bluuebunny/crossref_metadata_2025_split huggingface dataset:
41 Outcomes and Safety of ERCP in Nonagenarians Compared to a Younger Cohort
Authors: Walker John T. , Shah Ruchit , Patel Sunny , Khara Harshit S. , Diehl David L. , Confer Bradley 
Published: October 2019

INTRODUCTION:
Limited data exists regarding safety of ERCP in elderly patients, particularly nonagenarians. Anecdotal experience suggests technical difficulty of ERCP in elderly patients may be increased by anatomic abnormalities such as large hiatal hernia and peri-ampullary diverticula. Several small studies suggest increased ERCP-related adverse effects in the elderly. We aim to evaluate the safety and difficulty of ERCP in nonagenarians compared to a younger cohort of patients.

METHODS:
A prospectively maintained endoscopy database was queried for patients age ≥90 years and patients age 40–69 years undergoing ERCP from 2013 to 2018. One hundred eleven nonagenarian patients who underwent 165 procedures were identified. One hundred eleven patients from a potential 1,982 patients in the younger cohort were randomly selected. Of the 111 patients included in the younger cohort, 205 ERCPs were performed. Outcomes were compared using student's t-tests for continuous variables and Fisher's Exact tests for categorical variables. A general estimating equation was utilized to calculate odds ratio comparing the groups by outcome.

RESULTS:
The mean age in the nonagenarian cohort was 92.4 (±2.2) years compared to 51.4 (±14.3) years for the young patients. In the elderly group, 37 (33%) were male compared to 40% (N = 44) for the young patients. The most common indication for ERCP was choledocholithiasis (38% nonagenarian vs. 24% young). There was no difference in difficulty passing the duodenoscope between the older group (7.3%) and young group (7.7%), OR 0.93 [0.35, 2.48], P = 0.88. There was a higher rate of peri-ampullary diverticula in nonagenarians (16.4%) compared to young patients (3.4%), OR 5.53 [1.45, 21.15], P = 0.01. There was no statistical difference in failed cannulation for the elderly group (5.5%) vs. the young group (2.9%), OR 1.91 [0.61, 6.00], P = 0.27) or need for pre-cut access in the elderly cohort (10.9%) vs. the young group (8.3%), OR 1.67 [0.37, 7.53], P = 0.50. Most importantly, there was no difference in adverse events between nonagenarians (9.1%) and younger patients (9.3%), OR 0.98 [0.49, 1.94], P = 0.60).

CONCLUSION:
Despite perceived increased risk and difficulty performing ERCP in nonagenarians, our data demonstrate success rate and number of adverse events of ERCP is similar to younger patients. Based on this data, reasonable informed consent can be given regarding the safety and technical success of ERCP in nonagenarians.
42 Safety of Endoscopic Retrograde Cholangiopancreatography for Choledocholithiasis in Patients With Age ≥80: A Nationwide Analysis
Authors: Radadiya Dhruvil K. , Devani Kalpit H. , Charilaou Paris , Patel Pranav D. , Young Mark , Reddy Chakradhar 
Published: October 2019

INTRODUCTION:
Endoscopic retrograde cholangiopancreatography (ERCP) is a necessary procedure for exploration and management of pancreaticobiliary ductal system disorders. Safety of ERCP in the elderly population with more underlying co-morbidities remains a concern. We aimed to study if ERCP, particularly for biliary calculus (BC)-related indications, is associated with higher complications including mortality in patients with age ≥80.

METHODS:
We performed a retrospective analysis using data from the National Inpatient Sample (NIS) from the year 2016. We included all adult patients admitted with BC who underwent ERCP, and we further identified those with concurrent pancreatitis and/or cholangitis, using ICD-10-CM codes. Patients with missing information on age, gender or inpatient mortality were excluded. We analyzed patients by two groups: age <80 and ≥80 years. Chi-square analysis and t-tests were used to compare categorical and continuous variables, respectively. Predictors of ERCP-related complications, including inpatient mortality, were assessed by multivariable logistic regression analysis.

RESULTS:
Total of 102,095 patients were included in the study who underwent ERCP for BC related etiology, out of which 20,530 (20.1%) were patients age ≥80 years. In the age ≥80 group, mean age was 85.4 years, and 56.5% patients were female. Unadjusted mean length of stay (6.3 vs. 5.3 days), hospitalization costs ($75,326 vs. $72,110) and inpatient mortality (2.2% vs. 0.8%) were significantly higher in patients with age ≥80. BC without pancreatitis or cholangitis was the most common indication for ERCP in both groups. Prevalence of complications related to ERCP were comparable between two groups except for cardiorespiratory complications and mortality (Table 1). On multivariate analysis, patients with age ≥80 had statistically no significant difference in complications in compared to patients with age <80 years (aOR: 0.96, 95% CI 0.92–1.01, P = 0.133). Among all patients, ERCP performed for biliary pancreatitis (BP) had 70% lower rate of complications while ERCP for cholangitis had 26% higher rate compared to ERCP for simple BC (Table 2).

CONCLUSION:
In the United States, about 1 in 5 ERCP for BC are performed in patients with age ≥80. Overall, BP is associated with significantly lower risk of complications. Among patients undergoing ERCP for BC-related indications, patients with age ≥80 do not carry a higher risk of ERCP-associated complications.
43 Non-Alcoholic Fatty Liver Disease (NAFLD) Is Associated With Severe Acute Pancreatitis (SAP)
Authors: El Kurdi Bara , El Iskandarani Mahmoud , Babar Sumbal , Haddad Ibrahim , Alomari Mohammad , Young Mark 
Published: October 2019

INTRODUCTION:
Approximately 15 to 25 percent of patients with AP go on to develop severe AP (SAP) with mortality rising up to 20% as this transition happens. This underlies the significance of identifying predictors of deterioration to SAP. The pancreas is often spared from hepatic disorders, however in non-alcoholic fatty liver disease (NFALD), the pancreas can also be involved mainly through pancreatic peripancreatic fat deposition. We hypothesized that increased fat deposition in and around the pancreas would lead to increased severity of AP. Therefore, we have performed a comprehensive systematic review and meta-analysis to we evaluate NAFLD's association to SAP.

METHODS:
A systematic review was conducted in Pubmed, EMBASE, and Cochrane databases from inception through April 2018 to identify studies which explored the correlation between NAFLD and SAP was conducted. Conference abstracts, review papers, non-english papers and unrelated papers were excluded. Relevant data were collected and analyzed using comprehensive meta-analysis software. Publication bias was assessed for using Egger's test.

RESULTS:
4 case-controls studies examining a total of 4349 patients were included in our analysis. 31.8% of patients with acute pancreatitis were found to have NAFLD. The odds ratio (OR) of SAP in NAFLD compared to non-NAFLD was 2.57 (CI95% 2.15–3.06). No publication bias was noted using Egger's test.

CONCLUSION:
We note NAFLD to be found in about 31.8% of patients presenting with AP. Patients with NAFLD were significantly more likely to develop SAP than controls with OR 2.57 (CI95% 2.15–3.06) indicating a predisposition for SAP in this patient population. While this increase in SAP is likely related to increased pancreatic and peripancreatic fat deposition in NAFLD patients, further research is needed to determine the exact pathophysiology behind this association.
45 The Role of the Biliary and Gut Microbiome in the Progression of Cholangiocarcinoma and Primary Sclerosing Cholangitis
Authors: Katsuyuki Miyabe , Chandrasekhara Vinay , Wongjarupong Nicha , Chen Jun , Johnson Stephen , Chia Nicholas , Gossard Andrea A. , Walther-Antonio Marina , Oli Sharad , Giama Nasra H. , Ali Hamdi A. , Sravanthi Lavu , Hassan Fatima , Ali Hawa , Yao Janet Z. , Harrington Sean C. , Enders Felicity T. , Rizvi Sumera H. , Gores Gregory J. , Topazian Mark D. , Kashyap Purna C. , Roberts Lewis R. 
Published: October 2019

INTRODUCTION:
Primary sclerosing cholangitis (PSC) is a chronic, fibroinflammatory, cholestatic liver disease of unknown etiopathogenesis which is recognized as a major risk factor for cholangiocarcinoma (CCA). We aimed to investigate the roles of the biliary and intestinal microflora in the inflammatory process of PSC and to determine if the microflora is associated with progression to CCA.

METHODS:
We studied the bile and stool microbiomes in samples obtained from patients with PSC (31 stool and 35 bile samples), sporadic CCA (11 stool and 26 bile samples), and PSC coexisting with CCA (16 stool and bile 17 samples). Control bile was obtained from patients with cholelithiasis or choledocholithiasis (n = 17). DNA extraction was followed by amplification and high-throughput next generation sequencing (MiSeq) of the 16S rDNA (V3-V5) region to identify the microbiota present. We performed: 1. analysis of the stool microbiome between PSC and CCA patients; 2. analysis of the biliary microbiome in PSC and CCA patients; 3. comparison of the biliary microbiome collected before and after biliary stent placement.

RESULTS:
Although bile samples from study patients had significantly lower sequencing depths than stool, their sequencing depths were much higher than bile from negative controls. The microbiomes of stool and bile samples from the same patients were significantly correlated (P = 0.022). CCA bile samples had significant difference of alpha diversity from control bile samples with less Streptococcaceae and Desulfovibrionaceae (FDR < 10%) than PSC whereas no significant change of stool microbiome was identified between CCA and PSC. Fusobacterium and Gemella were correlated to PSC duration. An increased abundance of Fusobacteria after stent placement was revealed. Fusobacteria, which is inflammation-promoting, was also increased with the number of stents in the bile duct.

CONCLUSION:
Our study suggests that the bile microbiome is potentially a more distinctive biomarker than the stool microbiome for PSC and CCA development. There is increased inhabitance of inflammation-promoting bacteria in the bile of CCA patients and after biliary stent placement. Increased PSC duration also increases the microbial burden in the bile, which may also promote CCA development. We further detected specific bile microbes statistically associated with CCA or stent presence in the bile ducts, which raises the possibility of their role in the CCA progression or stent obstruction. Additional analyses with more samples are needed.
47 Acute Pancreatitis Management Discrepancies Between Different Services in a Single Hospital Setting Affecting Patient Outcomes
Authors: Mohy-ud-din Nabeeha , Deyl Ivana , Umar Shifa , Baki Heitham Abdul , Morrissey Suzanne 
Published: October 2019

INTRODUCTION:
In the US, acute pancreatitis (AP) is a leading cause of inpatient care among Gl conditions at an aggregate cost of >$2.6 billion per year. Multiple clinical guidelines exist for AP, however institutional practices vary in adherence to these. Our study compares the management of AP and adherence to published guidelines among teaching and non-teaching medicine services within the same center. Survey-based methods of analysis were performed.

METHODS:
A retrospective chart review of patients with an unplanned admission to a non-ICU hospital ward between Jan 2016–Jan 2017 with primary diagnosis of AP was performed. ICU admissions and hospital transfers were excluded. Clinical and epidemiological data was extracted, and patients were stratified to their respective admitting services: academic teaching medical service and non-teaching hospitalist service. Mean fluid resuscitation was defined as fluids ordered for patient for the first 24–48 hours.

RESULTS:
A total of 75 patients were included in the study. 37% (n = 28) were admitted to a resident teaching service (TS) and 63% (n = 47) to a hospitalist non-teaching service (NTS). Baseline characteristics between the two groups were comparable with similar age, sex, etiology of pancreatitis and BISAP scores (Table 1). The most common cause of acute pancreatitis on the TS and NTS were alcohol induced (35.7%, n = 10) and gallstone pancreatitis (42.5%, n = 20), respectively. 96% of patients (n = 27) admitted to a TS and 25% (n = 12) on NTS had CRP ordered on admission (P = < 0.001). Lactated Ringers was ordered for 68% (n = 19) and 21% (n = 10) of patients on TS and NTS (P = < 0.001), respectively. Mean fluid resuscitation for patients admitted to TS was 153 ± 45 ml/hr compared to 113 ± 43 ml/hr for NTS (P = < 0.001). A Gastroenterology consult was placed for 43% (n = 12) of patients admitted to TS and 75% (n = 35) of NTS (P = 0.008). Length of stay was comparable at 4.85 ± 6.2 and 4.53 ± 4.9 days for TS and NTS, respectively. Details of differences in management between both services are summarized in Table 2.

CONCLUSION:
Wide variability exists in management of patients admitted to different services within the same institution. Significant differences exist in labs ordered, type of fluid ordered on admission, rate of fluid and consultations to the GI team. We aim to target these differences through a multi-faceted quality improvement initiative.
52 Decline in Total Serum Bilirubin Level Is Sensitive but Not Specific Marker for Spontaneous Common Bile Duct Stones Passage
Authors: Al-Ghanoudi Ashirf , Frandah Wesam , Mardini Houssam 
Published: October 2019

INTRODUCTION:
Increased serum total bilirubin (T. bili: mg/dl) on presentation is one of the commonly used markers for the presence of common bile duct (CBD) stones. We sought to examine the relationship between the decrease in T. bili level and the probability of spontaneous stone passage in patients (pts) with suspected or confirmed choledocholithiasis.

METHODS:
Pts who were 18 or older and admitted to our institution between October 2015 and December 2017 with ICD 10 code(s) used in pts with confirmed or suspected choledocholithiasis were identified through the University of Kentucky Medical Services Database. Only pts with documented elevated T. bili with at least 3 measurements 12 hours apart were included for further review. Only pts with high-probability of choledocholithiasis based on very strong and/or strong clinical predictors of choledocholithiasis per ASGE guidelines were included in the final analysis. All selected pts underwent one or more of the following confirmatory studies: MRCP, ERCP, EUS or IOC. Categorical variables were compared using chi square tests and continuous variables using two-sample t-tests. Regression analysis was performed to identify independent variables associated with retained stone despite consistent decline in T. bili level.

RESULTS:
825 pts were identified according to the screening criteria. 723 pts were excluded due to having pathologies and 102 pts were included in this study (48 males & 54 females). Mean age of 57.4 years ± 22. 33 pts had fluctuation or no decline in T. bili level and 30 of them (92%) were confirmed to have retained stones. Among the 75 pts with consistent decline in T. bili level after 48 hours from initial presentation, 26 (34.7%) were found to have retained stone while 49 (65.3%) were confirmed to have no retained stones (passed spontaneously). On regression analysis, predictors of the presence of retained CBD stone(s) despite consistent decline in T. bili level included: pts older than 55 (OR 1.9; 95% CI: 1.1, 3.4) and pts presented with severe cholangitis defined as WBC > 16,000 and hypotension (OR 1.6; 95% CI 1.2–2.7).

CONCLUSION:
Although consistent decline in T. bili level is a sensitive predictor for spontaneous CBD stone passage, it is not specific and can be seen in at least one third of patients with documented retained stones. Possible explanations for decreased specificity include vigorous medical support (hydration & antibiotics) that may contribute to decline in T. bili level even in the setting of retained stones.
53 Impact of Insurance Status and Race on Outcomes of Choledocholithiasis With Acute Cholangitis: A Nationwide Analysis
Authors: Sharma Sachit , Khan Zubair , Poudyal Abhushan , Acharya Ashu , Uprety Alok , Ghimire Subash 
Published: October 2019

INTRODUCTION:
We examined the impact of insurance and race on in-hospital mortality and time to early ERCP in adult patients with choledocholithiasis with acute cholangitis.

METHODS:
Adult patients with choledocholithiasis with acute cholangitis were selected from the National Inpatient Sample 2016. Primary outcome: in-hospital mortality. Secondary outcomes: Time to early ERCP defined as ERCP performed within 24 hours of hospitalization. We stratified patients based on race and insurance (Medicare, Private insurance, Other-Medicaid, uninsured).

RESULTS:
Mortality was similar for Medicare and private insurance [adjusted odds ratios (aOR): 0.89 95% confidence interval (CI) 0.40 to 2.00), P = 0.796], and for under/uninsured patients [aOR: 1.02 (CI: 0.87 to 1.19), P = 0.76] as well. Compared with Medicare, there was no change in the likelihood of ERCP in patients with private insurance [aOR: 1.21 (CI: 0.98 to 1.50), P = 0.074] or uninsured patients [aOR: 1.02 (CI: 0.87 to 1.19), P = 0.76]. Similarly, compared to Medicare, there was no change in the likelihood of early ERCP in patients with private insurance [aOR: 1.13 (CI: 0.92 to 1.40), P = 0.22], or in uninsured patients [aOR: 1.07 (CI: 0.91 to 1.26), P = 0.38]. Similar analysis was done to look at the impact of race. White race was taken as reference as this was the largest population. Compared with whites, there was no significant difference in in-hospital mortality between blacks [aOR: 1.76 (CI: 0.94 to 3.29), P = 0.073]; Hispanics [aOR: 0.82 (CI: 0.32 to 2.04), P = 0.67] and others. Compared with whites, there was no significant difference in likelihood of ERCP between blacks [aOR: 0.87 (CI: 0.72 to 1.76), P = 0.198]; Hispanics [aOR: 0.94 (CI: 0.77 to 1.15), P = 0.59] and others. However, blacks were less likely to have early ERCP compared to whites [aOR: 0.78 (CI: 0.63 to 0.96), P < 0.05]. Compared to whites, there was no difference in likelihood of early ERCP in other races: Hispanic [aOR: 0.81 (CI: 0.66 to 1.00), P = 0.051].

CONCLUSION:
Insurance and race do not have significant effect on in-hospital mortality, likelihood of ERCP and early ERCP in patients with choledocholithiasis with acute cholangitis. Only significant difference that we found in our study was that blacks were less likely to have ERCP within 24 hours of hospitalization compared to whites. This may be reflective of changes in healthcare delivery due to the impact of the Affordable care act. However, further analysis is needed in more recent data to ascertain the trends.
54 Disparities in the Diagnosis and Treatment of Bile Duct Cancer Among People With Disability: A National Cohort Study in the Republic of Korea
Authors: Kim Seongmin , Kwon Hyeonwoo , Lee Jun Su , Choi Jongwook , Cho Byungha , Park Seon Mee 
Published: October 2019

INTRODUCTION:
This study aimed to evaluate the disparity of diagnosis, treatment and prognosis of bile duct cancer (BDC) by the presence, severity and type of disability.

METHODS:
Patients diagnosed with BDC were selected from a cohort, consisted with 1:3 ratio of age- and sex-matched population with or without disability from the National Disability Database, the Korean Central Cancer Registry, and the Korean National Health Insurance claims database. We evaluated the demographics, socioeconomic status, stages, treatment, and survival rates of BDC patients depending on the presence, severity and type of disability.

RESULTS:
The cohort included 15,065 patients with BDC, with a significantly lower rate among people with severe disabilities than people without or with mild disabilities (110.6 vs. 136.5 or 147.6 per 105 persons, respectively). Patients with disabilities had higher Charlson comorbidity index (1.43 vs. 2.00) and more below poverty line (6.0% vs. 11.9%) than those without disabilities. People with severe disabilities were diagnosed BDC at earlier age, but less likely to undergo surgery (adjusted odds ratio 0.52, 95% confidence interval 0.45–0.61) or chemotherapy (0.55, 0.45–0.67) than those without disabilities. This trend was more evident in patients with mental disorders. The overall and cancer specific mortality rates were higher in patients with disabilities than those without disabilities.

CONCLUSION:
In Korea, people with disabilities have a lower rate of BDC diagnosis, receive less surgery or chemotherapy, and have a lower survival rate than people without disabilities. This trend was more evident in patient with severe disabilities and with mental disorders.
58 Prevalence, Trend, and Predictors of Opioid Abuse Among Patients With Chronic Pancreatitis
Authors: Akanbi Olalekan , Adejumo Adeyinka C. , Alayo Quazim A. , Tripathi Nishant , Yarra Pradeep , Kudaravalli Praneeth 
Published: October 2019

INTRODUCTION:
Opioids are a mainstay of chronic pain management however their continued use has become a public-health crisis with potential for abuse and associated adverse outcomes. Patients with Chronic Pancreatitis (CP) suffer from recurrent debilitating pain and are thus susceptible to opioid abuse. We aimed to determine the prevalence, trends and determinants of Opioid Use Disorder (OUD) among hospitalized patients with CP.

METHODS:
Patients with OUD were identified in the Healthcare Cost and Utilization Project – Nationwide Inpatient Sample (HCUP-NIS), 2007–2014 and the temporal trend of OUD was analyzed and compared among patients with and without CP. We then extracted patients with a discharge diagnosis of CP from HCUP-NIS 2012–2014 and identified the characteristics of OUD in these patients. Predictors of OUD was evaluated using multivariate logistic regression models (SAS 9.4).

RESULTS:
87,068 patients with a primary diagnosis of CP were identified, of which 3,008 (3.45%) had concomitant OUD. With an average annual increase of 29.4 cases per 10,000 hospitalizations vs. 10.6 cases per 10,000 hospitalizations, the rate of OUD in CP patients is increasing at a steeper rate than patients without CP. Predictors of OUD were young age, females, Medicare or Medicaid insurance, mental health disorders, non-opioid substance abuse and comorbid conditions such as arthritis, back pain and headache. The northeast region, urban and large bed size hospitals also have higher odds of OUD.

CONCLUSION:
OUD affects a significant proportion of patients with CP and occurs at an increasing rate; almost 3 times the rate of those without CP. A better recognition of predisposing pre-existing demographic and clinical variables among at-risk individuals may help guide the utilization of opioids in this patient group, slowing and potentially reversing the rates of OUD.