bluuebunny/crossref_metadata_2025 huggingface dataset:
SKRINING AWAL AKTIVITAS ANTIBAKTERI DAN ANTIOKSIDAN EKSTRAK SEMUT (INSECTA: FORMICIDAE) DARI GARUT - JAWA BARAT
Authors: Efendy Oscar , Fathoni Ahmad , Praptiwi Praptiwi , Royyani Mohammad Fathi , Wulansari Dewi , Agusta Andria
Published: October 2019

Studies on the therapeutic use of insects and insect products have been neglected compared to the use of other animals or plants.This study aims to determine the antibacterial and antioxidant potential of ants extracts. Preliminary study related to antibacterial and antioxidant screeningof 17 extracts of ant colonies that belongs to 8 species were performed by Thin Layer Chromatography (TLC)-Bioautography. Antioxidant activity was measured by DPPH free radical scavenging method. The antibacterial activity was done against three pathogenic bacteria, i.e Bacillus subtilis InaCC B-1, Staphylococcus aureus InaCC B-4 and Escherichia coli InaCC B-5 were performed by non-eluted TLC-autobiography assay. The minimum inhibitory concentration (MIC) and IC50 values of DPPH radical scavenging activity of active extracts were determined by microdilution in 96-well microplate. The results showed 6 extracts active against B.subtilis, 5 extracts active against S.aureus. The lowest MIC value was 512 µg/ ml.  Ten extracts had the antioxidant activity with various IC50 values. The extracts of ants might be used as bioactive resources for antibacterial and antioxidant.
CAPITAL INTENSITY IMPACT TOWARDS WORK ACCIDENT COMPENSATION IN INDONESIA MANUFACTURING INDUSTRY
Authors: Prawira Yuda
Published: October 2019

mohon agar dihapus, karena format yang diupload belum sesuai dengan ketentuan yang berlaku
5 The Prevalence and Epidemiology of Pancreatic Cancer in the USA: A Population-Based Study
Authors: Khoudari George , Saleh Mohannad Abou , Baidoun Firas , Sarmini Muhammad Talal , Vega Kenneth J. , Sanaka Madhusudhan R.
Published: October 2019

INTRODUCTION:

Pancreatic cancer is the fourth leading cause of cancer-related death in the United States. Multiple studies have reported the epidemiology of this disease with conflicting results and limited sample size. Our aim is to further investigate the epidemiology of pancreatic cancer using a large database.

METHODS:

We used a commercial database (Explorys Inc, Cleveland, OH) which includes electronic health record data from 26 major integrated US healthcare systems. We identified all patients aged 18 and older who were diagnosed with pancreatic cancer, over the last 5 years based on Systematized Nomenclature Of Medicine – Clinical Terms (SNOMED-CT) and evaluated the prevalence of pancreatic cancer among all the patients in this database. We also performed univariate analysis to describe age-, race-, and gender-based distributions and to identify potential risk factors.

RESULTS:

Of the 36,728,450 individuals in the database, we identified 41,610 individuals with pancreatic cancer with an overall prevalence of 0.11%. Individuals with pancreatic cancer were more likely to be males, senior adults (age >65), Caucasians, (P < 0.0001 to all) compared to patients without pancreatic cancer. Similarly, patients with pancreatic cancer were more likely to have cystic fibrosis, viral hepatitis B and C, acute and chronic pancreatitis, diabetes mellitus type 1 and 2, (P < 0.0001 to all). Additionally, patients with pancreatic cancer were more likely to be smokers, drink alcohol, and take non-steroidal anti-inflammatory drugs (NSAIDs), (P < 0.0001 to all). Table 1 represents the odds ratio (OR) for all factors.

CONCLUSION:

This is one of the largest epidemiological studies investigating the prevalence and epidemiology of pancreatic cancer. Estimated prevalence rate of pancreatic cancer was 0.11%. Patients with pancreatic cancer were more likely to be males, senior adults (age >65), Caucasians, smokers, and take NSAIDs. They were also more likely to have Diabetes, Chronic pancreatitis, Hepatitis B, and Hepatitis C. Further studies are needed to confirm these findings.
8 Role of HMG CoA Reductase Inhibitors and Proton Pump Inhibitors in the Prevention of Post ERCP Pancreatitis
Authors: Muftah Mayssan , Shah Rushikesh , Cristofaro Sarah , Chawla Saurabh , Patel Vaishali , Keilin Steven , Cai Qiang , Willingham Field
Published: October 2019

INTRODUCTION:

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most frequent complication following ERCP. Studies have suggested that HMG CoA reductase inhibitors (statins), due to their anti-inflammatory properties, are protective against acute pancreatitis and may lessen the severity. Additionally, it has been postulated that by increasing gastric pH, proton pump inhibitors (PPIs) can prevent premature activation of pancreatic enzymes, reducing the risk of pancreatitis. The role of statins and PPIs in PEP have not been examined. The purpose of this study is to assess the impact of statin and PPI medications on PEP in native papilla ERCP in a tertiary referral center.

METHODS:

Patients who underwent ERCP in a large tertiary care referral setting were retrospectively reviewed from January 2015–December 2017. 1288 patients were screened, and 226 met inclusion criteria. Patients who had ERCP with a native papilla (index ERCP) were included. Data were extracted from chart review. Over 40 variables including demographics, clinical parameters, and procedure-related data points were collected. Variables were collected toinvestigate factors related to PEP and control for cofounders. PEP was defined using the Cotton criteria. A multivariate regression model was constructed to determine independent predictors of post-ERCP pancreatitis.

RESULTS:

226 index ERCPs were collected. Mean age was 58.2 years, 48.7% of the patients were female, and 67.1% were Caucasian. Demographics and clinical variables collected are present in Table 1. The overall rate of PEP was 5.3%. 16.7% of those with PEP were on statin therapy compared to 18.4% (P = 0.88), and 25% of patients who had PEP were on PPIs compared to 41.5% (P = 0.3). The presence of a difficult cannulation was more common in patients with PEP (36.4% vs 12.8%, P = 0.028), as was wire cannulation in the main pancreatic duct (66.7% vs 29.9%, P = 0.008). Variables with a P value < 0.1 were included in a multivariate regression model. The only significant predictors of PEP were difficult cannulation (P = 0.033) and wire cannulation of the MPD (P = 0.021). Subgroup analysis including only patients that had MPD cannulation showed that PPI use (P = 0.025) was an independent predictor of PEP.

CONCLUSION:

Use of statins was not found to be different between PEP groups. In patients that had MPD cannulation, PPI was a predictor of PEP. Further prospective studies are needed to determine the clinical significance of statin and PPI use in relation to PEP.
17 Cholangiocarcinoma: Incidence, Prevalence and Descriptive Analysis in the VA Caribbean Healthcare System in Puerto Rico
Authors: Estremera-Marcial Rodolfo , Marzan-Loyola Adriana , Martin-Ortiz Jose , Toro-Lugo Doris
Published: October 2019

INTRODUCTION:

Cholangiocarcinoma (CCA) is a rare cancer that arises from the epithelial cells of the bile ducts. Although uncommon, it is highly lethal, since usually it is advanced at the time of presentation. According to the Global Burden of Disease Study there were 139,500 deaths from biliary tract cancers in 2013, which is a 22% increase from the estimated 115,400 deaths in 1990. The incidence and prevalence of CCA at the VA Caribbean Healthcare System (VACHS) in San Juan, Puerto Rico, has not been statistically determined. The aim of this study is to determine the incidence and prevalence of CCA and to provide a descriptive analysis of the veteran population at the VACHS.

METHODS:

Veteran male subjects ≥21 years old with a diagnosis of CCA as documented in ICD-9/ICD-10 were included in this study from 2001–2017. The data was collected from the electronic medical record at the VACHS.

RESULTS:

A total of fifty-seven patients were diagnosed with CCA by the ICD 9-10 criteria. Fifty-four confirmed by biopsy. The mean age of the subjects was 75 years old. The overall estimate prevalence of CCA is 88/100,000 population. According to the data collected, 63%, 30%, 5% and 2% patients with CCA served in the Korean, Vietnam, WWII and Persian Gulf wars, respectively. The most common comorbidities in the biopsy-proven subjects were diabetes mellitus type II (50%), cirrhosis (26.4%), cholelithiasis (21.8%) and obesity (10.5%). Among the patients who had underlying cirrhosis, 29% had HCV. A total of 29 patients (54%) had a positive history of tobacco use and 15% of ethanolism. The most common clinical presentations identified were painless jaundice (44.4%), weight loss (29.6%), RUQ pain (27.8%) and incidental finding on imaging (18.5%). Most of the cases (85%) presented with a cholestatic pattern on routine laboratories. A total of 59.6% of the CCAs were intrahepatic and 26.9% were located distally. At the time of diagnosis, more than half (51.2%) had distant metastasis.

CONCLUSION:

This clinical study, although limited by a small population size and the absence of a control group for comparison, describes the most common clinical and social characteristics related to CCA and its overall prevalence and incidence per year at the VACHS from 2001–2017. Although, the overall estimate prevalence of CCA in our population is low, the rarity of this tumor, along with its asymptomatic presentation and poor prognosis, supports the claim that further research is needed to achieve early detection and better outcomes.
23 Serially Molecular Testing of Pancreatic Cyst Fluid Over Time: Progression and Regression
Authors: Toney Nicole A. , Jackson Sara A. , Narick Christina M. , Finkelstein Sydney D.
Published: October 2019

INTRODUCTION:

Currently, guideline recommended surveillance of pancreatic cysts is based on low quality evidence, as the natural history of such lesions is not well understood. Our study aimed to review pancreatic cystic lesions serially tested by an integrated molecular pathology (IMP) to better understand their natural history and their resulting risk classifications over time.

METHODS:

We conducted retrospective data review of patients that underwent ≥2 endoscopic ultrasound-guided fine needle aspirations (EUS-FNAs) of their pancreatic cyst, each of which had IMP testing as part of standard of care (PancraGenTM, Interpace Diagnostics) between April 2012–March 2019. The four category IMP result classifies pancreatic cysts as either low risk (Benign and Statistically Indolent [SI]), moderate risk (Statistically High Risk [SHR]) or high risk (Aggressive).

RESULTS:

2,167 pancreatic cysts underwent serial IMP testing. The median number of serial tests performed was 2. The majority of cysts serially tested had time intervals between <1 year and 1–2 years (66%, 1,442/2,167), with 10% (208/2,167) having testing with a >4 year time interval (Table 1). Among cases serially tested, 86% initially had a low risk IMP result of which 92% remained low risk at follow-up EUS-FNA while 8% progressed to a moderate/high risk IMP classification. 99% of diagnostic progression was only to moderate risk IMP. Conversely, among cases serially tested, 14% initially had moderate/high risk IMP results of which 21% remained moderate/high risk at follow-up while 79% regressed to low risk IMP classification. >99% of diagnostic regression was from moderate risk IMP.

CONCLUSION:

Examining molecular progression and regression of pancreatic cysts over time can lead to a better understanding of their natural history, which can help guide surveillance intervals. The majority of cases (92%) that initially had low risk IMP results remained low risk overtime, supporting less frequent surveillance intervals. Of those that progressed, 99% were only to moderate risk levels where diagnostic regression most often occurs.
26 Outcomes of Acute Pancreatitis in Liver Transplant Patients. A Nationwide Readmission Database Analysis
Authors: Gad Mohamed , Simons-Linares Roberto , Saad Anas , Saleh Mohannad Abou , Chahal Prabhleen
Published: October 2019

INTRODUCTION:

Acute pancreatitis (AP) is a well-recognized and generally serious complication following liver transplantation. We sought to assess AP following adult liver transplantation to describe the risk factors, natural history of the disease and outcomes.

METHODS:

Data from Nationwide Readmission database from 2010 to 2015 was analyzed. All adult patients who were hospitalized for a primary diagnosis of acute pancreatitis were identified and patients who had a history of liver transplantation were compared to patients with no transplantation, using the appropriate ICD 9 codes. Continuous variables were expressed as means ± standard deviation or median (IQR), and categorical variables were expressed as percentages. All statistical tests were two-sided.

RESULTS:

1,575,148 AP patients were included, and out of those 1581 patients (0.1%) had a history of liver transplantation. Patients with a history of transplantation had higher rates of hypertension 59.1% vs. 53.8%, P-value < 0.001, uncomplicated diabetes mellitus, 32.6% vs. 22.9%, P-value < 0.001, diabetes mellitus with chronic complications, 5.8% vs. 3.8%, P-value < 0.001, chronic pancreatitis, 18.2% vs. 16.1%, P-value = 0.02, chronic renal failure 39.6% vs. 7.9%, P-value < 0.001. Transplant patients had higher rates of in-hospital AP complications: acute kidney injury 20.3% vs. 8.3%, P-value < 0.001, transfusion requirement 7.2% vs. 3.0%, P-value < 0.001. No significant difference in the rates of systemic inflammatory response syndrome (SIRS), 2.1% vs. 2.1%, P-value = 0.929, or ileus, 4.0% vs. 3.7%, P-value = 0.595. Transplant patients had lower rates of acute respiratory distress syndrome and/or ventilation need, 0.6% vs. 2.3%, P-value < 0.001, and sepsis 0.5% vs. 1.6%, P-value < 0.001. In-hospital mortality was higher in patients with history of liver transplantation 0.8%vs. 0.3%, P-value = 0.053. Median length of stay was not significantly different 3.00 (2–6) days vs. 3.00 (2–5), P-value = 0.17. Charges of hospitalization were significantly higher in the transplantation group 23,615 USD vs. 21,020 USD, P-value < 0.001.

CONCLUSION:

Post-liver transplant AP carries significant morbidity and mortality. The extensive nature of the anatomical dissection around the pancreas, the type of biliary reconstruction and anastomosis, chronic immunosuppression medications, associated comorbidities, could be contributing factors. Our study highlights possible areas for further investigation in the liver transplant population.
32 Outcomes of Pancreatic Cancer Surveillance in High Risk Individuals
Authors: Kwon RIchard , Dust Henry , McCarthy Sean , Hosmer Amy , Carulli Alexis , Scheiman James , Koeppe Erika , Anderson Michelle , Stoffel Elena
Published: October 2019

INTRODUCTION:

Consensus guidelines recommend surveillance for pancreatic cancer (PC) for individuals who meet specific high-risk criteria, however outcome data are lacking. We report findings of pancreatic surveillance in individuals at high risk for PC.

METHODS:

Subjects at high risk for PC were identified through the Cancer Genetics Registry at the University of Michigan. High risk individuals (HRI) included the following: 1) familial pancreatic cancer (FPC) defined as ≥3 relatives, or 2 first degree relatives with PC, 2) pathogenic germline variant in BRCA1/BRCA2, PALB2, ATM or Lynch Syndrome (LS) DNA Mismatch repair genes (LS) with ≥1 relative affected with PC or 3) pathogenic germline variant in CDKN2A, STK11, or PRSS1. Results of pancreatic imaging tests were ascertained through chart review.

RESULTS:

121 patients (65 FPC, 20 CDKN2A, 13 LS, 10 ATM, 6 STK11, 4 BRCA, 2 PALB2,1 PRSS1) underwent ≥1 pancreatic imaging tests. Mean age at first screening was 56 ± 10 y with mean of 4 exams per subject (range 1–16). 53 (44%) subjects had abnormalities noted on exam, including parenchymal abnormalities in 28 (53%), cystic lesions in 20 (38%) and ductal abnormalities in 3 (6%). 29 (24%) patients had worrisome findings associated with increased risk for PC (multiple cysts (21), possible solid mass (5), dilated main pancreatic duct (3), cyst >3cm (2)). Of these, there were 13 patients (23%) with a germline mutation (5 CDKN2A, 3 ATM, 2 LS, 2 STK11, 1 PRSS1) versus 16 FPC pts (24%) (P = NS). Seven (24%) patients underwent surgical resection after median 1.9 y (range 0.6–8.6 y) surveillance (indication = mass (2), main duct involvement (3), cyst >3 cm (2)) (Table 1). Pathology revealed PC (1), main duct IPMN with high grade dysplasia (1), neuroendocrine tumors (2, both with IPMN), IPMN with low grade dysplasia (2), and chronic pancreatitis (1). In our cohort, there was one other patient (LS) with PC (a 2cm mass found on initial imaging (MRI); pt now undergoing treatment). The remaining 21 pts are cancer-free with mean 4.3 ± 3.8y follow up.

CONCLUSION:

One in 4 high risk individuals have worrisome pancreatic lesions. The presence of a mass, main duct dilation, and cyst size appear to be the most important findings. Further studies are necessary to better stratify patients and imaging findings at highest risk for progression to PC.
38 Does Cannabis Consumption Impact Chronic Pancreatitis Related Complications?
Authors: Mbachi Chimezie , Wang Yuchen , Barkin Jodie A. , Demetria Melchor V. , Barkin Jamie S. , Kroner Paul T. , Simons-Linares Roberto
Published: October 2019

INTRODUCTION:

Chronic pancreatitis (CP) does not currently have a cure and it leads to multiple complications (pain, exocrine pancreatic insufficiency, steatorrhea, bone disease), its management is still a challenge. There is evidence that stimulating the endocannabinoid system may reduce inflammation and fibrosis in pancreatic stellate cells. Cannabis is the most frequently used recreational drug in the US and in recent years its legalization has increased. There are currently multiple States in the US that have approved medical cannabis for CP. We investigate the prevalence and outcomes of CP-related complications amongst cannabis-exposed (CE) and non-cannabis-exposed (non-CE) CP patients.

METHODS:

The National Inpatient Sample (NIS) database from 2005 to 2014 was queried for all patients with a primary or secondary discharge diagnosis of chronic pancreatitis as per the International Classification of Diseases 9th revision (ICD-9) code 577.1 and a complication related to chronic pancreatitis. Active exposure to cannabis was ascertained based on ICD-9 code 304.3X and 305.2X. We compared CE vs. non-CE patients. Outcomes included pancreatic cancer diagnosis, biliary stricture, pancreatic duct stricture, cholangitis, endoscopic retrograde cholangiopancreatography (ERCP) use for either diagnostic or therapeutic purpose. Propensity match analysis for age, gender, race, median income quartile, hospital characteristics and Elixhauser comorbidity index and multivariable logistic regression models were performed using SAS software (STATA 14).

RESULTS:

109,326 patients with CP were analyzed (Figure 1). Prevalence of CE was 2.2% (2360 patients). The mean age of CP patients was 49. When comparing CE vs. non-CE, the CP-related complications amongst matched cohorts were as follows chronic abdominal pain 5.2% vs 0.3% (P < 0.001), steatorrhea/diarrhea 1.2% vs 13.5% (P < 0.001), biliary stricture 0.3% vs. 7.1% (P < 0.001), pancreatic cancer 0.4% vs. 11.8% (P < 0.001), cholangitis (0.1% vs 2.6%; P < 0.001), pancreatic cancer (0.4 vs 11.8; P < 0.001). Cannabis users also required less diagnostic ERCP (1.4% vs 5.5%; P < 0.001) and therapeutic ERCP (3.5% vs 9.3%; P < 0.001) (Figure 2).

CONCLUSION:

In CP patients admitted to the hospital, CE patients had lower rates of CP-related complications and importantly pancreatic cancer. These effects could possibly be through the effect of cannabis in the endocannabinoid system as previously shown in mice studies in Germany. More studies are needed to corroborate our findings.
46 Comparison of Endoscopic Ultrasound Fine-Needle Aspiration and Fine-Needle Biopsy for Solid Pancreatic Masses
Authors: Woldesellassie Fitsum , Cristian Rios , Ganguli Surosree , Thomas Chandler , Furmanek Stephen , McClave Stephen , Omer Endashaw
Published: October 2019

INTRODUCTION:

The superiority of endoscopic ultrasound (EUS) guided fine needle biopsy (FNB) over fine needle aspiration (FNA) in sampling pancreatic solid masses is still controversial. FNA samples are relatively small and sometimes required increased number of needle passes to obtain a sample with preserved architecture.

METHODS:

Medical records of 182 patients who underwent ultrasound guided EUS with FNA and/or FNB of pancreatic lesions from University Louisville Hospital were reviewed in this retrospective study. Only those patients who had pancreatic solid mass lesions as pre-procedure diagnosis were included. Size of the lesions were classified in three groups: 0–1 cm, > 1 cm–2 cm, >2 cm. Adequacy of samples were determined by a pathologist. Post-procedure readmissions and/or ER visits, up to one month after EUS, were obtained from University of Louisville medical records. Welch Two sample t-test analysis was performed to assess the relationship between the number of passes and the technique used for biopsy. A P-value < 0.05 deemed statistically significant.

RESULTS:

78 patients were included in analysis. The average age was 63 and males represented 59% of the total population. 64% of the lesions were localized on the head, 16% in the tail, 11% in the body, and 9% in the neck of the pancreas. Size of most of the lesions were >2 cm (74%) and >1 cm–2 cm (19%). The mean number passes was 4, SD = 2. Compared with FNA, FNB did not require significantly lower number of passes (3.58 vs 4.36, 95% CI: −0.49, 2.06; P = 0.216). FNA was performed in 41% of the cases. From all the specimens submitted to pathology, there were 0 unsatisfactory specimens in the FNB group, and 2 (7%) unsatisfactory specimens in the FNA group (P = 0.161). From suspected malignant lesions, FNA could detect 31% of malignant neoplasms, and FNB 41%. Six patients required ER visit/Hospital admission after the procedure, but only 3 patients were admvitted for problems related to the procedure (pancreatitis, intractable nausea and abdominal pain).

CONCLUSION:

There is no difference between the number of passes between EUS-FNA and EUS-FNB for pancreatic solid masses.
57 Risk of Venous Thromboembolism in Acute Necrotizing Pancreatitis: A Population-Based National Study
Authors: Ahmad Dina , Wong Richard C. , Smith Zachary L.
Published: October 2019

INTRODUCTION:

Studies on the incidence of venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism (PE), in patients with acute pancreatitis (AP) with or without necrosis are scarce. We conducted a population-based national study to evaluate the incidence of VTE and PE in patients with AP using a large database.

METHODS:

Data were extracted from a large database which incorporates 26 major integrated healthcare systems and over 300 hospitals in the United States (Explorys, Cleveland, OH). Using Systematized Nomenclature of Medicine (SNOMED) codes we identified patients with a diagnosis of acute pancreatitis with and without necrosis in the year 2018. The primary outcome was the incidence of index (first-ever) VTE at 7-days after diagnosis of AP. Patients with a prior history of VTE were excluded. Secondary outcomes included rates of sepsis, mechanical ventilation, intensive care unit admission, acute kidney injury, need for dialysis, and all-cause mortality. Univariate analysis was performed; P value < 0.05 was considered statistically significant.

RESULTS:

A total of 10,840 cases of acute necrotizing pancreatitis (ANP) and 65,960 cases of AP without necrosis were identified. Cohort demographics and outcomes are shown in Table 1. At 7 days after onset of ANP, VTE occurred at a rate of 18.5%, compared with 5.9% in AP without necrosis (OR 2.75, 95% CI 2.64–2.87, P < 0.01), while PE occurred at a rate of 2.3% in ANP vs. 0.4% in AP without necrosis (OR 6.2, 95% CI 5.20–7.41, P < 0.01) (Figure 1). In the setting of ANP, VTE was associated with a significantly higher all-cause mortality (follow-up 121–485 days) (OR 1.54, 95% CI 1.36–1.73, P < 0.01). In ANP cohort, univariate analysis demonstrated significantly higher associations of VTE with baseline smoking, alcohol consumption, and elevated BMI. Secondary outcomes including sepsis, intensive care unit admission, mechanical ventilation, acute kidney injury, and the need for dialysis, were all significantly associated with the development of VTE in ANP (Table 1).

CONCLUSION:

Patients with ANP have a near 3-fold risk of VTE, and a 6-fold risk of PE, compared to those with AP without necrosis. The development of VTE in the setting of ANP is associated with higher all-cause mortality. This study was unable to assess whether early pharmacologic VTE prophylaxis would improve outcomes. A large prospective study would aid in investigating the effect of this intervention.
60 The Utility of Inflammatory Markers to Predict Adverse Outcome in Acute Pancreatitis: A Retrospective Study in a Tertiary Care Academic Center
Authors: Mubder Mohamad I. , Dhindsa Banreet , Nguyen Danny , Saghir Syed , Cross Chad , Makar Ranjit , Ohning Gordon
Published: October 2019

INTRODUCTION:

Acute pancreatitis (AP) is a commonly encountered emergency where early identification of severe complicated cases is important. Inflammatory markers like lymphocyte to monocytes ratio (LMR) and Neutrophil to Lymphocytes ratio (NLR) have been utilized as a prognostic tool in various medical condition. In this study, we are evaluating the prognostic values of these markers in Acute pancreatitis and the optimal ratio of severity prediction.

METHODS:

A retrospective chart review of patients admitted to an academic center with the diagnosis of Acute pancreatitis between August 2015 to September 2018. The patients were identified using ICD-10 codes. LMR and NLR were calculated and compared between complicated AP and non-complicated AP on admission and with change through time over 48 hours. Severity defined using revised Atlanta classification. Descriptive statistics and models were calculated using SPSS software (IBM; v. 25). Epidemiological measures and their associated confidence intervals were calculated using MedCalc (v. 18).

RESULTS:

A total of 239 out of 426 patients were eligible to be included. 41 patients had a complicated AP. The LMR showed a significant difference between groups, with the non-complicated cases consistently higher than the complicated cases on admission (F = 11.34, P = 0.001), But there were no significant temporal differences (F = 1.48, P = 0.232) (Figure 1). The NLR showed a significant difference between groups, with the non-complicated cases consistently lower than the complicated cases on admission (F = 23.11, P < 0.001) and through time on day 1 and day 2 post admission (F = 3.88, P = 0.040), with significant differences notable at both post-admission days (P < 0.05; Figure 2). Cut points for potential clinical use were investigated using the bound of the 95% confidence interval separating the two groups. LMR cut-point <2 indicating a complicated case and NLR cut-point >10.5 indicating a complicated case. Overall sensitivity was low (23–69%); however, specificity was high (85–92%). Hence, these cut-points were very good at discerning non-complicated cases (Table 1).

CONCLUSION:

Our data show persistently low LMR is associated with severe AP and value <2.0 can be used clinically to predict the severity of AP on admission. It also shows elevated NLR is associated with complicated AP and prolonged ICU stay with a value >10.5 can be used to predict severe complicated AP throughout the admission.
70 A 20-Year Outcomes' Study of Patients With Immunoglobulin G4-Related Sclerosing Cholangitis: The Mayo Clinic Experience
Authors: Ali Ahmad H. , Bi Yan , Machicado Jorge , Garg Sushil , Carey Elizabeth J. , Lindor Keith D. , Tabibian James H. , Chari Suresh T.
Published: October 2019

INTRODUCTION:

Immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) has been recognized worldwide. However, its natural history and long-term outcomes are not well known.

METHODS:

In this retrospective, single center, cohort study, we identified patients who received a diagnosis of IgG4-SC at Mayo Clinic Rochester from 1999 to 2018. The diagnosis of IgG4-SC was rigorously ascertained by review of medical records and using the validated HISORt criteria. Comprehensive clinical data was extracted from patients' charts. Long-term outcomes of interest included cirrhosis, cholangiocarcinoma (CCA), and death. To compare outcomes, a random sample of PSC patients was selected in a 1:1 ratio matched for age of diagnosis and gender. Survival analyses were performed for comparisons using the Kaplan-Meier method, and log-rank test, and the cumulative incidence of cirrhosis and CCA was assessed using the competing risks regression method.

RESULTS:

A total of 61 patients were diagnosed with IgG4-SC during the study period. The median age of diagnosis was 66 years (IQR: 56–71 years), 85% were male, and the median follow-up was 6.1 years (IQR: 3.2–8.3 years). The pancreas was the most commonly involved extra-biliary organ (93%). Fifty-five patients received prednisone of whom 96% experienced complete or partial remission. Sixteen patients received rituximab as maintenance therapy, of whom 88% maintained remission. Three patients (5%) developed cirrhosis, and 2 patients (3%) developed CCA. Nine patients (15%) died; 2 due to cirrhosis, 2 due to CCA, 1 due to pancreatic cancer, and 4 due to non-hepatobiliary causes. Patients with IgG4-SC had significantly lower 5- and 10-year cumulative incidence of developing cirrhosis (5 y: 4% vs. 34%; 10 y: 6% vs. 43%; P < 0.001) and CCA (5 y: 3% vs. 17%; 10 y: 4% vs. 22%; P = 0.012) compared with PSC patients. Two patients in the PSC group underwent liver transplantation, while none in the IgG4-SC group. Overall 5- and 10-year survival was greater in the IgG4-SC cohort (5 y: 92% vs. 70%; 10 y: 77% vs. 57%; P = 0.02).

CONCLUSION:

Patients with IgG4-SC, the majority of whom received treatment, have a small potential risk of long-term hepatobiliary complications. Their risk of cirrhosis, CCA and death, was lower than in patients with PSC. The better outcome in the IgG4-SC group is likely due to the benefit of treatment. Surveillance in this population needs further assessment, especially the subset that does receive or respond to treatment.
83 The Pancreatitis Activity Scoring System Predicts Post-Intervention Outcomes and Early Readmission in Patients With Infected Pancreatic Necrosis
Authors: Thiruvengadam Nikhil , Miranda Janille , Masadeh Maen , Arain Mustafa
Published: October 2019

INTRODUCTION:

The Pancreatitis Activity Scoring System (PASS) score comprises of five weighted components (organ failure, SIRS, abdominal pain, opiate requirement, and oral intake), and has been externally validated to predict readmission and development of moderate to severe acute pancreatitis (AP). Our aim was to study the predictive role of PASS score (PS) in patients with suspected or confirmed infected pancreatic necrosis (IPN).

METHODS:

Consecutive inpatients with IPN requiring intervention treated at UCSF January 2011 through January 2019 were identified. PSs were calculated at admission, prior to and 72-hours after each intervention, and at discharge. Multivariable logistical regression was used to assess the relationship between PS and various outcomes; development of multi-organ failure (MOF), need for early re-intervention (<1 week) and 30-day readmission.

RESULTS:

67 patients (median age 54) were identified; organ failure rates were 55% respiratory, 60% shock, and 72% renal. Median admission PS was 440 (IQR 345–605). 38 patients underwent surgical therapy and 29 underwent step-up endoscopic therapy; median admission PSs were similar (405 vs 460, P = 0.62). A 20% reduction in the baseline PS at 72 hours post-intervention was associated with a lower rate of MOF development (aOR 0.01; 95% CI: 0.001–0.13, P < 0.001) and early re-intervention (aOR 0.03; 95% CI: 0.003–0.16, P < 0.001). The 72-hour post-intervention PS (AUC = 0.88) was superior to admission PS, post-intervention SIRS or pain score (AUC = 0.66, 0.51, 0.43, respectively P < 0.001) for the prediction of development of MOF. Discharge PS < 250 was associated with 89% lower odds of 30-day readmission (aOR 0.11; 95% CI: 0.03–0.46, P = 0.002) and the discharge PS (AUC = 0.88, Figure 1) had superior prediction of readmission compared to discharge pain or admission PASS scores (AUC = 0.66 and 0.60, respectively P < 0.001).

CONCLUSION:

In this retrospective cohort study, the PASS score was associated with post-intervention clinical outcomes and early readmission suggesting it is a valid measure of disease activity in patients with infected pancreatic necrosis. Prospective studies are needed to further validate these results.
87 Comparison of EUS-Guided Fine-Needle Aspiration Alone Versus Combined Fine-Needle Aspiration and Fine-Needle Biopsy in the Diagnostic Evaluation of Solid Pancreatic Lesions
Authors: Wadhwa Vaibhav , Gonzalez Adalberto , Singh Harjinder , Ahmed Ishtiaq , Erim Tolga , Sanaka Madhusudhan R.
Published: October 2019

INTRODUCTION:

Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is the standard method to obtain tissue sample for diagnosis of solid pancreatic masses but has variable accuracy. Endoscopic ultrasound guided fine needle biopsy (EUS-FNB) is a new technique that has been shown to have higher diagnostic yield compared to EUS-FNA. In October 2016, one of the authors (MS) began performing a combination of both FNA and FNB for solid pancreatic masses using a single 22 g Shark-core needle for possible higher diagnostic yield. Our study aims were to compare the diagnostic yield of combined EUS-FNA plus FNA versus EUS-FNA alone in solid pancreatic lesions.

METHODS:

We performed a retrospective chart review on all patients who underwent endoscopic ultrasound (EUS) by a single operator (MS) at Cleveland Clinic between 2015–2018. We included all adult patients who underwent either EUS-FNA or EUS-FNA + FNB for solid pancreatic or peripancreatic masses for the first time. Our primary outcome was to compare the diagnostic yield between the two groups (EUS-FNA versus EUS-FNA + FNB). EUS-FNA was performed using a 22-gauge needle (Boston Scientific) and EUS-FNA + FNB was performed using a 22-gauge Shark-core needle (Medtronic). Diagnostic yield was defined as the proportion of patients in whom a definitive tissue diagnosis was established from EUS sampling. The diagnostic accuracy was defined as the proportion of true positive and true negative EUS sampling results. P < 0.05 was considered significant.

RESULTS:

A total of 544 patients underwent EUS during the study period, of which 78 patients met the inclusion criteria. Of these 78 patients, 44 patients underwent EUS-FNA and 34 patients underwent EUS-FNA + FNB. EUS-FNA + FNB had a statistically significant higher diagnostic yield compared to EUS-FNA (97.1% vs. 72.7%; P = 0.02). EUS-FNA + FNB also had a higher diagnostic accuracy than EUS-FNA, but this was not statistically significant (P = 0.13). The number of needles passes were lower in the combined FNA + FNB group compared to FNA group (4 vs 5, P = 0.005). There was no significant difference in procedure duration between the two groups.

CONCLUSION:

Our study showed that combined EUS-FNA + FNB had higher diagnostic yield and required lower number of needle passes compared to EUS-FNA alone for solid pancreatic masses. EUS-FNA + FNB also had higher diagnostic accuracy; although this was not statistically significant. Based on our study findings, we suggest considering the combination of EUS-FNA + FNB for solid pancreatic lesions.
91 Colon Involvement in Necrotizing Pancreatitis—Incidence, Predictors and Outcomes From a Single Tertiary Care Center
Authors: Dirweesh Ahmed , Choo Christopher , Amateau Stuart , Azeem Nabeel , Mallery Shawn , Freeman Martin , Trikudanathan Guru
Published: October 2019

INTRODUCTION:

Colonic involvement significantly impacts the clinical course of necrotizing pancreatitis (NP) and reported in 6–40%. The spectrum of colonic complications includes fistula, strictures and ischemic colitis. The study aimed to determine the incidence, risk factors and clinical outcomes of colonic involvement of NP managed in our institution.

METHODS:

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

RESULTS:

Colonic involvement occurred in 20 (3.9%) of the 515 NP patients managed during the study period, with colon fistulation detected in 12 (2.3%), strictures in 6 (1.2%) and ischemic colitis in 2 (0.4%). Males were predominantly involved [16 (80%)]. The median (range) age was 56 (23–84) years and alcohol was the main etiology of pancreatitis [10 (50%)]. All patients had extensive pancreatic and extra-pancreatic necrosis, with average BISAP score of 3 and modified Marshall score of 5. Infected necrosis noted in 18 (90%) patients. Subsequently, all underwent endoscopic and/or percutaneous drainage. Fistulae involved the left colon (mainly splenic flexure) in 9 (69.2%) and the right colon in 4 (30.8%) patients. While spontaneous closure occurred in 7 (53.8%); 4 (30.8%) were managed with over the scope clips and 2 (15.4%) surgically. Clinical outcomes were successful in 11 (92%) and all-cause mortality was 2 (17%). Colonic strictures and ischemia were managed conservatively in 3 (37.5%) subjects; 3 (37.5%) had stent placement, 1 (12.5%) underwent balloon dilation, and 1 (12.5%) underwent right sided hemicolectomy. Outcome was successful in all 8 (100%) patients.

CONCLUSION:

Male gender, obesity, alcohol etiology, infected necrosis, extensive pancreatic and extra-pancreatic involvement, and need for adjuvant percutaneous drainage may be predictors for development of colon complications in NP. Majority resolved conservatively after complete debridement of necrotic collection, some needed endoscopic management and very few needed surgical interventions.
98 Combination Rectal Indomethacin and Topical Epinephrine Is Not Superior to Rectal Indomethacin in the Prevention of Post-ERCP Pancreatitis—A Meta-Analysis
Authors: Laoveeravat Passisd , Perisetti Abhilash , Vutthikraivit Wasawat , Wongjarupong Nicha , Garcia-Saenz-de-Sicilia Mauricio , Inamdar Sumant , Garg Shashank , Thandassery Ragesh , Tharian Benjamin
Published: October 2019

INTRODUCTION:

Post Endoscopic Retrograde Cholangiopancreaticography Pancreatitis (PEP) remains one of the major complications despite the advances. Several medications have been used in an attempt to prevent PEP. The efficacy of rectal indomethacin (RI) and topical epinephrine (TE) has been proved. However, the role of combination of epinephrine and indomethacin in PEP prevention has not been extensively explored. We aimed to determine the efficacy of combined RI and TE compared to RI alone for PEP prevention in high risk patients.

METHODS:

We searched the databases of MEDLINE, EMBASE, and CENTRAL from inception to May 2019. The inclusion criteria were published randomized controlled trials comparing the efficacy of PEP prevention between patients receiving combined RI and TE vs. RI alone in high risk patients. The outcome of interest was the rate of PEP occurrence. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate pooled risk ratio (RR) and 95% confidence intervals (CI). I2 statistics was used to assess heterogeneity among studies, with I2 >50% indicates significant heterogeneity.

RESULTS:

Three randomized controlled trials met our inclusion criteria and were included in the meta-analysis and reported a total of 772 and 728 patients in RI alone and combined RI and TE group, respectively (Table 1). The occurrence of PEP in combined RI and TE group is comparable to RI group with pooled RR of 1.10 (95% CI: 0.58–2.08, I2 = 47%) (Figure 1). Studies did not stratify PEP based on the severity and hence a subgroup analysis could not be performed in this meta-analysis.

CONCLUSION:

Based on the results from RCTs, combination of RI and TE do not give additional benefit to RI alone for PEP prevention in high risk patients for post ERCP pancreatitis. The mechanism of action of these two medications are different but the effects are not synergistic. The single use of each medication is effective to prevent PEP. Further RCTs are required to confirm our finding in high-risk patients.
108 Hypertriglyceridemia-Induced Pancreatitis Results in Favorable Outcomes Despite Greater Predicted Severity on Admission
Authors: Yeh Jeffrey , Lee Alice A. , Ko Christopher , Quezada Michael , Sahakian Ara , Lee Helen , Buxbaum James L.
Published: October 2019

INTRODUCTION:

Hypertriglyceridemia-induced acute pancreatitis (HP) has been reported to have a more severe presentation and clinical course compared to other types of pancreatitis. Our aim was to determine if HP has a different predicted and actual clinical course than pancreatitis from other etiologies.

METHODS:

We analyzed a cohort of 455 consecutive patients admitted for acute pancreatitis to the Los Angeles County (LAC) Hospital between March 2015 and March 2017. Comprehensive characterization included pancreatitis etiology, substance use history, biochemical profile, and detailed clinical course. Predicted severity was defined using the Glasgow, Ranson, Pancreatitis Activity Scoring System (PASS), and systemic inflammatory response syndrome (SIRS) scores. Clinical outcomes included the development of local complications (pseudocyst, necrosis, walled-off necrosis), SIRS, organ failure, length of hospitalization, and days until oral nutrition tolerated. At LAC, patients with HP are admitted to a monitored care unit and managed with aggressive hydration and insulin. They are followed by endocrinology for lipid control and by hematology to initiate plasmapheresis if indicated.

RESULTS:

HP was identified in 17 patients and was the fifth most common etiology, behind gallstones (N = 219), alcohol (N = 120), medication-induced (N = 38), and idiopathic pancreatitis (N = 20) (Figure 1). HP patients had an average age of 37 with 71% having diabetes. HP patients were more likely to have had a prior history of pancreatitis (OR 13.5, 95% CI 4.6–39). HP patients were predicted to have more severe disease at admission based on the Glasgow and PASS scores and were more likely to have SIRS on admission (OR 5.7, CI 2.0–15.8). Despite having greater predicted severity, logistic regression analysis revealed that patients with HP were not more likely to develop local complications, SIRS after admission, or organ failure. Linear regression modeling also indicated that HP patients did not have a significantly longer length of hospitalization or time to tolerate oral intake (Table 1).

CONCLUSION:

Hypertriglyceridemia-induced acute pancreatitis patients are more likely to have SIRS on admission and are predicted to have a more severe clinical course based on validated scoring systems. However, with close multidisciplinary management including endocrinology and hematology consultations when indicated, these patients do not have a more adverse course relative to those with pancreatitis from other etiologies.
109 Persistent Hemoconcentration After Initial Resuscitation Is Associated With Increased Need for Opiates in the ED in Patients Presenting With Acute Pancreatitis
Authors: Yang Allison L. , Jin David X. , Banks Peter A. , McNabb-Baltar Julia
Published: October 2019

INTRODUCTION:

Opiates are commonly used in the management of abdominal pain in acute pancreatitis (AP). The factors associated with increased need for opiates during the initial management are unknown.

METHODS:

Medical records of adults presenting to the ED from 9/1/2013 to 8/31/2016 with AP were identified retrospectively. AP was diagnosed, and severity stratified using the revised Atlanta Classification (2012). Total quantity of opiates required during ED phase of care was converted to morphine equivalents (ME) and divided by number of hours in the ED to get mean ME per hour in the ED (MME). Log-linear multivariable regression analysis was performed to identify factors associated with MME. Hemoconcentration was defined as hematocrit ≥44%.

RESULTS:

318 AP patients were identified. 248 received opiates in the ED. Baseline characteristics are shown in Table 1. At ED presentation, 75 (30.65%) had at least 2 SIRS criteria and 46 (18.55%) had hemoconcentration. On the second set of labs (still within 24 hours of ED arrival), 11/46 (23.9%) remained hemoconcentrated and 2 developed hemoconcentration despite resuscitation. The distribution of mean ME per hour in the ED (MME) ranged from 0.12 mg to 24.81 mg. Mean MME was 2.15 mg (SD = 2.54). Simple linear and multivariable regression analyses are shown in Table 2. Age and first episode of AP were independently associated with less MME. After exponentiation, for every 1-year increase in age, a 1% decrease in MME was observed. Patients with the first episode of AP required 34.9% less MME compared to those with prior AP. On subgroup analysis of patients who were opiate naïve at presentation (N = 193), first episode of AP was still associated with less MME (b-coefficient −0.4024, P = 0.0025); they required 33.1% less MME compared to those with prior AP. Hemoconcentration after initial resuscitation (but within 24 hours of presentation) was associated with increased MME. Patients with hemoconcentration on the second set of labs required 95% higher MME compared to those without hemoconcentration. Increasing number of SIRS criteria was also associated with increased MME; one additional SIRS criteria was associated with a 15% increase in MME.

CONCLUSION:

Persistent or new hemoconcentration within 24 hours of presentation is associated with increased opiate requirement in the ED in patients with AP. This suggests that inadequacy of initial fluid resuscitation to correct intravascular fluid losses may lead to increased pain and need for opiate medications.