bluuebunny/crossref_metadata_2025_split huggingface dataset:
46 Comparison of Endoscopic Ultrasound Fine-Needle Aspiration and Fine-Needle Biopsy for Solid Pancreatic Masses
Authors: Woldesellassie Fitsum , Cristian Rios , Ganguli Surosree , Thomas Chandler , Furmanek Stephen , McClave Stephen , Omer Endashaw 
Published: October 2019

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CONCLUSION:
Hypertriglyceridemia-induced acute pancreatitis patients are more likely to have SIRS on admission and are predicted to have a more severe clinical course based on validated scoring systems. However, with close multidisciplinary management including endocrinology and hematology consultations when indicated, these patients do not have a more adverse course relative to those with pancreatitis from other etiologies.