bluuebunny/crossref_metadata_2025_split huggingface dataset:
107 The Prevalence of Endoscopic Retrograde Cholangiopancreatography-Related Complications in Patients With Liver Transplant: A Meta-Analysis and Systematic Review
Authors: Al Momani Laith , Alomari Mohammad , Nehme Fredy , Almomani Shaden , Aasen Tyler , Young Mark 
Published: October 2019

INTRODUCTION:
Biliary complications following liver transplantation are usually managed with endoscopic retrograde cholangiopancreatography (ERCP); however, the literature on post-ERCP complications remains poorly reported and largely inconsistent in this patient population. Hereby we aimed to systematically review and analyze the literature on complication rates associated with the performance of ERCP in patients with liver transplant.

METHODS:
We performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through May 2019 to identify all the studies that evaluated post-ERCP complications in patients with liver transplant. Effect estimates from the individual studies were extracted and combined using the random effect, generic inverse variance method of DerSimonian and Laird, and a pooled odds ratio (OR) and prevalence were calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques.

RESULTS:
Fourteen studies with a total of 1787 patients were included in this analysis. In total, 3192 ERCPs were performed on these patients. The pooled all-complication rate was 5.2% (95% CI: 0.035–0.075) (Figure 1). Procedural complications analyzed included post-ERCP pancreatitis 3.4% (95% CI: 0.025–0.047), bleeding 1.1% (95% CI: 0.006–0.020), infections 0.2% (95% CI: 0.025–0.047), and cholangitis 0.8% (95% CI 0.004–0.020) (Figure 2a–d). No cases of periprocedural death were reported. The pooled OR for post-ERCP pancreatitis in patients with liver transplant compared to patients without liver transplant was 1.289 (95% CI: 0.455–3.653, P = 0.633, I2 = 72.88%) (Figure 3).

CONCLUSION:
The risk of post-ERCP complications has been a major concern for many endoscopists in patients with liver transplantation. This might be related to theoretical concerns of distorted anatomy and difficult cannulation, combined with a general lack of evidence on the true prevalence of these complications. Our study confirms that post-ERCP complication rates are comparable to the general population undergoing ERCP and hence, peri-procedural evaluation and management should be continued as per the standard of care in this patient population.
112 A Contemporary Analysis of Obese Patient Characteristics and Outcomes With Pancreatitis
Authors: Chaudhary Fahad , Albeiruti Ridwaan , Hutson William 
Published: October 2019

INTRODUCTION:
The rates of obesity continue to increase in the US and may have an adverse effect on clinical outcomes in patients with pancreatitis. As the management of acute pancreatitis has improved over the past 2 decades, we sought to evaluate the impact of obesity on patients with pancreatitis using contemporary inpatient data.

METHODS:
The Nationwide Inpatient Sample (2016) was used to identify all adult inpatients older than 18 years with a primary diagnosis of acute and chronic pancreatitis. Primary outcomes included mortality, acute renal failure, acute respiratory failure and septic shock as well as secondary outcomes included length of stay and hospital cost were analyzed.

RESULTS:
During 2016, the national estimate for patients hospitalized with acute and chronic pancreatitis was 519,035. Of these, 70,670 (13.6%) patients carried a diagnosis of obesity. Patients hospitalized for pancreatitis with and without obesity had similar baseline characteristics. Patients with obesity were more likely to be younger (35% vs 31%, P < 0.001), female (35% vs 31%, P < 0.001), and Hispanic (15% vs 11%, P < 0.001). These patients presented to smaller hospitals (70% vs 48%, P < 0.001). Additionally, the etiology of pancreatitis was less likely to be a biliary source (67% vs 79%, P < 0.001). Obese patients had a lower likelihood of mortality (1.5% vs 2.1%, P < 0.001) and septic shock (2.7% vs 2.9%, P < 0.001) but were more likely to have respiratory failure (7.9% vs 7.2%, P < 0.001). Both populations had a similar median length of stay (4) however obese patients had a higher cost of hospitalization ($34,180 vs $29186).

CONCLUSION:
Patient with obesity seem to have a lower likelihood of mortality and biliary causes of pancreatitis. Further, larger epidemiologic studies are needed for further elucidate the exact cause of this finding.
113 Are Antibiotics Necessary for EUS-FNA of Pancreatic Cysts: A Retrospective Study
Authors: Badrinath Madhuri , Kanagalingam Gowthami , Iorio Natalya , Sapkota Bishnu 
Published: October 2019

INTRODUCTION:
Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is commonly used to further characterize cystic lesions of the pancreas. Antibiotic prophylaxis has been recommended by the Americal Society for Gastrointestinal Endoscopy for EUS-FNA of cystic pancreatic lesions. The aim of this study was to compare the rate of post-procedural infection in patients who received periprocedural antibiotics for EUS-FNA of pancreatic cystic lesions versus those who did not.

METHODS:
A retrospective review of medical records of individuals with pancreatic cysts who underwent EUS-FNAs at a tertiary academic hospital between January 2015 and March 2018 was performed. All procedures were performed by four board-certified gastroenterologists. The data reviewed included patient demographics, cyst description, FNA needle size, cytology and use of antibiotics. Post-procedural infections were identified by the presence of leukocytosis, fever, or positive blood cultures during follow-up clinic or hospital visits for 30 days after FNA. Excluded from the study were solid neoplasms, obvious side branch intraductal papillary mucinous neoplasm without high risk features and subjects with evidence of infection or leukocytosis before the FNA.

RESULTS:
Two hundred and ten EUS-FNA procedures were included in this analysis. Ninety six were males and 114 were females; median age was 65 years. Cysts were 1–5 cm in diameter and evenly distributed throughout the pancreas. One hundred and fifteen of the 210 (55%) cysts were >2 cm and 95 (44%) were <2 cm. 27 out of 210 (13%) were pancreatitis related cysts. 22-gauge needle was used for 55% of the procedures with the remaining procedures using 19 and 25-gauge needles. Eighty nine of 210 (43%) patients received periprocedural antibiotics. Only one of the total 210 patients (0.4%) developed post-procedural gram-negative bacteremia related to EUS within 1 week of procedure. This patient had received periprocedural antibiotics. None of the patients in the “no antibiotic” group had post-procedural infections (Table 1).

CONCLUSION:
The evidence supporting universal use of antibiotics for all cystic lesions as recommended is lacking and overall infection risk with FNA is low, at approximately 0.3% based on small studies. Our study of 210 patients including pancreatitis related cysts demonstrate that routine use of antibiotics may not be required for FNA of pancreatic cysts. Further prospective studies may be required to support this.
114 Opportunistic Screening of Bone Mineral Density With CT Scans in Chronic Pancreatitis
Authors: Manickavasagan Hanisha , Shah Zarine , Hart Phil , Lara Luis , Hinton Alice , Lu Andrew , Yadav Dhiraj , Conwell Darwin 
Published: October 2019

INTRODUCTION:
Osteoporosis and fragility fractures have been repeatedly shown to increase morbidity, mortality and socioeconomic costs. Chronic pancreatitis (CP) has multiple shared risk factors and complications that promote an imbalance in bone mineralization and remodeling which ultimately contributes to a high prevalence of metabolic bone disease. However, in the absence of societal guidelines regarding screening, dual-energy x-ray absorptiometry (DEXA) scans are not routinely performed and are not universally covered by insurance. While DEXA scan is the gold standard to assess bone mineral density, a Computed Tomography (CT) L1 vertebral density less than 135 Hounsfield Units (HU) has been validated to diagnose osteoporosis in the general population. The aim of this proof of concept study was to determine if the CT L1 vertebral threshold of 135 HU is also valid as an opportunistic screening cut-point for osteoporosis in chronic pancreatitis patients.

METHODS:
We selected patients with a definitive diagnosis of CP (according to the American Pancreatic Association guidelines) who were enrolled into The Ohio State Wexner Medical Center Pancreas Disease Biobank. Basic demographic information was abstracted including age, sex, race, BMI, smoking and alcohol history. Pertinent laboratory values and imaging studies, including DEXA scans, were also obtained from these patients. Baseline L1 vertebral HU values on CT scans were determined for BMD assessment (Pickhardt et al, Annals of Internal Medicine 2013).

RESULTS:
Sixty-four patients with definite CP were identified, including 27 (42%) with a CT and DEXA scan. Of these, 15/27 (56%) had evidence of metabolic bone disease (z-score < −1.5), including 15% with osteoporosis. Mean L1 HU value in those with osteoporosis was 106. There was a statistically significant association between osteoporosis (z score < −2.5) and the CT L1 HU threshold of 135 (P = 0.025, positive likelihood ratio of 8.62, PPV 60%). The L1 HU threshold of 135 had sensitivity of 75% and specificity of 91.3% for osteoporosis and a NPV of 95.45%.

CONCLUSION:
CT scans performed during routine clinical care of patients with CP may be useful for opportunistic screening for osteoporosis using L1 HU attenuation, especially at a threshold of 135. Larger sample sizes of patients are needed to further develop risk stratification models in CP considering other clinical risk factors.
116 The Impact of Laparoscopic Cholecystectomy on 30-Day Readmission Rate for Acute Cholangitis Patients: A Single Center Study
Authors: Alsayid Muhammad , Awadalla Mohanad , Albo Betty , Talat Arslan , Wassef Wahid 
Published: October 2019

INTRODUCTION:
Acute cholangitis is a serious inflammatory and infectious disease of the bile duct that requires prompt treatment. Choledocholithiasis is the main cause of acute cholangitis and requires biliary clearance using endoscopic retrograde cholangiopancreatography (ERCP). Following endoscopic clearance of the bile duct in patients with acute cholangitis, laparoscopic cholecystectomy (LC) is recommended for patients with gallstones. However, the timing of LC following acute cholangitis is still debatable. The aim of our study was to assess the impact of performing LC during admission following ERCP on the 30-day readmission rate.

METHODS:
A retrospective cohort study of acute cholangitis patients between April 2013 and May 2018. Patients were 18 years or older with a definite diagnosis of acute cholangitis based on Tokyo guidelines 2018. We only included acute cholangitis patients who underwent ERCP with complete clearance of the bile duct. Patients with malignant biliary strictures, a history of cholecystectomy, acute cholecystitis, intrahepatic ductal stones, primary sclerosing cholangitis, or cirrhosis were excluded. The primary outcome of the study was the 30-day readmission rate.

RESULTS:
A total of 95 patients with acute cholangitis were included in the study (Tables 1 and 2). Of these patients, 35 patients (36.8%) underwent LC during admission. The 30-day readmission rate was significantly lower in the LC group compared to the ERCP alone group (2.8% vs. 26.6%, P 0.003). There were no reported deaths in the LC group within 30 and 90 days of discharge, however the mortality rates in the ERCP alone group were 5.0% and 6.6%, respectively. In a multivariate analysis, performing LC during admission was an independent factor for 30-day readmission after adjusting for all other factors, where patients who underwent LC during admission had 90% less chance of readmission within 30 days (OR 0.1, 95% CI (0.01–0.86), P 0.03) (Table 2).

CONCLUSION:
Performing laparoscopic cholecystectomy during admission for acute cholangitis patients following endoscopic clearance of the bile duct was associated with a significant decrease (Absolute Reduction Rate 23.8%) in 30-day readmission rate. Several studies reported the safety of early LC in acute cholangitis patients as well as a decrease in the recurrence of biliary symptoms. Therefore, performing LC during admission should be recommended for acute cholangitis patients following endoscopic clearance of the bile duct.
130 Focusing With a New Lens: Analyzing the Quality of Internet Literature Related to the Gut Microbiome
Authors: Clarke Lindsay , Baumgartner Scott , Szvarca Daniel , Tabbara Nadeem , Basso Jessica , Dawit Lillian , Dave Jenny , Borum Marie 
Published: October 2019

INTRODUCTION:
The study of intestinal microbiota and its potential impact on human disease is an emerging field of research. Investigations initially focused on gastrointestinal disorders, but have expanded to include issues related to metabolic, immune, and neurologic function. Since individuals increasingly use electronic resources for medical decisions, assessment of available information is important. This study evaluated the readability, quality and use of evidence-based support of readily accessible online information about intestinal microbiota.

METHODS:
The search terms “gut microbiome” were inputted into Google. Exclusion criteria included websites that were non-accessible, included videos without transcripts, provided veterinary information or were duplicates. Sites were categorized by intended audience, either patient or professional. Readability was determined using the validated Flesch-Kincaid Grade Level Calculation. Websites were reviewed for inclusion of references, provision of additional links for further reading, and the acknowledgement of areas of uncertainty. Statistical analysis using a two-tailed Fisher's Exact Test and a Two-Sample T-test were used with a P-value set at < 0.05.

RESULTS:
100 websites were assessed with 87 meeting criteria for inclusion. 46 (52.9%) were intended for patients and 41 (47.1%) were for medical professionals. The average Flesch-Kincaid Grade level was 14.1, with significant difference (P < 0.0001) between patient (12.6 grade level) and professional (15.8 grade level) websites. 58.6% (25 patient; 26 professional) of websites provided additional links for further information. While 36.7% (12 patient, 20 professional) of all websites acknowledged areas of uncertainty, patient websites significantly more often (P = 0.04) acknowledged areas of uncertainty compared to professional. Patient sources were significantly (P < 0.0001) less likely to provide references (34.7%) as compared to non-patient sources (87.8%).

CONCLUSION:
Online resources on gut microbiome are readily accessible for patient and professional audiences. However, the readability of patient information exceeded the NIH 6th grade recommended reading level. Additionally resources infrequently provided references, links for additional information or acknowledged areas of uncertainty. As the gut microbiome becomes increasingly studied, it is critical that online information be readable and supported by evidence based research.
131 What's Your Gut Feeling? Evaluating Patient Resources on the Impact of the Gut Microbiome on Disease
Authors: Szvarca Daniel , Baumgartner Scott , Clarke Lindsay , Tabbara Nadeem , Basso Jessica , Borum Marie 
Published: October 2019

INTRODUCTION:
The gut microbiome is implicated in the pathogenesis of several inflammatory disorders and reported to influence extra-intestinal diseases, including malignancy, neuropsychiatric and cardiovascular disease (CVD). As dysbiosis is implicated in multiple health concerns, the accessibility and accuracy of information available to patients needs review. This study evaluated online sources addressing the role of the gut microbiome in-and-beyond gastrointestinal disease.

METHODS:
“Gut microbiome” was entered into Google to obtain the first 100 websites. Websites were excluded if non-accessible, duplicates, videos without transcripts or discussed veterinary topics. Sites were categorized by intended audiences: patient or professional. Sites were assessed for discussion of diseases, references and acknowledgement of uncertainty of claims. Readability was determined using the validated Flesch-Kincaid Grade Level Calculation. Statistical analysis used a two-tailed Fisher's Exact Test with P-value set at < 0.05.

RESULTS:
87 websites met inclusion criteria: 46 (53%) intended for patients, 41 (47%) intended for professionals. The average readability grade level for patient sites was 12.6 compared to professional sites at 15.8 (P < 0.0001). 69 sites discussed dysbiosis and disease: 38 GI (C. difficile, IBD, IBS) vs. 66 extra-intestinal disorders (psychiatric, neurologic, obesity, CVD, malignancy, other inflammatory conditions). 52 (60%) sites (16 patient; 36 professional) provided references; fewer in patient vs. professional sites (P < 0.0001). Patient sites less frequently provided references compared to professional sites when discussing psychiatric disease (P = 0.017), neurologic disease (P = 0.001), obesity (P < 0.001), CVD (P = 0.016), C. difficile (P = 0.035), IBD (P = 0.023) and cancer (0.022). Of those sites that discussed gut microbiome in relation to disease, 44 (64%) provided references and 29 (42%) noted uncertainty in claims with no significant difference between patient and professional sites.

CONCLUSION:
The functional gut microbiome may have a significant role in many gastrointestinal and extra-intestinal disorders. The content of patient intended sources about dysbiosis infrequently provides references, inadequately addresses areas of uncertainty and had a higher than NIH recommended 6th grade reading level. This study suggests a need for more evidence-based information with greater patient-centered language among online resources available to patients.
134 Fecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection: Efficacy and Predictors of Success
Authors: Abdallah Mohamed , Abdalla Abdelmohaymin , Wiedel Noah , Baloun Brett , Gilbert Jorge 
Published: October 2019

INTRODUCTION:
Clostridioides (formerly Clostridium) difficile infection (CDI) is the most commonly identified cause of healthcare-acquired infections in the united states (US). Fecal microbiota transplantation (FMT) is recommended for patients with three or more episodes of CDI. We aim to examine factors associated with the success of FMT in our institution.

METHODS:
A retrospective study of 59 patients who underwent FMT for CDI at Sanford Medical Center, Sioux Falls SD, the US between 2013–2018. All patients underwent FMT via colonoscopy. Antibiotics prior to FMT, donor screening, preparation and delivery of FMT, and post-procedural follow up were based on a standardized protocol in our institution. Data on baseline characteristics, CDI, safety and success rate of FMT (defined by resolution of symptoms and absence of CDI recurrence at 8 and 52 weeks) were collected.

RESULTS:
Baseline characteristics of our study population are shown in (Table 1). The mean age at FMT was 57 years (19–92 years). There were 96% Caucasians and 76% of females. 40% and 35% had three and four episodes of CDI prior to FMT, respectively. Antibiotics were implicated in CDI development in 80% of subjects, most commonly: penicillins (28.8%), cephalosporins (28.8%) and fluoroquinolones (23.7%). 20% had inflammatory bowel disease (IBD), 47% were on proton pump inhibitors (PPIs), and 22% were on immunosuppressants at the time of FMT. Regarding antibiotics used to treat CDI: 58/59 patients received at least one trial of oral vancomycin (84% had vancomycin with six weeks taper), 72% had oral metronidazole and 15% had fidaxomicin. In patients with available data, the success rate of FMT at 8 and 52 weeks was 82.7% (48/58) and 82.6% (43/52), respectively. Two patients (3.4%) had a repeat FMT for CDI recurrence. No major complications, mortalities related to FMT were reported in our study. Failure of FMT at 8 and 52 weeks was associated with female gender, IBD, and immunosuppressants. In our study, IBD was associated with hypertension, PPI, immunosuppressants, and FMT performed without antibiotic coverage for CDI.

CONCLUSION:
FMT is safe and effective for recurrent CDI. In our study, we demonstrated that IBD and immunosuppressants, closely related variables, were associated with FMT failure. Previous studies have shown that IBD is associated with poor outcomes in CDI, and in FMT for CDI. However, it is not clear why FMT failures occurred more frequently in females. Prospective studies with larger sample size are needed.
138 Multiplex Gastrointestinal Pathogen PCR Testing in HIV/AIDS Patients: The Relationship Between Enteric Infection and CD4 T-Cell Count
Authors: Hine Ashley M. , Lebwohl Benjamin , Axelrad Jordan E. 
Published: October 2019

INTRODUCTION:
Diarrhea is a common complication of HIV/AIDS. Although non-infectious enteropathy may be attributed to HIV infection, enteric pathogens are frequently detected in episodes of diarrhea. The objective of this study was to investigate the relationship between CD4 count and enteric infection as detected by multiplex gastrointestinal PCR stool testing in HIV/AIDS patients.

METHODS:
We performed a cross-sectional analysis of adult inpatients and outpatients who underwent stool testing with a FilmArray multiplex gastrointestinal pathogen PCR panel (GI PCR panel) during an acute episode of diarrhea from December 2015 to February 2019. Our primary endpoint was the detection of any enteric pathogen. Patients were stratified by the presence of HIV infection and CD4 count at time of stool testing.

RESULTS:
Of 80 HIV+ patients who underwent a GI PCR panel, 45 (56%) tested positive for an enteric pathogen (Table 1). HIV+ patients with CD4 counts >500 (n = 26) were more likely to have a pathogen detected (19, 73%) compared to patients with a CD4 count <200 (n = 30) consistent with AIDS (12, 40%; P = 0.03; Figure). Patients with a CD4 count between 201 and 499 (n = 24) had a positivity rate that was in between that of patients with low and high CD4 counts (14, 58%). Of 30 AIDS patients, 9 (30%) had a GI infection not detected by GI PCR including CMV, HSV, LGV, MAI, and syphilis. Among this subset of 9 AIDS patients, 4 (44%) tested negative on GI PCR. AIDS patients were less likely to be adherent to antiretroviral therapy, and more likely to be on opportunistic infection prophylaxis compared to HIV+ patients with CD4 counts >200 (P = 0.03 and P = 0.002 respectively.) Compared to patients with CD4 counts >200, those with AIDS were more likely to receive empiric antimicrobial therapy at stool testing (P < 0.001), and in the 30 days following stool testing, as likely to visit an emergency room (P = 0.24), require hospitalization (P = 0.31), or undergo endoscopic procedures for continued GI symptoms (P = 0.67).

CONCLUSION:
Enteric infections were common in HIV+ patients who underwent a GI PCR panel for an episode of diarrhea, with the highest proportion of positive results in patients with CD4 counts >500. Based on historical data, this rate of positivity is considerably higher than in the general population of patients with an episode of diarrhea. These data suggest that AIDS patients may be more likely to have a pathogen not included on the GI PCR panel, or a chronic cause of diarrhea such as HIV-enteropathy.