bluuebunny/crossref_metadata_2025_split huggingface dataset:
48 An Overused Lab Test? Evaluating Repeat Lipase in the Management of Acute Pancreatitis and Its Impact on Patient Outcomes
Authors: Datta Samit K , Inaganti Anupama , Nguyen Michael T. , Singh Maharaj , Affi Aboud 
Published: October 2019

INTRODUCTION:
Lipase has historically been used to diagnose acute pancreatitis. Its role in prognostication and determining illness severity has been poorly elucidated. A recent literature review demonstrated an inconclusive role of serial lipase in managing acute pancreatitis. Our aim was to evaluate the frequency of repeat lipase and its effect on outcomes.

METHODS:
Retrospective chart review on patients admitted to 3 facilities with a new diagnosis of acute pancreatitis between 2016–2018. Patients (age > 18) who presented with epigastric pain and lipase levels > 1179 (3x ULN) were included. Those with an unclear admission diagnosis or prior pancreatitis were excluded. Data collected included baseline characteristics, admission and any repeat lipase values, admission SIRS and BUN, cause of pancreatitis, length of stay (LOS), and mortality. Statistical analysis was performed using SAS Institute Statistical Analysis Program Version 9.4.

RESULTS:
203 patients met inclusion criteria. There were statistically significant differences in sex and pancreatitis etiology (Table 1). Baseline lipase was not significantly different between the repeat lipase group (RLG) and the non-repeat lipase group (NRLG) (13268.7 vs 7472.8, P = 0.059) (Table 1). LOS was significantly different (5.35 d in RLG vs 2.72 d in NRLG, P = 0.001) (Table 1). There was no difference in mortality (1.8% in RLG vs 0.0% in NRLG, P = 0.450). When done, lipase was repeated an average of 2.88 times and it dropped to <3x ULN in 81.2% of patients (Table 2). Lipase was repeated in 63.6% of patients after lipase to <3x ULN. There was no difference in LOS (5.57 d if lipase <3x ULN vs 4.22 d if lipase not <3x ULN on repeat, P = 0.095) and lipase trended down in 98.8% of patients (Table 2).

CONCLUSION:
Our study demonstrates a frequent remeasurement of lipase levels for first acute pancreatitis episodes. Patients who did not have their lipase repeated had a statistically significant shorter LOS. Age, SIRS, and BUN were used as surrogate markers of severity (BISAP unable to be calculated) and there were no statistically significant differences. Lipase trend unlikely affected discharge as there was no difference in LOS in patients whose lipase went to < 3x ULN. Lipase was repeated even after returning to <3x ULN, suggesting overuse of repeat lipase. There was no difference in mortality. Therefore, our study suggests that repeat lipase does not affect patient discharge and is being overutilized.
49 National Trends in Liver and Pancreatic Malignancy in the U.S.: Increasing Interventions yet Mortality Persists
Authors: Chkhikvadze Tamta , McNary James , Gigauri Nino , Feng Zizhen , Shi Junxin , Kwak Ye Eun 
Published: October 2019

INTRODUCTION:
Although there have been recent advances in the treatment of liver and pancreatic cancer, the incidence of both has continued to rise in the USA as well as worldwide. Our aim was to analyze the most recent trends in hospital admissions for malignant liver and pancreas neoplasms and the associated interventions, as well as in-hospital mortality in the US using the largest administrative database, the National Inpatient Sample (NIS).

METHODS:
We extracted admission data of patients of all ages (0–70+) from 2006 to 2014 with associated primary ICD-9 diagnosis codes of liver (155.0) and pancreatic neoplasms (157), and queried for associated procedures (total/local excision/destruction, transplantation, Whipple procedure). Survey data analysis methods were used for national estimates and trend analysis.

RESULTS:
National estimates of admissions due to liver cancer continued to rise from 29,388 in 2006 to 54,930 in 2014. Pancreatic cancer related admissions have also been increasing from 71,479 in 2006 to 95,145 in 2014 (Figure 1). The majority of liver and pancreatic cancers manifested in patients over the age of 50 (92.5%), with the highest number of hospitalizations occuring in patients above age 70 (38%, Table 1). There were more males than females who were admitted due to liver or pancreatic cancer (59% vs. 41%), and most patients were White (67%), followed by Black (14%), Hispanic (11%), Asian/Pacific Islander (4.4%) and Native American/other (3.5%). Despite increasing numbers of cancer related hospitalizations, in-hospital mortality has been decreasing from 11% to 8% in the same 9 year period. Liver transplantation has tripled (650 in 2006 to 1940 in 2014), and the number of loco-regional interventions on liver cancer as well as partial pancreatectomy and Whipple procedures have together all increased at greater rates than hospitalizations for each malignancy (Table 1).

CONCLUSION:
Liver and pancreatic cancer related hospitalizations in the USA has risen for the last decade, and so has the intent-to-cure procedures for these malignancies. The curative liver transplant and Whipple procedure have almost tripled and doubled in number, respectively. However, in-patient mortality from both liver and pancreatic cancer has decreased only by 3% in the past decade and mortality rates remain at 8%. Future strategies to optimize liver and pancreatic cancer screening and medical/surgical treatment is urgently needed in order to decrease liver and pancreatic cancer related admissions and mortality.
55 Choice of Sedation in Endoscopic Retrograde Cholangiopancreatography: Is Monitored Anesthesia Care Safer Than General Anesthesia? Systematic Review and Meta-Analysis
Authors: Dhaliwal Amaninder , Dhindsa Banreet , Satiya Jinendra , Mashiana Harmeet , Bhogal Neil , Rangray Rajani , Ofosu Andrew , Sayles Harlan , Bhat Ishfaq , Singh Shailender , Adler Douglas G. 
Published: October 2019

INTRODUCTION:
Monitored anesthesia care (MAC) and general anesthesia (GA) are the two most common methods of sedation used for endoscopic retrograde cholangiopancreatography (ERCP). We performed systematic review and meta-analysis to compare the overall safety between MAC versus GA in ERCP.

METHODS:
We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Web of Science databases, Google Scholar and manual search of references (from inception through May 2019) to identify the studies reporting use of MAC or GA as choice of sedation for ERCP. The primary outcome was to compare the overall sedation related side effects including hypoxia, arrhythmias, hypotension and aspiration in MAC versus GA groups. The secondary outcome was to study the total duration of procedure and recovery time. The meta-analysis was performed using Der Simonian and Laird random effect model.

RESULTS:
A total of 28 studies (11 in GA group and 18 in MAC group) reporting on 12918 patients were included. One study was included in both the groups. The mean age in both the groups was 60 years. A total of 27 studies reported sedation related side effects. The overall sedation related side effects were similar in GA (12.76%; 95% CI = 5.80–21.73, I2 = 95%) versus MAC (12.08%; 95% CI = 5.38–20.89, I2 = 99%) groups with P = 0.859 (Figure 1). In sub-group analysis, hypoxia, arrhythmias, hypotension, aspiration and other sedation related side effects were similar between the two groups (Table 1). The recovery time and duration of procedure was reported in 10 and 14 studies respectively. Although, the mean duration of procedure was more in MAC group (47 min versus 33 min) but mean recovery time was less as compared to GA group (47 min versus 59 min). Only 1.7% of the MAC patients were converted to GA. Significant heterogeneity was noted in in our meta-analysis.

CONCLUSION:
In our meta-analysis, overall sedation related side effects were similar between MAC versus GA groups. The mean duration of procedure was lower in GA group but on contrary recovery (mean) was noted to be faster in MAC group. Based on our meta-analysis, monitored anesthesia care could be used as an alternative to general anesthesia when performing ERCP, although high risk patients may be better served by general anesthesia. Large multicenter randomized control trials are needed to further validate our findings.
56 Is There Association Between Pancreatic Divisum and Other Pancreatic Conditions Including Acute Pancreatitis, Chronic Pancreatitis, and Pancreatic Tumors?
Authors: Al-Aboodi Yasir , Alazzawi Yasir , Al-Chalabi Ahmed , Nawras Ali 
Published: October 2019

INTRODUCTION:
Over many decades, there has been controversy about pancreatic divisum and its association with acute and or chronic pancreatitis. In this study, we used the largest national data registry to examine the relation between pancreatic divisum and the other forementioned pancreatic conditions.

METHODS:
A retrospective analysis is performed on the National Inpatient Data base (NIS) of 2014 to examine the association between pancreatic Divisum, pancreatitis (Acute and chronic) and pancreatic tumor. Case (Divisum) -control (No divisum) design is created. The no divisum (Control) is selected using the random percentage. The international code for diseases version nine (ICD9) is used to identify all variables. All ages, sex and races were included.

RESULTS:
660cases vs 5000 control encounters are identified with a mean age of 49 years. Of the 660, 35.5% (235) male, and 64.5% (426) female. 481 (72.9%) are white, 62 (9.4%) black, 71 (10.8%) Hispanic, 19 (2.9%) Asians, 9 (1.4%) Native Americans and 18 (2.7%) others. 262/660 (39.7%) in the Divisum group has been found to have a diagnosis of chronic pancreatitis vs.0.6% in the non Divisum group (control). P < 0.005, OR = 103, CI 95% (70–153). 327/660 (49%) in the pancreatic divisum group have acute pancreatitis vs 1.4% (70) in the control group. P < 0.000, OR = 70.78, 95% CI (53.081–94.398) with the adjustment to other risk factors for chronic and acute pancreatitis including smoking, alcohol, cystic fibrosis, TGD pancreatitis, and gallstones pancreatitis and idiopathic pancreatitis. Only 3 cases of pancreatic tumor were detected in the pancreatic Divisum group.

CONCLUSION:
There is strong association between Pancreatic divisum and acute and chronic pancreatitis. Yet this association might be influenced by the selection bias from inpatient population only. There is no association found between pancreatic Divisum and pancreatic tumor.
59 Pancreas Enzyme Replacement Dosing Before and After Total Pancreatectomy and Islet Autotransplantation
Authors: Lara Luis , Buss Jill , Schaefer Monica , Black Sylvester , Rajab Amer , Kuntz Kristin , Hart Phil , Conwell Darwin , Washburn Kenneth 
Published: October 2019

INTRODUCTION:
Pancreas enzyme replacement therapy (PERT) is used to improve nutrient digestion, especially of lipids, in patients with exocrine pancreas insufficiency who otherwise may experience maldigestion, malabsorption, malnutrition, and steatorrhea. Although underdosage of PERT is common, adequate dosing is particularly important in patients who undergo total pancreatectomy and islet autotransplantation (TPIAT). Current PERT dosing guidelines do not explicitly provide recommendations following TPIAT so we determined the adequacy of PERT dosing in a cohort of patients with TPIAT.

METHODS:
The TPIAT database from 2009-2018 was searched to determine PERT dosing in subjects before TPIAT (n = 14), immediately after TPIAT and at 6 and 12 months (n = 11). Adequate weight based dosing was established using Cystic Fibrosis Foundation guidelines. Average PERT dose was calculated and the ranges were reported, P < 0.05 was significant.

RESULTS:
Data was available in 14 patients, and 6 and 12 month data was available in 11 patients. Indication for TPIAT included 6 idiopathic chronic pancreatitis (CP), 4 genetic CP (4 PRSS1, 1 CFTR), 3 idiopathic recurrent AP, 1 alcohol induced CP. 3 patients were not using PERT before TPIAT, 7 were underdosed (average 62,000 U/day, range 6,000–108,000), and 4 were adequate (205,250 U/day; 125,000–228,000). At discharge 9 patients were underdosed (72,222 U/day; 6000–108,000), and 5 were adequate (248,200 U/day; 125,000–360,000). At 6 months 3/11 pts (27%) were underdosed (56,666 U/day; 30,000–80,000) and 8/11 pts (73%) were adequate (228,000 U/day; 144,000–432,000). At 12 months 2/11 pts (18%) were underdosed (108,000 U/day each) and 9/11 (82%) pts were adequate (430,222 U/day; 144,000–384,000). PERT dose increase was significant for the period post-TPIAT to 6 months (P = 0.04). The graph shows the trend of PERT during the study period.

CONCLUSION:
Underdosing of PERT was common before and immediately after TPIAT. It is possible that poor oral intake dictated the immediate low post TPIAT dose. Significant PERT dose increase was noted in the first 6 months, and was sustained at 12 months. PERT dosing needs to be monitored closely and weight based dosing should be considered to achieve optimal nutritional benefit.
64 Acute Pancreatitis Outcomes May Not Be Worse in Post-Transplant Patients
Authors: Wadhwa Vaibhav , Gonzalez Adalberto , Gupta Kapil , Castaneda Daniel , Garg Sushil , Bilal Mohammad , Lara Luis 
Published: October 2019

INTRODUCTION:
The average incidence of acute pancreatitis (AP) in patients with a history of solid organ transplant ranges from 2 to 8%. Patients with a history of bone marrow transplant are reported to have an incidence of 4%. Presentations include “chemical” pancreatitis with enzymes elevation only and clinical pancreatitis according to the revised Atlanta criteria. A few previous studies have shown that multi-organ failure and death are frequent complications of AP in transplanted patients. Most of the studies individualize their findings based on a specific organ transplanted (such as kidney or heart or liver, etc.) The aim of our study was to evaluate the outcomes of patients with acute pancreatitis with a history of any solid organ or bone marrow transplant using a national database.

METHODS:
We performed a retrospective cross-sectional analysis using the National Inpatient Sample (NIS) database from 2014. We included all patients with acute pancreatitis (ICD 9 Code: 577.0). Next, we divided the AP patients into two groups - one with history of a transplant and those without a history of transplant. We compared the outcomes of both groups. Both univariable and multivariable analyses were performed to assess the risk factors and outcomes of patients with acute pancreatitis in post transplant patients.

RESULTS:
We analyzed more than 35 million US hospitalizations in 2014 out of which 279,145 were acute pancreatitis related hospitalizations. There were 1,265 hospitalizations for acute pancreatitis in previously transplanted patients, an incidence of 4.53%. The mortality rate of AP was similar in non-transplanted patients (0.66%) than in transplanted patients (0.4%). The mean length of stay (4.62 days vs. 4.61 days) and mean total charges ($35,723 vs. $31,202) were similar in acute pancreatitis for transplant and non-transplant patients. Multivariable regression analysis showed that multiorgan dysfunction risk among AP patients was significantly higher if they had a history of transplant (OR of 2.27; P < 0.01).

CONCLUSION:
Our study showed that AP generally has similar outcomes in transplant and non-transplant patients even with a higher risk of multiorgan failure. More data is needed to determine if this holds true for subjects who develop AP in the immediate post transplant period.
66 Predictors of Increased Hospital Length of Stay Among Elderly Individuals With Acute Pancreatitis
Authors: Bassi Mehak , Mohapatra Sonmoon , Charilaou Paris , Bandla Harikrishna , Pitchumoni Capecomorin 
Published: October 2019

INTRODUCTION:
Acute pancreatitis (AP) is one of the most common conditions affecting the elderly. Older age is recognized as a marker of severity in most severity scoring systems. In this study, we aim to compare the demographics, clinical and laboratory variables, and outcomes between elderly (age ≥65 years) versus younger (age <65 years) patients with AP. We also aimed to determine the factors associated with increased hospital length of stay (LOS) in elderly individuals admitted with AP.

METHODS:
For this retrospective study, our hospital's inpatient database was used to identify patients with AP between January 2015 to August 2018. Group differences were tested with Chi-square for categorical variables and t-test/quantile regression analysis for continuous variables. After the univariate analysis was conducted and the clinical relevance of significant variables was assessed, the multivariate accelerated failure time model was used to determine factors affecting LOS.

RESULTS:
Among 277 subjects with AP, 64 (23%) were elderly (≥65 y, mean 74.3 ± 0.9 y). Compared to the younger population (age <65 y, mean 42.5 ± 0.9 y), elderly patients were more associated with Type 2 DM (40.6% vs 22.5% P = 0.004), hypertension (78.1% vs 29.1%, P < 0.001), congestive heart failure (10.9% vs 1.9%, P = 0.001), CKD (12.5% vs 2.8%, P = 0.002), malignancy (23.4% vs 5.6%, P < 0.001), coronary artery disease (15.6% versus 2.8%, P < 0.001), and COPD (17.2% vs 4.2%, P < 0.001) (Table 1). Elderly patients had a higher blood urea nitrogen, creatinine, amylase, and low albumin levels at the time of admission compared to the younger population. The mean LOS was higher in the elderly population (5.2 ± 0.7 vs 4.5 ± 0.2 days, P = 0.037) compared to the younger individuals. Presence of pancreatitis related complications, the performance of cholecystectomy and endoscopic interventions (EUS and ERCP) during the same admission, and higher serum creatinine at the time of admission were independently associated with increased LOS (Table 2).

CONCLUSION:
1. Older age in itself is not a cause of increased mortality or morbidity in AP. 2. Comorbid conditions are commonly associated with older age but not significantly associated with increased LOS in AP. 3. The factors associated with increased LOS in elderly AP patients include the presence of pancreatitis related complications, the performance of cholecystectomy and endoscopic interventions during the same admission, and higher serum creatinine at the time of presentation.
71 The Safety of Endoscopic Retrograde Cholangiopancreatography in Renal Transplant Patients
Authors: Alomari Mohammad , Sarmini Muhammad Talal , Asfari Mohammad Maysara , Al Momani Laith , Nehme Fredy , Aasen Tyler , Young Mark 
Published: October 2019

INTRODUCTION:
Patients with renal transplant (RT) are prone to higher rates of complications after procedures and surgical interventions. The literature that evaluates the outcomes of endoscopy retrograde cholangiopancreatography (ERCP) in RT patients is scarce. Therefore, we conducted this study to evaluate the outcomes of ERCP in RT patients using a large nationwide inpatient database.

METHODS:
Using data from the National Inpatient Sample (NIS) database between 2011 and 2014, we identified all patients who underwent ERCP using appropriate ICD 9 coding. Afterwards, we divided patients who had ERCP into two groups: patients with RT (study group) and patients without RT (control group). Primary outcomes included post ERCP adverse effects (AE): post ERCP pancreatitis (PEP), bleeding, and perforation. Secondary outcomes included inpatient mortality (IM) and length of stay (LOS). AEs and mortality were compared using multivariate logistic regression analysis after adjusting for potential cofounding factors including: (age, race, gender, smoking, and Elixhauser comorbidities).

RESULTS:
A total of 108,199 patients underwent ERCP, of which 343 (0.32%) had RT. RT patients were younger (median age: 58 vs. 59), less likely to be female (48.1% vs. 59.8%), and more likely to be African American (12.1% vs. 9.1%) compared to the control group (P < 0.05). In addition, RT patients were less likely to have alcohol abuse (2% vs. 4.1%) and smoking (3.8% vs. 12.1%) compared to the control group (P < 0.05) (Table 1). Using multivariate logistic regression, individuals in the RT group had a statistically significant higher odds for PEP (OR 1.61, 95% CI: 1.05–2.47, P < 0.05) compared with the control group. On the other hand, there was no statistically significant difference between the two groups in bleeding (OR 1.32, 95% CI: 0.42–4.14, P > 0.05) and IM (OR 0.97, 95% CI: 0.31–3.06, P > 0.05). The post ERCP perforation rate was 0.04% (n = 48) in the control group while the RT group had no reported perforations. Finally, the adjusted LOS was longer in the RT group compared to the control group (6.51 vs 5.49, P < 0.05) (Figure 1).

CONCLUSION:
This is one of the largest studies that assessed the outcomes of ERCP in RT patients to date. Our analysis showed that patients with RT had increased risk for PEP, while there was no significant difference in the post ERCP bleeding rate or IM. Careful selection and close monitoring for RT patients requiring ERCP is warranted to avoid complications in this population.
79 A Multi-Center Comparison of Proceduralist Versus Radiology Technician-Driven Fluoroscopy in Endoscopic Retrograde Cholangiopancreatography: Best When You Do It Yourself!
Authors: Hughes Michelle , Khara Harshit S. , Thosani Nirav , Bartell Nicholas , Bittner Krystle , Ullah Asad , Kumar Vikas , Khalid Ammara , Diehl David L. , Confer Bradley , Patil Prithvi , Johnson Alexandra , Kothari Truptesh , Kaul Vivek , Kothari Shivangi 
Published: October 2019

INTRODUCTION:
Patients are exposed to radiation during endoscopic retrograde cholangiopancreatography (ERCP) which may increase the cumulative risk of the development of cancer and/or of other radiation-related adverse events. ERCP utilizes radiological guidance to direct diagnosis and therapy of biliary and pancreatic pathology. There is limited data available evaluating if the amount of radiation directed to the patient during ERCP is different by endoscopist-directed fluoroscopy versus when ERCP is assisted by radiology technician. Our aim was to assess the difference in the dose of radiation administered to the patient when fluoroscopy during ERCP is operated by the endoscopist versus the radiology technician.

METHODS:
This is an IRB-approved multi-center retrospective chart review of patients who underwent ERCP between 07/2017 and 11/2018 at three high-volume academic centers. Patient-specific data was collected including demographics, cholecystectomy status and indication for ERCP. Procedural and fluoroscopic data were also obtained. Descriptive and inferential analyses were performed utilizing SPSS software.

RESULTS:
During the study period, a sample of 100 patients that underwent ERCP performed with radiology technician (RT) assistance (two tech-driven institutions; n = 50 each) and a sample of 50 patients with endoscopist-led fluoroscopy (ELF) were compared. Patient characteristics are summarized in Table 1. The most common indication for ERCP was choledocholithiasis (n = 26 vs. 24, RT vs ELF, respectively). Mean procedure time (34.6 vs. 26.6 min, RT vs. ELF; P = 0.056) and mean fluoroscopy time (5.2 vs. 4.9 min, RT vs. ELF; P = 0.897) were similar in both groups. The ELF group obtained a significantly greater number of images during ERCP (RT 9.9 vs. ELF 14.6, P < 0.001). The mean dose of radiation (Gy/cm2) administered to the patient was significantly higher in the RT group (RT 40.6 vs. ELF 20.3; P = 0.016).

CONCLUSION:
Endoscopist-driven fluoroscopy during ERCP is associated with lower radiation dose compared to radiology technician assisted fluoroscopy at high volume ERCP centers. Endoscopists are also better at saving more images during an ERCP. Future education and training of radiation technicians may help reduce the radiation to the patients.