–2014. Patients with a primary diagnosis of CP and OUD were included. OUD-related diagnosis were identified using previously published studies. The primary outcome was to evaluate the prevalence and trend of OUD in patients hospitalized with CP over time. Secondary outcomes were: i) to assess the impact of OUD on healthcare resource utilization, ii) identify predictors of OUD in hospitalized CP patients.

RESULTS:

A total of 176,857 CP patients were included, and OUD was present in 3.8% of patients. The prevalence of OUD in CP doubled from 2.7% in 2005 to 5.4% in 2014 (Figure 1). Patients with CP who had OUD were found to have higher mean length of stay (adjusted mean difference: 1.2 days (95% CI: 1.1–1.4), P < 0.001) and total hospitalization costs (adjusted mean difference: $1,936 (95% CI: 1590–2282), P < 0.001). Independent predictors of OUD in CP patients were obesity, presence of depression, and increased severity of illness (Table 1).

CONCLUSION:

OUD related diagnoses are increasing among patients with CP and are associated with increased healthcare resource utilization. Our study identifies an important group of patients at high-risk for OUD whose pain should be carefully managed.
97 Performance Comparison Between Endoscopic Ultrasound/endoscopic Retrograde Cholangiopancreatography and Intraoperative Cholangiography for Detecting Choledocholithiasis
Authors: Vyas Neil , Alshati Ali , Kosa Dimas , Shehzad Pir , Bhattarai Bikash , Bellapravalu Sharad , Nadir Abdul , Srinivasan Indu , Chuang Keng-Yu
Published: October 2019

INTRODUCTION:

The diagnosis and management of choledocholithiasis have been evolving given multiple diagnostic modalities. One of these diagnostic modalities is intraoperative cholangiogram (IOC) which is typically performed during laparoscopic cholecystectomy for evaluation of choledocholithiasis. Our aim is to compare endoscopic ultrasound (EUS) to IOC in the accurate detection of a common bile duct stone using endoscopic retrograde cholangiopancreatography (ERCP) as gold standard for diagnosis.

METHODS:

A five-year retrospective single center study was performed for patients diagnosed with choledocholithiasis due to a positive IOC during laparoscopic cholecystectomy. These patients subsequently were tested with EUS and ERCP (Group 1). Analysis was also performed in which patients underwent IOC with subsequent ERCP without EUS (Group 2). We used ERCP as the gold standard to ascertain a percentage of true positives, true negatives, sensitivity, specificity and corresponding 95% exact confidence intervals. Demographic data and laboratory values (bilirubin and liver enzymes) prior to endoscopic procedure were also described.

RESULTS:

All of the 24 IOC positive patients (Group 1) were subjected to EUS and the majority of these patients underwent an ERCP. EUS detected 80% (8/10, 95% CI: 48.1–96.5) true positives and 92.3% (12/13, 95% CI: 67.5–99.6) true negatives among these IOC positive patients (Figure 1). 52 patients who underwent IOC and subsequent ERCP without EUS (Group 2). 43 of the 52 patients were positive to IOC. Nine IOC negative patients were examined with ERCP and 6 were negative. IOC detected 69.7% (30/43, 95% CI: 54.9–82.0) of true positives and 66.7% (6/9, 95% CI: 33.2–90.7) true negatives (Figure 1). With a sensitivity of 90.9% (95% CI: 75.7–98.1) and specificity of 31.6% (95% CI: 12.6–56.6), IOC resulted 30.2% (13/43, 95% CI: 18.0–46.1) false positives and 33.3% (3/9, 95% CI: 9.27–66.8) false negatives.

CONCLUSION:

Test performance of EUS in IOC-positive patients compared to test performance of IOC in patients not tested with EUS were comparable. However, with about a third of patients exposed to unnecessary ERCP, clinical practicality of IOC as the screening test is questionable. Large proportion of false positives is not desirable for a screening test with less than perfect sensitivity. Thus, EUS can help risk stratify patients and presumably avoid or minimize unnecessary ERCP risks to patients. Additional studies with large patient populations will be more conclusive.
101 The Effect of Disability on the Diagnosis and Treatment of Pancreatic Cancer in the Republic of Korea: A National Cohort Study
Authors: Choi Jongwook , Cho Byungha , Lee Jun Su , Kwon Hyeonwoo , Kim Seongmin , Park Seon Mee
Published: October 2019

INTRODUCTION:

Pancreatic ductal adenocarcinoma (PC) is the fifth leading cause of cancer-related mortality and the eighth most common cancer in Korea. Korea has various national databases that can provide information regarding different health status factors, such as disability status, cancer, and delivery of health-care and associated medical costs. This study aimed to determine whether the diagnosis, treatment approach and prognosis of pancreatic cancer (PC) varied according to the presence, severity and type of disability.

METHODS:

Demographic, socioeconomic, and medical data were obtained from the National Disability Database, the Korean Central Cancer Registry, and the Korean National Health Insurance claims database. An age- and sex-matched cohort was established using a 1:3 ratio of 2,776,450 people with disabilities and 8,329,350 people without disabilities. Adult patients diagnosed with PC were subsequently selected from this cohort. Disabilities were categorized as physical, brain, communication, mental impairment, and affecting the major internal organs.

RESULTS:

The cohort included 12,402 patients with PC, with a significantly lower rate per 105 persons among people with disabilities than among people without disabilities (114.9 vs. 102.1, P < 0.0001). People with disabilities were more diagnosed PC at earlier age (P < 0.0091). Patients with disabilities had higher Charlson comorbidity index (1.47 vs. 2.00) and more below poverty line (5.8% vs. 13.3%) than those without disabilities. People with severe disabilities were diagnosed PC at earlier age, but less likely to undergo surgery (adjusted odds ratio 0.83, 95% confidence interval 0.77–0.96) or chemotherapy (0.81, 0.74–0.90) than those without disabilities. The overall and cancer specific mortality rates were higher in patients with disabilities than those without disabilities. This trend was more evident among patients with severe disabilities and in those with mental disorders.

CONCLUSION:

In Korea, people with disabilities generally have a lower rate of PC diagnosis, receive less intensive treatment, and have a lower survival rate than people without disabilities.
105 Are Race or Sex Associated With Mortality, Interventions, or Palliative Care Use in Pancreatic Cancer Patients? An Urban Center Experience, 2010–2017
Authors: Jamorabo Daniel S. , Renelus Benjamin D. , Gurm Hashroop , Bhesania Siddharth , Briggs William M.
Published: October 2019

INTRODUCTION:

Treatment options for pancreatic cancer are well-established, but patients do not necessarily receive the same treatments for various reasons including unequal access to care, differences in medical literacy, or cultural barriers. We investigated whether or not disparities existed in the management of pancreatic cancer based on sex and race at our university-affiliated, urban hospital from 1/1/2010 through 12/31/2018.

METHODS:

We did a retrospective review of all pancreatic cancer cases diagnosed from 2010–2017 at our institution. We used Fisher's exact test to evaluate overall mortality and palliative care team involvement by patient sex and race. We used Cox proportional univariate regressions to compare survival following surgery, chemotherapy, and palliative care involvement based on sex, race, and age group (≤80 years old and >80 years old). Kaplan-Meier plots were used to determine mortality by sex, race, and age group.

RESULTS:

We identified 201 patients with biopsy-proven pancreatic cancer. Of those, 110 (54.7%) had died by date of last contact. We found no statistically significant difference in overall mortality based on sex, race, or age group. Chemotherapy did not confer a survival advantage, but we found an overall decrease in mortality following surgical intervention (HR 0.39, 95% CI 0.24–0.65; P = 0.0003) that was particularly evident in the first 1000 days following diagnosis (Figure 1). The palliative care team was involved in just 61/201 (30.3%) of cases with white patients being 70% less likely to have documented contact with the service compared to non-white patients (P = 0.004). Black patients had a higher likelihood than white patients of being seen by the palliative care team while hospitalized (OR 3.36, 95% CI 1.70–6.96; P = 0.0007).

CONCLUSION:

Sex and age group were not associated with differences in treatment. While surgical intervention appeared to be beneficial for the first three years following diagnosis, overall mortality after 1000 days was unchanged. Palliative care service has been underutilized across the cohort, despite there not being a long-term survival benefit with chemotherapy or surgery. White patients were less likely than black patients to be seen by our palliative care team, which could reflect a tendency to pursue more aggressive treatments or possibly decreased receptivity to palliative care involvement in this patient population. This discrepancy must be examined further through prospective or cross-sectional studies for clarification.
111 Clinical Utility of EUS-Guided Needle-Based Confocal Endomicroscopy of Pancreatic Cystic Lesions for Surgical Decision Making
Authors: Krishna Somashekar , Hart Phil , Luthra Anjuli K. , Porter Kyle , Papachristou George , Lara Luis , Conwell Darwin
Published: October 2019

INTRODUCTION:

There is a need to assess the clinical impact of utilizing EUS-guided needle-based confocal endomicroscopy (nCLE) in the surgical management of PCLs. Hence, we sought to evaluate the concordance of diagnoses using the standard of care (SOC) clinical data with EUS-nCLE, and the impact on surgical resections of PCLs.

METHODS:

Subjects included consecutive patients enrolled in a prospective study (2015–2018) evaluating EUS-nCLE for the diagnosis of PCLs who underwent a clinically indicated EUS-FNA, along with EUS-nCLE. Data used to derive the SOC diagnosis included clinical history, cross-sectional imaging, EUS morphology, cyst fluid CEA, and cytology (based on hierarchical group assignment, Table 1). Decisions for patient management also involved multidisciplinary tumor board meetings. A final diagnosis of PCLs was defined for those with surgical histopathology or presence of established mutations in the cyst fluid (KRAS/GNAS: mucinous cyst, VHL: serous cystadenoma). The diagnostic concordance of EUS-nCLE alone with SOC was assessed.

RESULTS:

A total of 138 subjects with PCLs (mean cyst size 36.4 ± 15.7 mm) underwent SOC and EUS-nCLE. A final diagnosis was available in 93 subjects (surgical histopathology, n = 67, molecular markers in cyst fluid, n = 26). Diagnostic concordance was observed in 80 (86%) subjects, with a discordant nCLE diagnosis in the remaining 13 (14%) subjects. Among PCLs with discordant diagnoses (Table 2), EUS-nCLE was “clinically advantageous” in 11 subjects with successful downstaging of PCLs which were otherwise classified as mucinous by SOC, hence potentially preventing unwarranted surgery. In one subject, nCLE was “clinically advantageous” with successful upstaging of PCL (final diagnosis: IPMN), while SOC inaccurately classified the lesion as a non-mucinous PCL. EUS-nCLE was “clinically disadvantageous” in one subject (final diagnosis was mucinous cystic neoplasm) who were classified as a mucinous cyst by SOC, but nCLE did not reveal diagnostic image patterns.

CONCLUSION:

EUS-nCLE has a significant clinical impact by preventing at least one unwarranted pancreatic surgery for every ten subjects undergoing multimodality SOC evaluation. Hence EUS-nCLE should be considered for a comprehensive assessment of PCLs when FNA is being performed.
115 Bone Health in Chronic Pancreatitis: A Pilot Study
Authors: Manickavasagan Hanisha , Shah Zarine , Hart Phil , Lara Luis , Hinton Alice , Lu Andrew , Yadav Dhiraj , Conwell Darwin
Published: October 2019

INTRODUCTION:

Metabolic bone disease is associated with increased morbidity, mortality, and resultant health care costs. Chronic pancreatitis (CP) has multiple overlapping risk factors and complications (smoking, vitamin D malabsorption, fat maldigestion, alcohol abuse, and chronic inflammation) that promote an imbalance in bone mineralization and remodeling. This, in turn, leads to an increased risk of osteoporosis and fragility fractures. In this pilot study, we sought to assess the distribution of bone mineral density (BMD) and the clinical factors associated with reduced BMD in CP.

METHODS:

We selected patients with a definitive diagnosis of CP (according to the American Pancreatic Association guidelines) who were enrolled into The Ohio State Wexner Medical Center Pancreas Disease Biobank. Demographic and clinical details were abstracted, including age, sex, race, BMI, smoking, and alcohol history, and compared to BMD assessed by DEXA scans.

RESULTS:

Sixty-four patients with definite CP were identified. A total of 32 (50%) had bone mineral density screening with DEXA scans completed. Of those with BMD assessment, 59.3% (19/32) had a Z-score < −1.5. The overall mean of the lowest DEXA Z-score for the CP cohort was −1.39. Of the CP patients with metabolic bone disease, the majority were older than 50 years of age (68%), and there was an equal distribution of males (59%) to females (60%). The mean Z-score was lower for females than males, although this did not reach statistical significance (−1.9 versus −1.3 respectively; P = 0.25). There was no association with bone disease and race, smoking and alcohol.

CONCLUSION:

Despite the increased risk of metabolic bone disease, only 50% of patients with CP had screening DEXA scans. Of these, metabolic bone disease was seen in up to 60% of CP patients. Older patients and female-gender had similar bone mineral density trends in CP as expected in the general population. A larger sample size of CP patients is needed to evaluate the true impact and predictors of metabolic bone disease in CP.
117 Gender and Racial Disparities in the Annual Percent Change of Incidence and Mortality Rates of Pancreatic Cancer
Authors: Bhagat Vicky , Kahaleh Michel
Published: October 2019

INTRODUCTION:

In the United States, pancreatic cancer is the fourth leading cause of cancer death for both men and women. The purpose of this study is to investigate the impact of gender, and race/ethnicity on the annual percent change of incidence and mortality rates of pancreatic cancer from 2000–2016 using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS:

Patients diagnosed with pancreatic cancer from 2000–2016 were identified from the SEER Registry. We retrospectively evaluated gender-specific, and race/ethnicity variations in age-adjusted annual percent changes in incidence rates and mortality rates for people above the age above 20. We used ethnic groups consisting of White, Non-Hispanic White, Black, Asian/Pacific Islander, American Indian/Alaska Native, and Hispanic.

RESULTS:

Based on the SEER 21 areas data sets, the age-adjusted incidence rates of pancreatic cancer increased from 2000–2014 but remained stable from 2014–2016. The annual percent of change in incidence for both males and females from 2000–2014 was 0.9 and was −1.4 from 2014–2016. Females had an annual percent change of incidence of 0.7 from 2000 to 2016. For males, the annual percent change was 1.2 from 2000–2009 but the annual percent change from 2009–2016 was 0.2. Females had an upward trend of annual percent change of incidence rates during this period. The annual percent change of incidence by race/ethnicity can be seen in Table 1. The annual percent change in mortality rates was analyzed during 2000–2016. Females had an annual percent change of 0.2 and males had an annual percent change of 0.3. The trend of mortality rates was upward for males and females. The annual percent change of mortality rate by race/ethnicity can be seen in Table 2.

CONCLUSION:

The poor outcome and silent nature of pancreatic cancer necessitates the need to understand the trends associated with disease. Females had an upward trend in the annual percent change of incidence rates of pancreatic cancer from 2000–2016. There is also upward trend for annual percent change of incidence rates for Asians, Hispanics, and Non Hispanic Whites. The trend of annual percent change of mortality rates was increasing for both males and females during 2000–2016. The trend was increasing for both Non-Hispanic White and White Americans. This may support interventions to inform certain race/ethnic populations about the importance of screening for pancreatic cancer in high-risk populations.
118 Effects of Gallstones or Cholecystectomy on Gastrointestinal Cancer Risk and Prognosis: A Population-Based Cohort Study
Authors: Kwon Hyeonwoo , Kim Seongmin , Lee Jun Su , Cho Byungha , Choi Jongwook , Park Seon Mee
Published: October 2019

INTRODUCTION:

It is debatable whether the gallstones or cholecystectomy increases gastrointestinal cancer (GIC) risk. We evaluated GIC risk and prognosis in gallstone patients treated with or without cholecystectomy and compared them with controls.

METHODS:

We identified gallstone patients (n = 480,688; follow-up: 12 years) and 1:10 age- and sex-matched healthy controls from Korean National Health Insurance data (2002–2016). Incidence and mortality rate of gastric cancer (GC), colon cancer (CC), rectal cancer (RC), hepatocellular carcinoma (HCC), bile duct cancer (BDC), and pancreatic cancer (PC) were compared. Possible risk factors such as sex, age, metabolic syndrome-related parameters (hypertension, obesity, hyperlipidemia, and hyperglycemia), liver enzyme levels, and smoking and drinking habits were adjusted.

RESULTS:

Compared to controls, gallstone patients without cholecystectomy revealed 0.78-, 0.95-, and 0.80-fold lower incidences of GC (88.87 per 105 person-year), CC (54.65), and RC (30.57) and 4.23-, 4.87-, and 1.60-fold higher incidences of HCC (107.69), BDC (33.85), and PC (22.29), respectively. Cholecystectomy was performed in 132,901 gallstone patients (27.6%); 87.5% of them were diagnosed with acute cholecystitis or cholangitis. Compared to gallstones without cholecystectomy, the incidences of gallstone patients treated with cholecystectomy revealed decreased in HCC (38.43) and BDC (13.90), increased in GC (107.32) and CC (59.58), and unchanged in RC (29.91) and PC (21.22). All GIC patients who underwent cholecystectomy had higher survival rates than controls.

CONCLUSION:

Risks of HCC, BDC, and PC were higher in gallstone patients, which decreased or unchanged after cholecystectomy. Gallstones or cholecystectomy had minimal effects on the incidences of GC, CC, and RC.
119 Kinetics of Stool Polymerase Chain Reaction in Clostridioides difficile Infection and Its Utility in Predicting Recurrence
Authors: Saha Srishti , Pardi Ryan , Patel Robin , Pardi Darrell , Khanna Sahil
Published: October 2019

INTRODUCTION:

Testing strategies for Clostridioides difficile infection (CDI) remain a clinical conundrum with stool polymerase chain reaction (PCR) being highly sensitive; this high sensitivity may mean that PCR would remain positive for several weeks after CDI resolution. We studied the kinetics of PCR testing positivity in CDI, and whether a positive test during or after treatment predicts recurrence.

METHODS:

Adults with watery diarrhea and positive C. difficile PCR from 10/2009 to 5/2017 were included. Treatment was given per standard of care. Five serial stool samples collected within 60 days after treatment initiation and additionally clinically indicated samples were included. Recurrent CDI was defined as typical CDI symptoms after interim symptom resolution with positive stool PCR within 56 days of treatment. A positive stool test in the absence of symptoms was considered colonization and treatment was not offered. Descriptive statistics and Fisher's test were used, as appropriate. Kaplan-Meier survival curves for time to first negative PCR from treatment initiation, and log-rank test to compare treatments [metronidazole (MET) vs vancomycin (VAN)] were used. P < 0.05 was considered statistically significant.

RESULTS:

Fifty patients, median age 51 (range 20–86) years, 66% female, were included. Initial treatment was MET in 50% (25), VAN in 44% (22), both MET and VAN in 4% (2) and fidaxomicin in 2% (1). Median treatment duration was 14 (range 8–60) days. Overall, 82% (41) patients submitted ≥3 samples at variable times. Median time to first negative PCR was 9 days (95% CI, 7–14 days) after treatment initiation (Figure 1). This was similar in MET and VAN treated patients (P = 0.5; Figure 2). CDI recurred in 28% (14) of patients. Overall, 13 patients (33%) had ≥1 positive PCR(s) during and 45% (19) had ≥1 positive PCR(s) after treatment. Patients with positive vs negative PCR(s) during treatment trended towards a higher risk of recurrence [OR 3.9 (95% CI, 0.9–16.1), P = 0.054]. Patients with positive PCR(s) after treatment completion also had a non-significant trend towards a higher risk of recurrence [OR 2.8 (95% CI, 0.7–11.5), P = 0.15].

CONCLUSION:

Median time to first negative PCR in CDI was 9 days from treatment initiation. Positive PCR during or after treatment did not predict recurrence, though the positive odds ratio indicates the need for a larger study. Patients with CDI should not routinely undergo repeat testing to predict recurrence.
121 Opioid Use Are Independently Associated With Rectal Hyposensitivity and Dyssynergic Defecation in Chronic Constipation
Authors: Lodhia Nayna , Horton Laura , Goldin Alison , Chan Walter W.
Published: October 2019

INTRODUCTION:

The role of defecation dysfunction (DD) and rectal sensitivity in opioid related chronic constipation (CC) is unknown. The purpose of this study is to evaluate the relationship between opioid use and rectal sensation, defecatory function, and balloon expulsion on physiology testing.

METHODS:

This was a retrospective cohort study of consecutive adult patients who underwent high-resolution anorectal manometry (HRAM) at a tertiary care center for CC. Baseline patient clinical characteristics and HRAM findings were reviewed. Rectal hyposensitivity was defined by increased rectal sensation volume for first sensation, urge, and maximal tolerance. DD was defined by impaired anal sphincter relaxation (<20% decrease from resting pressure) during strain maneuver with or without weak push, defined as inadequate rectal contraction pressure (<40 mmHg increase from baseline). Successful balloon expulsion was defined by evacuation of 50 mL balloon within 2 minutes. Statistical analyses were performed using Fisher exact or student t-test for univariate analyses and logistical or general linear regression for multivariate analyses.

RESULTS:

317 patients (mean age 50.3 years; 86.8% female) were included. Patients with recent opioid use (<3 months of HRAM) had significantly increased volume for first rectal sensation (70.4 mL vs 61.5, P = 0.043), urge sensation (120.4 vs 104.5, P = 0.04), and maximal tolerance (170.2 mL vs 149.6, P = 0.0083) when compared to those without recent opioid use. No significant difference in rectal sensation was found in patients with a distant history of opioid use (>3 months) (Figure 1). Patients with recent opioid use also had increased risk of DD (63.4% vs 44.9%, P = 0.029), but no difference in failed balloon expulsion (75.9% vs 74.8%, P = 0.90). On multivariate analyses after controlling for potential confounders including history of irritable bowel syndrome (IBS), age, sex and history of abdominal or pelvic surgeries, recent opioid use (<3 months), but not distant use (>3 months), remained independently associated with increased volume for urge sensation (β-coefficient 14.3, P = 0.03) and maximal tolerance (β-coefficient 22.8, P = 0.006), and higher risk for DD (OR 1.67, P = 0.04) (Table 1).

CONCLUSION:

Recent opioid use was an independent risk factor for rectal hyposensitivity and DD on HRAM in patients with CC, but that effect may decrease with discontinuation of use. Anorectal physiology testing may be considered in patients on opioids with CC.
122 Multidisciplinary Quality Improvement Initiative to Reduce Bowel Complications in Post-Operative Orthopedic Patients
Authors: Latorre Melissa , Meneses Michelle , Arbuah Nancy , Adenikinju Abidemi , Wasterlain Amy , Swensen Stephanie
Published: October 2019

INTRODUCTION:

Gastrointestinal (GI) complications in patients undergoing orthopedic surgery are common but underreported. Prolonged immobility and the use of post-operative narcotics can increase the risk of GI complications which include: constipation, ileus, bowel obstruction, stercoral colitis, perforation, and death. In 2017 we observed an increase in GI complications among patients undergoing orthopedic surgery at our orthopedic hospital. This prompted a multidisciplinary quality improvement (QI) initiative to reduce GI complications among patients admitted after joint or spine surgery.

METHODS:

Following a surge of GI complications at our university-affiliated tertiary referral orthopedic satellite hospital in early 2018 we created a multidisciplinary QI program. The first component was a didactic lecture delivered by a GI attending to the orthopedic trainees, attendings, physician extenders, nurses and staff. The 1 hour lecture discussed an effective GI history, exam and reviewed the symptoms and treatment of common GI conditions affecting post-operative patients. The second component was the development of a post-operative constipation and bowel assessment algorithm focused on early identification, escalation and treatment of GI conditions (Figure 1). The third component was a redesign of the electronic medical record post-operative constipation order sets in order to facilitate implementation of the aforementioned bowel algorithm. This new order set changed laxative orders from “as needed” to standing with an option to be held for diarrhea. These QI initiatives were implemented on a rolling basis from 1/31/2018 to 5/31/2018. Cases of ileus, obstruction and perforation were determined based on coding for admitted orthopedic patients.

RESULTS:

The proportion of patients admitted with each diagnosis was compared from the first quarter (1/1 to 3/31) of 2018 to 2019 corresponding to 6 months after the implementation of all QI components (Figure 2). We achieved a 71% reduction in overall bowel complications (P < 0.05). The greatest reduction was achieved in post-operative ileus by 81% (P < 0.05). Following the QI initiative there was only 1 perforation corresponding to a 50% reduction.

CONCLUSION:

We created a multidisciplinary QI program that successfully reduced GI complications in patients hospitalized following orthopedic surgery. The greatest impact was in the reduction of post-operative ileus and serious adverse events such as perforation.