bluuebunny/crossref_metadata_2025 huggingface dataset:
Pengalaman Transplantasi Ginjal pada Anak di Jakarta
Authors: Pardede Sudung O. , Hidayati Eka Laksmi , Ambarsari Cahyani Gita , Puspitasari Henny Adriani , Trihono Partini P. , Tambunan Taralan
Published: October 2019

Latar belakang.Transplantasi ginjal merupakan terapi yang efektif untuk penyakit ginjal kronik (PGK) stadium 5 atau gagal ginjal terminal. Transplantasi ginjal di dunia pertama kali dilakukan pada tahun 1950an. Di Indonesia, transplantasi ginjal pada orang dewasa telah dilakukan pada tahun 1977 dan semakin berkembang dan telah dilakukan di beberapa kota di Indonesia. Transplantasi ginjal pada anak pertama kali dilakukan di Rumah Sakit Dr. Cipto Mangunkusomo pada bulan Maret 2013, terhadap seorang anak lelaki berusia 13 tahun dengan gagal ginjal terminal yang disebabkan sindrom nefrotik, dengan ginjal yang diperoleh dari non-related living donor. Ini merupakan transplantasi ginjal yang pertama kali dilakukan pada anak di Indonesia.Tujuan. Melaporkan data tentang kegiatan transplantasi ginjal yang dilakukan di Jakarta.Metode. Penelitian ini merupakan penelitian retrospektif yang mengambil data dari catatan medis. Hingga tahun 2018 telah dilakukan 11 kali transplantasi ginjal pada 10 orang anak terdiri atas 9 laki-laki dan 1 perempuan, dengan 1 kasus re-transplan. Rentang usia adalah 8-18 tahun, dengan penyakit dasar terdiri atas sindrom nefrotik (3 anak), dan ginjal hipoplasia (7 anak). Donor untuk kesebelas transplan anak tersebut terdiri atas 4 non-related living donor dan 7 orang related living donor, yaitu 5 orang donor ayah dan 2 orang donor ibu. Hasil. Di antara 10 pasien transplan, 3 orang menggunakan biaya pribadi atau asuransi swasta dan 8 orang dengan biaya dari Badan Penyelenggara Jaminan Sosial (BPJS). Hingga bulan Agustus 2018, di antara kesepuluh anak tersebut, 7 orang hidup dan di antaranya 2 orang mengalami rejeksi pada tahun ke-3 (1 orang konversi kembali ke hemodialisis dan 1 orang telah menjalani re-transplan). Tiga pasien meninggal akibat infeksi berat.Kesimpulan. Transplantasi ginjal di Rumah Sakit Dr. Cipto Mangunkusomo dimulai pada tahun 2013, dengan donor hidup yang sebagian besar berasal dari orangtua, dengan pembiayaan sebagian besar menggunakan BPJS.
Perbedaan Status Perkembangan dan Pertumbuhan Anak dengan Penyakit Jantung Bawaan Sianotik dan Non-sianotik
Authors: Pambudi Janaka , Dhamayanti Meita , Kuswiyanto Rahmat Budi
Published: October 2019

Latar belakang. Penyakit jantung bawaan (PJB) merupakan faktor risiko terjadinya gangguan tumbuh kembang pada anak. Anak dengan PJB sianotik dan non-sianotik memiliki karakteristik klinis yang berbeda sehingga perkembangan dan pertumbuhannya juga berbeda. Tujuan. Mengetahui perbedaan perkembangan dan pertumbuhan anak dengan PJB sianotik dan non-sianotik. Metode. Penelitian berupa observasional potong lintang dengan subjek penelitian adalah anak dengan PJB usia 1–3 tahun yang datang ke pelayanan rawat jalan RSUP Dr. Hasan Sadikin pada bulan Agustus sampai Oktober 2018. Penilaian perkembangan menggunakan Ages and Stages Questionnaires-3 (ASQ-3) dan penilaian pertumbuhan dengan WHO growth chart standarts 2006. Analisis data dilakukan dengan uji hipotesis Chi-square. Hasil. Terdapat 86 subjek penelitian terdiri dari 46 perempuan dan 40 laki-laki, dengan 31 subjek merupakan PJB sianotik. Gangguan perkembangan motorik lebih banyak pada anak dengan penyakit jantung bawaan siaonotik (p<0,05). Gangguan perkembangan motroik kasar pada PJB non-sianotik dan sianotik yaitu 87,1% dan 43.6%, motorik halus yaitu 64,5% dan 38,2%. Tidak terdapat perbedaan yang signifikan pada pertumbuhan antara PJB sianotik dan non-sianotik.Kesimpulan. Gangguan perkembangan motorik kasar dan halus lebih banyak terjadi pada anak dengan PJB sianotik. Tidak terdapat perbedaan gangguan pertumbuhan pada anak dengan PJB sianotik dan non-sianotik.
Estratégias de aprendizagem e variáveis sociodemográficas de professores de licenciaturas
Authors: Jeronymo Gisele Fermino Demarque , Alliprandini Paula Mariza Zedu
Published: October 2019

Este artigo fundamenta-se na Psicologia Cognitiva/Teoria do Processamento da Informação, com ênfase no estudo de estratégias de aprendizagem utilizadas por professores universitários para aprender. Analisa a frequência do uso de estratégias de aprendizagem de professores de uma universidade do norte do Paraná em função de variáveis sociodemográficas. Participaram da pesquisa 56 professores, sendo 57,14% do sexo feminino e 42,46% do sexo masculino. A coleta de dados foi online, por meio de formulários do Google Drive. Os resultados evidenciaram que grande parte dos professores utilizam com maior frequência as estratégias de Autorregulação Cognitivas e Metacognitivas se comparado as de Autorregulação de Recursos Internos/Contextual e Social. Os participantes do sexo feminino e professores do departamento de Letras Vernáculas apresentaram-se mais estratégicos. Ressalta-se a necessidade de incluir nos cursos de licenciatura os conteúdos sobre estratégias de aprendizagem, a fim de possibilitar aos professores acesso ao conhecimento de novos modelos de ensinar a aprender.
9 Predictors of Hospital Transfer and Associated Risks of Mortality in Acute Pancreatitis
Authors: Badal Bryan D. , Kruger Andrew , Hinton Alice , Lara Luis , Papachristou George , Conwell Darwin , Krishna Somashekar
Published: October 2019

INTRODUCTION:

There is limited data available on which patients are most likely to be transferred to tertiary acute care hospitals and their outcomes in acute pancreatitis (AP). We sought to determine predictors of hospital transfer in AP from small/medium sized hospitals to other acute care hospitals and determine if those patients incur higher rates of mortality.

METHODS:

Using the Nationwide Inpatient Sample (2011–2013, age ≥18 years), patients hospitalized with AP were identified. Baseline demographic and hospital characteristics, etiology, related procedures, transfer rates, and mortality data were collected. Hospital size was defined by the Agency for Healthcare Research and Quality (Table 1). Patients with pregnancy, pancreatic neoplasms, chronic pancreatitis, and history of bariatric surgery were excluded. Two different multivariate analyses were performed.

RESULTS:

There were 381,818 patients admitted with AP to small/medium sized hospitals where the mortality rate was 0.81% (n: 3,101). The rate of “transfer-out” to acute care hospitals was 4% (n: 13,947). Multivariate analysis for the outcome of “transfer-out” from small/medium to acute care hospitals revealed that older patients (OR for a 5-year increase 1.04; 95% CI 1.03–1.06), men (OR 1.15; 95% CI 1.06–1.24), lower income quartiles (OR 1.45; 95% CI 1.33–1.59), admission to a non-teaching hospital (OR 3.38; 95% CI 3.00–3.80), gallstone pancreatitis (OR 3.32; 95% CI 2.91–3.79), pancreatic surgery (OR 3.13; 95% CI 1.76–5.56), and severe AP (OR 3.06; 95% CI 2.78–3.37) were independent predictors of transfer. ERCP (OR 0.53; 95% CI 0.43–0.66) and cholecystectomy (OR 0.14; 95% CI 0.12–0.18) were associated with decreased odds of “transfer-out.” There were 507,439 patients admitted with AP to large hospitals and 6.1% (n: 31,025) were “transferred-in” from other hospitals. The mortality rate among those transferred in was higher than those directly admitted (2.54% vs. 0.91%, P < 0.001). After adjusting for confounding factors (Table 2), being “transferred-in” from other hospitals was an independent predictor of mortality (OR 1.47; 95% CI 1.22–1.77).

CONCLUSION:

Transfer of patients with AP from lower to higher acuity of care adversely impacts mortality. Implementation of published clinical guidelines, early triage and transfer of high-risk patients can potentially offset adverse hospital outcomes.
15 Utilization Patterns of Prophylactic Pancreatic Stents for the Prevention of Post-ERCP Pancreatitis: A 2018 National Survey Study
Authors: Easler Jeffrey J. , Kandula Sailesh , Cote Gregory A. , Sherman Stuart , Gromski Mark A. , Watkins James L. , Lehman Glen , Fogel Evan L.
Published: October 2019

INTRODUCTION:

Post ERCP Pancreatitis (PEP) is the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). Prophylactic pancreatic stents (PPS) and rectal indomethacin (IND) prevent PEP, decrease severity in PEP and are endorsed by GI societies. It is unclear the extent to which these interventions are practiced throughout the United States (US). The impact of such factors as training, experience and practice setting on the use of PPS for PEP prophylaxis is unclear. The aims of our study are to describe utilization patterns and identify factors that impact physician decisions to use PPS for PEP prophylaxis.

METHODS:

A 27-question electronic survey was distributed using a cloud based program (Qualtrics). Questions assessed ERCP training, practice setting, experience, practice patterns and perceptions for PEP prophylaxis interventions. Endoscopists with practices based in the US, listed in the American Society for Gastrointestinal Endoscopy (ASGE) member directory received a survey invitation via e-mail. The invitation outlined the study and contained a link with instructions to complete the voluntary survey if they had an active ERCP practice. Data was de-identified for the purposes of analysis.

RESULTS:

Of survey respondents (n = 319/6276), 46% reported therapeutic endoscopy fellowship training and 37% practiced in teaching programs (Table 1). Annualized ERCP volume of >100 cases per year were reported by 47%, with pancreatic ERCP comprising ≤5% of procedures in the majority of respondents (61%). The majority of respondents utilized PPS and 54% reported frequent use (Table 2). The most common indications for PPS were: difficult cannulation, to assist biliary access and multiple pancreatic duct injections. The majority of respondents reported frequent use of IND (89%). Of physicians that do not use PPS, use of IND was the most common reason (80%). Variables associated with frequent use of PPS were therapeutic fellowship training (P = <0.001), practice at a teaching program (P = <0.001), <10 yrs in practice (P = 0.005), higher procedure volume (P = <0.001), higher proportion of pancreatic cases (P = <0.001), and selective use of IND (P = 0.002) (Table 3).

CONCLUSION:

Physicians with higher volume, teaching hospital based ERCP practices and regularly perform pancreatic ERCP are more likely to use PPS. Therapeutic fellowship training and recent entry into practice also associate with PPS utilization. Indomethacin use was prevalent and the most cited reason for electing not to use PPS.
33 Needle-Base Confocal Laser Endomicroscopy in the Diagnosis of Pancreas Cyst: A Systematic Review and Meta-Analysis
Authors: Angsuwatcharakon Phonthep , Cazacu Irina M. , Singh Ben S. , Rerknimitr Rungsun , Kongkam Pradermchai , Bhutani Manoop S.
Published: October 2019

INTRODUCTION:

EUS-guided needle-based confocal laser endomicroscopy (nCLE) provides real-time histology assessments and has been reported as an adjunctive tool that can be performed in the same session as EUS-fine needle aspiration. We aimed to perform a systematic review and meta-analysis regarding the diagnostic performance, success rate, and complications of nCLE in pancreas cysts.

METHODS:

This is a systematic review and meta-analysis following the PRISMA-P principles. Literature was systematically searched in February 2019 by two independent investigators in 3 major databases including PubMed, Embase, and Web of Science by using the terms “confocal endomicroscopy” AND “needle” AND “pancreas cyst.” The search was limited to English-written and in vivo human studies. Additionally, investigators manually reviewed the references of the primary identified studies for other eligible articles. The meta-analysis of success rate, complication rate, pooled diagnostic parameters with the respective 95% confidence interval (CI) of nCLE for diagnosis of pancreas cysts were performed.

RESULTS:

Of the 159 initially screened studies, 11 studies had 288 patients with pancreatic cystic lesions enrolled. The estimated overall success rate and adverse event rate with random effects model were 96% (95% CI: 92–95%) and 11% (95% CI: 7.5–16%), respectively. There were 7 studies which included 176 patients that reported the diagnostic parameters of nCLE for diagnosis of mucinous pancreas cyst. The estimated diagnostic odd ratio (DOR) was 50 (95% CI: 18.92–132.16). The estimated area under curve (AUC) was 0.939 (95% CI: 0.89–0.992) and AUC for SROC was 0.84 (95% CI: 0.72–0.98). The estimate sensitivity and specificity were 0.77 (95% CI: 0.62–0.87) and 0.91 (95% CI: 0.81–0.96), respectively. The meta-analysis estimated the prevalence rate of mucinous cysts to be 57% (95% CI: 43%–71%). The positive predictive value (PPV) and negative predictive value (NPV) were 0.91 (range: 0.86–0.95) and 0.72 (range: 0.62, 0.84), respectively. I2 index showed no heterogeneity between studies in success rate, adverse event rate, DOR, and specificity. However, heterogeneity was detected in sensitivity, PPV, and NPV between studies.

CONCLUSION:

nCLE has high sensitivity, specificity, PPV, and NPV for differentiating mucinous pancreas cyst from the other cystic lesion. However there is an increased adverse rate compared to standard EUS-FNA. Measures and methods to decrease the adverse event rate should be further investigated.
50 Prognostic Factors in Outcomes of Endoscopic Therapy for Biliary Leak Repair
Authors: Vachaparambil Cicily , Chawla Saurabh , Mekaroonkamol Parit
Published: October 2019

INTRODUCTION:

Despite advances, there is a 3–18% risk of bile leak after hepatobiliary surgery. Sepsis and repeat surgery have up to a 38% mortality rate. Therefore, endoscopic repair is preferred. This study evaluates efficacy of endoscopy and prognostic factors in success.

METHODS:

Of 41 patients who had endoscopic retrograde cholangiopancreatography (ERCP) for suspected post-surgery bile leak between 2015–19 at our hospital, 34 met inclusion with confirmed leak. Charts were reviewed for demographics, clinical and surgical parameters, ERCP findings, time to detection, to ERCP, to clinical improvement, and to resolution of bile leak. Success is defined as procedural (stent placement), clinical (improved leak), and resolution (no leak on follow-up). Two-tailed t test and chi square test were used in statistical analysis.

RESULTS:

Most patients were male (82.5%), average age 38, BMI 27, and pre-op CCI 0 (70.6%). 97.1% had emergent surgery and 67.6% had laparotomy; reasons and surgery types are in Table 1. In diagnosis, 70.6% of leaks were detected solely clinically (88% by bile in the JP drain, 21% had abdominal pain, 15% had fever, and 15% in the OR). 2.9% were found only on radiology and 26.5% were noted clinically and in imaging. Average surgery to diagnosis time was 8 days, from diagnosis to ERCP 4 days, to clinical success 8 days, and to confirmed resolution 98 days. 73.5% of leaks were identified at intrahepatic, 23.5% at cystic, and 3% at pancreatic ducts. After first ERCP, 28/34 patients had procedural and 27/34 had clinical success. 7/34 patients required further intervention following ERCP; 6 had CT guided drain and 1 had repeat surgery (Figure 1). 26/34 had confirmed resolution on repeat ERCP, while the other 8 were lost to follow up. 82.4% had no complications after ERCP; main complications were sphincterotomy site bleed, pancreatitis, further biliary injury, and infection. Median length of stay was 23.5 days among all patients.

CONCLUSION:

This study supports endoscopic repair in post-operative bile leak as safe and effective as all patients with follow-up ERCP had resolution. Surgery type and leak size may predict success. Bile leak after hepatic artery embolization/hemostasis (P = 0.024) and large bile leak (P = 0.007) were significantly more likely to need post-ERCP procedure (Table 2). A larger cohort will guide how to optimize care and warrants study.
63 Incidence of Choledocholithiasis and Its Impact on Outcomes in Patients Hospitalized With Acute Cholecystitis: A Nationwide 5-Year Analysis
Authors: Shah Rushikesh , Shah Hardikkumar , Mulki Ramzi , Qayed Emad
Published: October 2019

INTRODUCTION:

Patients with acute cholecystitis (AC) often present with laboratory and imaging findings suggestive of choledocholithiasis (CDL). There are no population studies to assess the incidence of CDL and its impact on outcomes in patients with AC. In this nationwide study, we examine the frequency of CDL in patients with acute cholecystitis, and examine the effect of choledocholithiasis on in hospital mortality, costs, and 30-day outcomes.

METHODS:

We analyzed the nationwide readmission database (NRD) from 2010 through 2014. We identified all admissions of adult patients with the principal diagnosis of acute cholecystitis. We compared hospitalizations with acute cholecystitis and choledocholithiasis (AC + CDL), with those with cholecystitis alone (AC group). Bivariate analysis was performed to compare the demographics, characteristics, and in-hospital and 30-day outcomes between the two groups.

RESULTS:

There were total of 552,207 hospitalizations for acute cholecystitis, of which 408,847 (74%) had acute cholecystitis alone (AC group) and 143,360 (26%) had coexistent choledocholithiasis (AC + CDL group). Characteristics of the groups are shown in Table 1. Patients with AC + CDL were more likely males and older than 65 (P < 0.0001). Patients with AC+CDL were more likely to have abnormal liver enzymes (1% vs. 0.7%), cholangitis (4.4% vs. 1.1%), acute pancreatitis (11.6% vs. 7.7%) and septic shock (1.7% vs. 1.1%, all comparisons P < 0.0001). ERCP was performed more commonly in AC + CDL group compared to the AC group (26.7 vs. 3.7%, P < 0.0001). Same admission cholecystectomy was more common in AC group (84% vs 38% P < 0.0001). Patients with AC + CDL had longer length of stay (4.9 vs. 4.1 days, P < 0.0001) and higher hospital costs ($15,966 vs $15,202, P < 0.0001). The AC + CDL group had higher in hospital and 30 day post-discharge mortality (4.5% vs. 1.2%, P < 0.0001) and 30-day readmission (13.6% vs. 8%, P < 0.0001), compared to the AC group.

CONCLUSION:

Approximately one in four patients with acute cholecystitis has coexistent choledocholithiasisPresence of choledocholithiasis in acute cholecystitis patients is associated with increased length of stay, hospitalization costs, in-hospital and 30-day mortality and readmissions. Further studies are needed to develop predictor models to identify coexisting CDL in patients with AC for timely diagnosis and optimizing management aimed at improving outcomes in this high risk subset of patients.
76 Hepatorenal Syndrome Carries the Highest Risk of In-Hospital Mortality Among Hospitalized Patients With Primary Biliary Cholangitis
Authors: Galoosian Artin , Hirode Grishma , Wong Robert
Published: October 2019

INTRODUCTION:

Primary biliary cholangitis (PBC) is an autoimmune and progressive cholestatic liver disease with significant morbidity and mortality. Hospitals with safety-net burden (SNB) provide an essential role to serving low-income and historically vulnerable populations. We aim to evaluate factors, including hospital SNB, associated with in-hospital mortality among hospitalizations with PBC.

METHODS:

Using the 2012–2014 National Inpatient Sample, we evaluated US adults hospitalized with PBC (using ICD-9 codes). Hospital SNB was defined as the percentage of hospitalizations among PBC with Medicaid or uninsured payer status per hospital, and was categorized into two groups: no SNB vs. any SNB. Between-group comparisons used chi-squared testing. Survey-weighted, adjusted multivariate logistic regression analysis was used to evaluate factors associated with in-hospital mortality.

RESULTS:

Among 7,364 hospitalizations with PBC (mean age 64.0 + 14.3y, 16.1% men, 70.3% non-Hispanic White), 65.3% were in no SNB and 34.7% were in low-high SNB hospitals. Crude in-hospital mortality was 4.15%, with no significant differences by hospital SNB. On adjusted regression, among the cirrhosis-related complications analyzed, the presence of ascites (OR 1.85, 95% CI 1.36–2.52, P < 0.001), hepatic encephalopathy (OR 2.32, 95% CI 1.75–3.08, P < 0.001) and hepatorenal syndrome (OR 7.58, 95% CI 5.12–11.2, P < 0.001) resulted in higher odds of in-hospital mortality compared to those without the respective complication present. Additionally, hospitalizations at urban teaching hospitals also had a higher odds of in-hospital mortality compared to rural hospitals (OR: 2.04, 95% CI: 1.20–3.46, P = 0.01).

CONCLUSION:

Hospitalizations with PBC with concomitant cirrhosis-related complications had significantly higher odds of in-hospital mortality. Specifically, PBC hospitalizations with hepatorenal syndrome were 7.6 times more likely to die during hospitalization. Urban teaching hospitals also had higher in-hospital mortality compared to rural hospitals.
81 Machine Learning Based Predictive Models Are More Accurate Than TNM Staging in Predicting Survival in Patients With Pancreatic Cancer
Authors: Das Amit , Ngamruengphong Saowanee
Published: October 2019

INTRODUCTION:

Accurate prognostic prediction is important for treatment planning in patients with pancreatic cancer (PC). Although clinical and socioeconomic factors impact patient survival, traditional prognostic evaluation methods [e.g., TNM staging] do not incorporate these factors. A more accurate and comprehensive tool is needed. We evaluated machine learning (ML) based analytic models to predict survival of patients with PC using data from the Surveillance, Epidemiology, End-Results (SEER) database.

METHODS:

The SEER database was accessed to identify patients aged ≥18 yr. with histologically confirmed PC diagnosed between 2004–2015. Demographic, socioeconomic, clinical variables (AJCC stage, site, grade, and size of the tumor, treatment received, survival in months) were extracted and analyzed. Using ML software, an ensemble of predictive analytic models (Classification Tree-based, Bayesian net, Neural net, support vector, and K-nearest neighbor classifier) was built and trained using supervised learning algorithms for prediction of 1-year survival probability. Separate models were built using only baseline variables (A model) and including treatment-related variables [surgery, chemotherapy, and radiotherapy (B model)].

RESULTS:

Data on 42,673 patients with PC were used to develop the predictive models [Table 1; mean age, 67 yr.; 52% males; 80% white; stage I/II/III/IV/unknown: 6.0%/27.7%/10.3%/52.5%/3.5%; median survival (range): 6 (2–13) months with 78% surviving ≤12 months]. Ten independent prognostic variables were identified in multivariate Cox regression analysis: year of diagnosis, tumor stage/grade, presence of metastasis, age, tumor size, marital status, insurance status, US region, socio-economic factors, and these variables were entered into the ML models. Figure 1 shows the predictive importance of the different variables used in the two models. AUROC (Area Under the Receiver Operating Characteristics) of the A and B models in predicting 1-year survival probability were 0.804 (95% CI: 0.800–0.808) and 0.832 (95% CI: 0.828–0.836), respectively, which were both significantly higher that of the TNM staging system (AUROC = 0.696; 95%CI: 0.691–0.700); P < 0.0001; Figure 2).

CONCLUSION:

Using advanced ML techniques for analyzing a large dataset, we developed predictive models that accurately predicted the survival of patients with PC and were superior to the existing TNM staging system. These models may serve as an effective tool for prognostic evaluation of PC in clinical settings.
85 Trends in the Use of TPN Among Patients Admitted With Acute Pancreatitis
Authors: Pievsky Daniel , Kabaria Savan , Shulik Oleg
Published: October 2019

INTRODUCTION:

Acute pancreatitis (AP) is a common condition impacting the gastrointestinal tract that accounts for a high amount of patient morbidity and mortality. It has long been recognized that enteral nutrition (EN) is the preferred feeding modality for patients with AP; however, parental nutrition (PN) has still been commonly used. In 2010 the Cochrane group published a meta-analysis showing the superiority of EN compared to PN in AP, but the first formal guidelines recommending against PN use in severe AP were not published until 2013. Our aim was to investigate the trends of PN use in AP and assess if the release of practice guidelines resulted in a change in clinical management.

METHODS:

We analyzed the National Inpatient Sample database for patients hospitalized with AP with and without PN from 2000 to 2014. Patients were identified using ICD 9 codes. Inclusion criteria were age ≥18, elective admission, and a primary diagnosis of AP. Trend models were fit to adjust for patient demographics, type of insurance, income quartile, Charlson Comorbidity Index, and hospital characteristics.

RESULTS:

Overall, 106,426 patients (3.41% of those hospitalized for AP) received PN. Baseline patient demographics, hospital characteristics, and insurance information are shown in Table 1. The trend of PN use by year in patients with AP can be seen in Table 2. Overall use has declined since 2007; however, the rate of decrease was greatest from 2011 to 2014, with a mean yearly decrease of 0.45%. While 55% of all patients who received PN were located at non-teaching hospitals, the percentage of hospital patients on PN was greater in teaching hospitals (3.84% vs. 3.12%, P < 0.0001). The yearly trend of PN use among teaching and non-teaching hospitals can be seen in Table 3. The mean yearly decrease in PN use from 2000 to 2014 is similar for teaching (0.18%) and non-teaching hospitals (0.17%). Since 2011, however, PN use for AP among teaching hospitals has been declining at a faster rate than among non-teaching hospitals (0.45% decrease vs. 0.41%).

CONCLUSION:

Use of PN for patients hospitalized with AP was significantly higher in teaching compared to non-teaching hospitals. This is likely due to the severity of AP treated at teaching hospitals. The greatest yearly decrease in the rate of PN use for AP was between 2011 and 2014, likely due to Cochrane meta-analysis published in 2010. Both teaching and non-teaching hospitals have decreased PN use in AP, as per published guidelines.
89 Opioid Dependence Among Chronic Pancreatitis Patients: A Trend Analysis of 15 Years
Authors: Twohig Patrick , Butt Muhammad , Gardner Timothy , Sandhu Dalbir S.
Published: October 2019

INTRODUCTION:

Pain is a common symptom in chronic pancreatitis (CP) and has a significant impact on quality of life. Although a variety of pain management strategies exist, opioids are the most frequently used analgesic given their high oral bioavailability and activity at multiple neuropathic and visceral pain receptors. Limited data exists on the trends of opioid dependence in CP. Our aim is to characterize trends in opioid use in CP over the last 15 years.

METHODS:

We performed a retrospective analysis in the IBM Explorys database (1999–2018), a pooled, de-identified clinical database of over 63 million unique patients from 26 health care networks and 300 hospitals across the United States. At the time of analysis there were 63,656,680 patients. Patient populations were identified using SNOMED and ICD codes. Cochrane-Armitage testing analyzed trends in chronic opioid use among CP patients between 2004–2018. Subgroup analysis for gender, age, race, and insurance status were assessed.

RESULTS:

83,650 adult patients (>18 years old) had CP. 7,220 patients with CP were opioid dependent. The odds of being opioid dependent if diagnosed with chronic pancreatitis was 21.90 (P < 0.0001). Over the 15-year period, opioid dependence in chronic pancreatitis patients has significantly increased (2.25% to 4.35%; P < 0.0001). Most significant increase is noted among Medicaid (P = 0.0004) and Caucasian (P = 0.0001) patients.

CONCLUSION:

We present the first study to assess trends in opioid dependence among patients with CP over the last 15 years. Pain management is a critical component of treating CP. Multiple patient-dependent factors influence pain scores and opioid use in CP patients, including a history of alcohol use and psychological comorbidities. Side effects and opioid hyperalgesia significantly hinders their efficacy for long-term pain control.3 Pain exacerbation is the most common reason for hospitalization in CP, resulting in significant cost to the health care system.9 Opioid use and hypoalbuminemia are the biggest patient-specific risk factors for being hospitalized. Our results indicate that chronic opioid use in CP has increased in the last 15 years. Given the risks and side effects of opioids, along with recent legislation that more strictly regulates dispensation, finding alternative pain management techniques is essential in maintaining good quality of life for these patients.
100 Outcomes of Acute Pancreatic in Patients With and Without History of Cholecystectomy
Authors: Singh Amandeep , Sarmini Muhammad Talal , Alomari Mohammad , Sanaka Madhusudhan R.
Published: October 2019

INTRODUCTION:

Acute pancreatitis (AP) has been shown to have a high mortality of up to 21%. But, data are lacking on the mortality and other outcomes in patients who underwent cholecystectomy. We aimed to assess the outcomes of AP in patients who had history of cholecystectomy versus who retained their gall bladder.

METHODS:

Using data from the National Inpatient Sample (NIS) database between 2002 and 2014, we identified patients who were diagnosed with AP using appropriate ICD 9 coding. Patients with AP were divided into two groups: with history of cholecystectomy (study group) and without history of cholecystectomy (control group). We then performed multivariate logistic regression analysis to compare the outcomes of AP between the two groups. Outcomes of interest included: inpatient mortality (IM), respiratory failure (RF) and acute kidney injury (AKI).

RESULTS:

A total of 1,094,214 total patients with AP were identified, of which 18,263 patients (1.67%) had history of cholecystectomy. Patients with cholecystectomy were older (53 vs 52), more likely to female (56.6% vs 49.9%) and less likely to be African American (11% vs 16.6%) than the control group (P < 0.001 for all). In addition, patients with cholecystectomy had less alcohol abuse (12.8% vs 22.8%, P < 0.001) but more likely to be obese (13.1% vs 9.4%) and smokers (23.1% and 19.4%) when compared to the control group (P < 0.001) (Table 1). Using Multivariate logistic regression, and after adjusting for potential cofounding factors including (age, race, gender, obesity, alcohol abuse, smoking and Elixhauser comorbidities), individuals in the cholecystectomy group had a lower rate of in-patient mortality (IM) (OR 0.21, 95%, CI: 0.16–0.28, P < 0.001), respiratory failure (RF) (OR 0.30, 95%, CI: 0.26–0.34, P < 0.001) and acute kidney injury (OR 0.58, 95%, CI: 0.54–0.63, P < 0.001) when compared to patients without cholecystectomy (Figure 1).

CONCLUSION:

Our study suggests that cholecystectomy in patients admitted with acute pancreatitis is associated with lower risk of IM, RF and AKI and should be considered in all patients admitted with acute pancreatitis.
110 Outcomes in Patients With Acute Pancreatitis and HIV Using the Nationwide Inpatient Sample Database
Authors: Patel Preet , Shaikh Amjad , Patel Pavan , Ahlawat Sushil
Published: October 2019

INTRODUCTION:

Acute pancreatitis has been extensively studied, however the effect of HIV status on outcomes has yet to be described. Here, we aim to assess the effects of positive HIV status on the mortality and overall outcomes in patients hospitalized with acute pancreatitis.

METHODS:

Data between 2008 and 2014 from the Nationwide Inpatient Sample database was extracted. Inclusion criteria for both groups included patients with a primary diagnosis of acute pancreatitis using International Classification of Diseases, 9th Revision codes and age greater than 17. Exclusion criteria included all ICD-9 codes for chronic pancreatitis and malignant pancreatico-biliary disorders and indeterminate HIV status. The study group consisted of patients with a primary diagnosis of acute pancreatitis and a concurrent diagnosis of HIV. In-hospital mortality was compared between the two groups. Univariate and multivariate analyses were used to generate odds ratios. Elixhauser Comorbidity scores predicting mortality and readmission were calculated based on weighted scores from 29 different comorbidities. Scores were compared between the two groups using univariate analysis.

RESULTS:

There were a total of 295386 patients with acute pancreatitis and no HIV and 2580 patients with acute pancreatitis and HIV for hospitals in the United States between 2008 and 2014. There was no significant difference in hospital mortality between acute pancreatitis with HIV and acute pancreatitis with no HIV on univariate analysis. There was a significant difference in hospital mortality on multivariate analysis for the HIV vs non-HIV groups (OR = 1.751, P = 0.011). HIV patients had a significantly higher Elixhauser mortality (5.72 ± 9.7) and readmission (31.63 ± 18.772) scores as compared to non-HIV patients' mortality (4.46 ± 8.58) and readmission (14.39 ± 13.28) scores P < 0.001, indicated a higher rate of comorbidities.

CONCLUSION:

Patients with HIV that are admitted with acute pancreatitis have a significantly higher mortality than those without HIV. We suspect the additional mortality may be due to an increased rate of comorbidities among HIV patients as evidenced by the greater Elixhauser scores. The higher rate of comorbidities among patients with HIV may be explained by a higher rate of infections and relative immunocompromised status compared to the non-HIV patients.
120 Microscopic Colitis and Risk of Colon Adenomas: A Multicenter Retrospective Cohort Study
Authors: Kamboj Amrit K. , Zylberberg Haley , Lane Conor , Colbenson Gretchen , DeCuir Nicole , Lennon Ryan , Khanna Sahil , Lebwohl Benjamin , Pardi Darrell
Published: October 2019

INTRODUCTION:

Microscopic colitis (MC) is a common cause of chronic watery diarrhea. Cross-sectional studies have suggested that patients with MC have a lower incidence of colon polyps compared to those without MC. However, existing literature is limited by a lack of longitudinal follow-up and the use of average-risk patients, rather than those with chronic diarrhea as controls. We aimed to further explore the association between MC and colon adenomas.

METHODS:

This retrospective cohort study included patients that underwent colonoscopy at Mayo Clinic (Rochester, MN) or Columbia University Medical Center (New York, NY) between 7/1/2006 and 12/31/2016. Consecutive cases with MC were identified using pathology databases at each center. Controls had chronic diarrhea, underwent colonoscopy, and did not have MC on biopsy. Cases and controls were matched 1:2 by age (±3 years), sex, and date of index colonoscopy (±6 months). Data was collected on demographics, tobacco and alcohol use, personal and family history of colon neoplasia, and presence of adenomas at the index or follow-up colonoscopies.

RESULTS:

The study included 376 patients with MC and 752 non-MC patients with chronic diarrhea. The median (range) age of patients was 64 (21, 88) years and 72% were female. Duration of follow-up was not significantly different between the 2 groups (total person years: cases 577, controls 972; P = 0.99) and 51 subjects had a new adenoma on follow-up. There were no significant differences in age, sex, alcohol use, family history of colon neoplasia, and personal history of inflammatory bowel disease between cases and controls. Patients with MC were more likely to be current tobacco users (10% vs. 6%, P = 0.02) and less likely to have a history of prior colon neoplasia (9% vs. 17%, P < 0.001). Patients with MC were significantly less likely to have colon adenomas at the time of their index colonoscopy (5% vs. 12%; odds ratio 0.36; 95% CI 0.21, 0.60; P < 0.001) after adjusting for tobacco use and history of prior lesions. However, when followed over time, there was no significant association between MC and risk of colon adenomas (Figure 1, P = 0.45) after adjusting for tobacco use, history of prior lesions, and presence of adenoma at index colonoscopy.

CONCLUSION:

Patients with MC are less likely to have colon adenomas at their index colonoscopy compared to those with chronic diarrhea without MC. However, when followed longitudinally, there appears to be no significant association between MC and risk of colon adenomas.
125 Underwater Versus Conventional Endoscopic Mucosal Resection for the Treatment of Colorectal Laterally Spreading Tumors: Results From an International, Multicenter, Randomized Controlled Trial
Authors: Hamerski Chris , Samarasena Jason , Lee David P. , Wang Andrew Y. , Strand Daniel , Amato Arnaldo , Watson Rabindra , Nett Andrew , Calitis Jona , Binmoeller Kenneth
Published: October 2019

INTRODUCTION:

Safe and effective resection of large colonic polyps remains a challenge for the practicing endoscopist. Recently, an underwater technique for endoscopic mucosal resection (UEMR) has emerged as an alternative to conventional injection-assisted EMR (CEMR). While the effectiveness of UEMR technique seems to be borne out in several case series and retrospective analyses, prospective data regarding its performance against CEMR technique is lacking.

METHODS:

This study was a prospective international multicenter randomized controlled trial involving 4 tertiary referral centers, 3 in the US and 1 in Italy, in order to compare the outcomes and safety of UEMR versus CEMR technique for large colon polyps (15 mm or larger). Block randomization was used to assign patients to either the UEMR arm or CEMR arm. Primary outcome was the rate of curative resection, as documented by presence of residual neoplasia on 3–6 month surveillance colonoscopy. Secondary outcomes included resection time, total procedure time, en bloc resection rates, and adverse events.

RESULTS:

A total of 303 patients with 303 lesions were enrolled in this trial. 145 patients were randomized into the CEMR arm, and 158 patients were enrolled in the UEMR arm. Among those in the CEMR arm, 13 patients crossed over into the UEMR arm at the discretion of the performing endoscopist. Among those in the UEMR arm, 1 patient crossed over to the CEMR arm. At follow up, a total of 95 patients had surveillance colonoscopy performed in the CEMR arm, with residual neoplasia found in 16 of these patients (16.8%). In the UEMR arm, 118 patients followed up, with residual neoplasia found in 10 of these patients (8.5%) [P = 0.06] The resection time and total procedure time were found to be less in the UEMR arm and there was a significantly higher rate of en bloc resection achieved by UEMR versus CEMR (P < 0.01). There was no difference in the rate of adverse events.

CONCLUSION:

This large multicenter randomized study supports that UEMR technique is a safe and effective alternative to CEMR technique and should be considered a first line option in the management of large laterally spreading colorectal tumors.
132 Failure of Prescribing Bowel Regimens at Hospital Discharge for Patients on Opioid Medications
Authors: Moore Andrew , Kapil Anuja , Jones Sabrina K. , Lee Salina
Published: October 2019

INTRODUCTION:

Opioid-induced constipation (OIC) is estimated to affect 40–80% of those on opioid therapy. Aside from added costs to the healthcare system, untreated constipation can cause adverse effects ranging from abdominal pain to more serious complications such as colonic perforation. No specific guidelines exist on the prescription of bowel regimens with opioid medications; however, expert opinion suggests that a bowel regimen should be prescribed with any opioid medication. The objective of this study was to evaluate the frequency of prescribing a bowel regimen with opioid medications on inpatient discharge medication reconciliations.

METHODS:

We identified all patients at an academic institution admitted on the general medical-surgical floors from the dates of 1/1–1/14/18. The discharge summaries of all patients admitted during the above time period were manually reviewed, and patients who were discharged on an opioid medication were identified. Of those patients, we identified those who were discharged on a bowel regimen and noted the specific regimen at discharge. No distinction was made between a new or prior prescription for opioid medication. We then calculated the percentage of patients who were discharged on an opioid medication with a bowel regimen.

RESULTS:

380 patients were admitted from 1/1–1/14/2018 on the general medical-surgical floors. Of those 380 patients, 12 were excluded due to chart restrictions and death during admission. Of the 368 patients remaining, 184 (50%) were male and 184 (50%) were female. 145 (39.4%) were discharged on an opioid. Of that population, only 72 (49.7%) were discharged on a bowel regimen. 116 of 145 were discharged on a single opioid regimen, and of those, 48 (41.4%) were discharged on a bowel regimen. 28 of 145 were discharged on dual opioid regimen, and of those, 23 (82.1%) were discharged on a bowel regimen.

CONCLUSION:

Despite the clear association of constipation with opioid use, more than half of patients discharged on an opioid medication were not prescribed a bowel regimen. Due to the wide-ranging complications of constipation and its economic burden, clear prescribing guidelines for bowel regimens with opioids need to be established. Within our institution, further research is to be conducted on developing a flagging system within the EMR at discharge to identify patients who are discharged on an opioid medication and to provide recommendation for the appropriate regimen for these patients.
136 Usefulness of Magnifying Narrow-Band Imaging Endoscopy for the Diagnosis of Sessile Serrated Adenoma/Polyp With Dysplasia/Carcinoma
Authors: Murakami Takashi , Sakamoto Naoto , Fukushima Hirofumi , Ueyama Hiroya , Shibuya Tomoyoshi , Nagahara Akihito
Published: October 2019

INTRODUCTION:

Sessile serrated adenoma/polyp (SSA/P) is an early precursor lesion in the serrated neoplasia pathway, which results in BRAF-mutated colorectal carcinomas with high levels of microsatellite instability. Therefore, accurate diagnosis of SSA/P and its dysplastic components is endoscopically important. However, the usefulness of magnifying narrow-band imaging (NBI) endoscopy for SSA/Ps with dysplastic change has not yet been fully elucidated. The aim of this study was to verify the usefulness of magnifying NBI endoscopy for the diagnosis of SSA/P with dysplasia/carcinoma.

METHODS:

Among 939 endoscopically or surgically resected lesions pathologically diagnosed as SSA/P with or without dysplasia/carcinoma at Juntendo University Hospital (Tokyo, Japan) between 2011 and 2018, a total of 709 lesions had images available. These SSA/P lesions included 647 with no dysplasia (ND), 37 with low-grade dysplasia (LGD), 15 with high-grade dysplasia (HGD), and 10 with submucosal invasive carcinoma (SIC). We retrospectively evaluated magnifying NBI endoscopic findings using the Japan NBI Expert Team (JNET) system.

RESULTS:

The clinicopathological and endoscopic characteristics of the studied lesions are summarized in Table 1. The HGD and SIC lesions were associated with advanced age. All the lesions were more frequently located in the proximal colon. The SIC lesions were significantly larger than the ND and LGD lesions. All the lesions frequently exhibited endoscopic findings characteristic of SSA/P, such as mucus cap and Type II-Open pit pattern. As for the JNET classification of magnifying NBI endoscopy findings, all 709 lesions were type 1. Six hundred and eighteen (96%) ND lesions exhibited type 1 only, whereas 52 (84%) SSA/P with dysplasia/carcinoma lesions had a combination of type 1 and types 2A, 2B, or 3, corresponding to SSA/P and dysplasia/carcinoma, respectively (Figures 1 and 2). Furthermore, the JNET classification had high sensitivity (84%) and specificity (96%) for diagnosing SSA/P with dysplasia/carcinoma.

CONCLUSION:

Recently, the JNET was established and has proposed a universal NBI magnifying endoscopic classification of colorectal tumors. Our findings suggest that the use of magnifying NBI endoscopy using the JNET classification might be useful for the diagnosis of not only conventional colorectal tumors, but also SSA/P with dysplasia/carcinoma. This increased awareness may also improve the recognition of SSA/Ps with dysplasia or invasive carcinoma.
137 Diverticular Paradox: Increasing Odds of Diverticulitis in Diverticular Disease With Younger Age
Authors: Gboluaje Temitayo , Gwengi Martha , Olanipekun Titilope , Ajose Taiwo , Simien Melvin
Published: October 2019

INTRODUCTION:

Diverticula disease historically has been known to be a disease of the elderly with estimated prevalence greater than 50% in people ages 60 and above. The healthcare costs associated with impact of diverticular disease is estimated at $3 billion per year. Diverticular disease is one of the commonest reasons for gastroenterology visit yearly. Acute diverticulitis is one of the most feared morbidity conferring complications of diverticular disease. Recent studies have reported an increasing incidence of acute diverticulitis in hospitalized individual younger than the age of 50. However, not much is known about the age-specific odds of having acute diverticulitis in diverticular disease.

METHODS:

We performed a retrospective cohort study of 1197 patients with diverticular disease at Grady Memorial Hospital. We evaluated association between age and diverticulitis, while adjusting for gender, race, BMI, HIV, COPD, hemorrhoids, and hypertension. A multivariate logistic regression model was used to compare diverticulitis and diverticulosis.

RESULTS:

Of the 1197 patients, 732 were females and 465 males. The average age of this patient sample was 58.14, with frequency of diverticulitis and diverticulosis in age group 23–29 years: 5 and 13, 30–44 years: 45 and 98, 45–59 years: 246 and 265, 60–74 years: 243 and 146, >75 years: 98 and 36 respectively. Primary diagnosis was diverticulosis in 637 of the patients and diverticulitis in 558 of the patients. Age group 23–44 was strongly associated with diverticulitis. The odds of diverticulitis increased with reduced age: 23–29 years (OR, 7.08; 95% CI, 2.36 to 21.26), 30–44 years (OR, 5.93; 95% CI, 3.52 to 9.97), 45–59 years (OR, 2.93; 95% CI, 1.93 to 4.46), 60 – 74 years (OR, 1.64; 95% CI, 1.06 to 2.52). In the multivariate logistic regression, age group 23–44 was strongly associated with diverticulitis, while hypertension was only marginally statistically significant (P-value = 0.05). In contrast BMI, HIV status, and COPD were not associated with diverticulitis, and neither was the interaction term: HIV, COPD, hypertension.

CONCLUSION:

Our study demonstrated that even though patients older than 45 had the highest number of diverticular disease cases, the odds of diverticulitis was highest in the younger age groups less that 45 years. More research should be done to evaluate this trend and clinicians should be aware of the high potential of diverticulitis in patients younger than 45 years old.