bluuebunny/crossref_metadata_2025_split huggingface dataset:
78 What Is the Impact of a Delayed Presentation on Outpatients With Post-ERCP Pancreatitis? An Analysis of Clinical Predictors and Outcomes
Authors: Bick Benjamin L. , Fogel Evan L. , Schmidt Suzette , Elmunzer Badih , Tong Yan , Gromski Mark A. , Sherman Stuart , Lehman Glen , Watkins James L. , Cote Gregory A. , Tarnasky Paul , Kwon Richard , Guda Nalini , Pleskow Douglas , Easler Jeffrey J. 
Published: October 2019

INTRODUCTION:
Post-ERCP pancreatitis (PEP) occurs in up to 15% of high risk patients. Symptoms after ERCP are common and usually determine admission. However, discharge of outpatients at risk for PEP is frequent after ERCP. In retrospective studies, discharged PEP patients are at increased risk for severity, possibly due to delays in IV fluid therapy. The aim of this study is to evaluate clinical predictors and outcomes in patients discharged and later admitted with delayed presentation of PEP.

METHODS:
We identified consecutive outpatients with PEP enrolled in a prospective study designed to evaluate the optimal rectal Indomethacin dose for prevention of PEP in high-risk patients. All patients received Indomethacin and were observed for at least 4 hours post-ERCP per protocol. All clinical data except IV fluids, recovery medications, and pain scores were collected prospectively. Diagnosis and severity of PEP was defined by Cotton criteria.

RESULTS:
107/720 (14.9%) developed PEP. 135/720 (18.8%) were directly admitted after ERCP. While the direct admission rate in patients that developed PEP was higher (P < 0.001), 58/107 (54.2%) were discharged and had a delayed presentation of PEP. Median time to presentation was 24 hours (IQR 15–31.75 h). Discharged patients were older (age 47.7 vs 41.1, P = 0.026), more often had a morning procedure (59.2% vs 39.7%, P = 0.044), less often had pancreatic stent placement (82.8% vs 95.9%, P = 0.032), spent less time in recovery (261 vs 312 minutes, P = 0.004), required less IV opioids (6.4 vs 17.3 MME, P < 0.001) and had lower pain scores (2.8 vs 6.5, P < 0.001) (Table 1). On multivariable analysis, an afternoon procedure (OR 4.00, P = 0.016) and pain score >3 (OR 1.37, P = 0.001) were associated with admission. While discharged patients were more likely to present with SIRS on admission (43.1% vs 10.2%, P < 0.001), a delayed presentation was not associated with severe PEP (Table 2).

CONCLUSION:
Delayed presentation of PEP after discharge of high-risk patients is frequent, but not associated with adverse outcomes or severe PEP. Systematic deployment of PEP prophylaxis with rectal Indomethacin, pancreatic stents, and IV fluids may attenuate the impact of delayed presentation on outcomes. Afternoon procedure time and increased pain appear to influence decisions to admit. However, given the frequency of delayed presentation of PEP, accurate and early diagnostic tests for PEP may be of clinical value.
80 Long-Term Follow-Up of Patients With Pancreatic Cystic Lesions Who Had No Significant Changes in the First 5 Years of Diagnosis
Authors: Lee Brian S. , Chang Karen , Nguyen Andrew K. , Tekeste Timnit F. , Girgis Agathon , Adeyemo Mopelola , Hanna Maryam S. , Kwok Karl , Giap Andrew Q. , Chaya Charles , Hunt Gordon C. , Kao Kevin , Attam Rajeev , Ko Albert , Yao Janis F. , Pio Jose R. , Tovar Stephanie , Lim Brian S. 
Published: October 2019

INTRODUCTION:
Discontinuation of surveillance after 5 years for pancreatic cystic lesions (PCL) without significant changes remains controversial. Long-term outcomes of patients with PCL with no significant changes in the first 5 years were evaluated.

METHODS:
We performed a retrospective analysis of patients with PCL diagnosis from 2005 to 2011 with follow-up until 2017. Significant changes were defined as the history of pancreatic cancer, pancreatectomy, high risk stigmata (HRS), worrisome features (WF) and worrisome EUS features (WEUS). Details of HRS, WF, WEUS in Table 1.

RESULTS:
Of 1551 patients with the diagnosis of PCL, 984 had no significant changes in the first 5 years. Range of follow-up was 5–13 years (190 patients >10 years). Median (Q1–Q3) cyst size at initial imaging was 12 (9–17) mm; maximum cyst size in first 5 years and post 5 years were 13 (9–18) mm and 15 (10–22) mm, respectively. 4 patients developed pancreatic cancer (0.41%; at 80, 97, 70, and 103 months). 7 (0.71%), 99 (10%), 5 (0.51%) patients developed HRS, WF, WEUS, respectively. Median (Q1–Q3) time to cancer, HRS, WF, and WEUS were 88.7 (75.3–100), 97.2 (66–109.6), 78.2 (72.5–97.9), 77 (68–104) months, respectively. Patients with CSO/clinically significant outcomes (defined as pancreatic cancer, HRS, WF, WEUS) post 5 years had larger maximum cyst size in the first 5 years compared to those without CSO [median (Q1–Q3) 16 (12–23) vs 12 (9–17) mm, P = 0.0001] (Figure 1). 152 patients died post 5 years (3 due to pancreatic cancer). The incidence of pancreatic cancer and CSO at 7 years post 5-year period (12 years from PCL diagnosis) in patients with no significant changes were 0.7% and 12.5%, respectively. The mortality due to pancreatic cancer was 0.45%; mortality due to all causes was 31.7%. Median (range) of Charlson Comorbidity Index (CCI) was 2 (0–16) at 5 years post PCL diagnosis. The mortality rate at 7 years post 5-year period for ACCI (age-adjusted CCI) of ≤3, 4–6, and ≥7 were 3.5%, 28% and 58% (P < 0.0001), respectively (Figure 2).

CONCLUSION:
The incidence of pancreatic cancer in patients with PCL with no significant changes in the first 5 years of diagnosis remains low at 0.7%. The incidence of clinically significant outcomes (CSO) was higher at 12.5%. Maximum cyst size of ≥15 mm in the first 5 years had higher cumulative incidence of CSO in long-term follow-up. These risks should be weighed against patients' overall mortality (based on scoring systems such as CCI) when making surveillance decision of PCL beyond 5 years.
82 A Comparison of Machine Learning and Logistic Regression Performance for the Prediction of In-Hospital Mortality Among Acute Biliary Pancreatitis Patients
Authors: Luthra Anjuli K. , Porter Kyle , Hinton Alice , Krishna Somashekar G. 
Published: October 2019

INTRODUCTION:
For population databases, traditional multivariate analysis is accepted standard for predictive modelling of mortality in acute biliary pancreatitis (ABP). Machine Learning (ML) and artificial intelligence (AI) are novel methodologies to analyze databases. The gradient boosting machine (GBM) is a tree-based ML approach. Tree-based algorithms partition the data based on predictors in an attempt to accurately classify the outcome. The gradient boosting approach employs successive trees to improve upon misclassifications of the earlier trees. Alternatively, logistic regression is a statistical approach, in which predicted probabilities are generated based on parameters estimated by maximum likelihood estimation. With the advent of universal electronic medical records, patient databases are more complex, large, and interlinked to multiple institutions. Hence, we sought to compare traditional statistical methods and ML in building prediction models for mortality in ABP.

METHODS:
Using the Nationwide Readmission Database (2010–2014), we identified all patients (age > 18 years) with index admissions for ABP. This data was randomly divided into a training set (70%) and a test set (30%), stratified by outcome in order to get similar event rates in both sets. The same training and test sets were used for GBM learning and logistic regression. The area under the ROC curve (AUROC) was calculated for both GBM and logistic regression modelling for predicting mortality in ABP.

RESULTS:
A total of 97,027 patients were hospitalized for ABP from 2010–2014 in the US. The in-hospital mortality rate was 0.97% (n = 944). Using the same set of predictor variables (demographic, hospital, etiological, comorbidities, severity of acute pancreatitis (AP), procedures, and duration of stay), ML and logistic regression performed similarly in predicting mortality with GBM achieving an AUROC of 0.955 and logistic regression AUROC 0.948 (Figure 1). Key predictors of mortality for AP using logistic regression included: Severe AP, sepsis, increasing age, and failure to perform cholecystectomy. Foremost predictors using GBM included length of stay, age, severe AP and income quartile.

CONCLUSION:
Notwithstanding emergence of novel AI methodologies, traditional logistic regression is comparable to novel ML algorithms in the predictive modelling of hospital outcomes in ABP and can continue to be utilized in large population databases.
92 Management of Pancreaticopleural Fistula in Necrotizing Pancreatitis: A Single Tertiary Care Center Experience
Authors: Dirweesh Ahmed , Choo Christopher , Amateau Stuart , Azeem Nabeel , Mallery Shawn , Freeman Martin , Trikudanathan Guru 
Published: October 2019

INTRODUCTION:
Pancreaticopleural fistula (PPF) is a rare sequelae of necrotizing pancreatitis (NP) consequent to pancreatic duct (PD) disruption. Due to low prevalence, experience in the management of this condition remains sparse outside specialized centers and management remains controversial. We report our center experience with PPF. The study aimed to report the demographic and clinical characteristics, management and outcomes of NP patients with radiologically confirmed PPF in our institution.

METHODS:
A retrospective analysis of all 515 NP patients managed at our institution between 2010–2019 was performed from a prospectively maintained database for the occurrence of PPF. Baseline characteristics, clinical presentation, management and outcomes were evaluated.

RESULTS:
Five white patients (three males and two females, median age 51 years [range, 38–63 years]) with PPF were managed in our institution during the study period, with a prevalence of 1%. The etiology of pancreatitis was alcohol in three and idiopathic in two. All patients had documented exudative pleural effusion with amylase content >1,000 U/L. All patients underwent computerized tomography (CT), magnetic resonance imaging (MRI) and/or sinogram studies to delineate the fistula and site of PD disruption. All patients required ERCP with PD stenting and/or chest tube placement. No patient required surgical intervention. Four patients (75%) remain well at a median follow up of 6 months, while one died during the same hospitalization (25%).

CONCLUSION:
Pancreaticopleural fistulae can present a challenging diagnostic dilemma and require a high index of clinical suspicion. Early recognition and a multi-disciplinary approach in centers with specialized experience are vital for successful management of this condition.
96 Impact of the National Opioid Epidemic on Chronic Pancreatitis Related Admissions
Authors: Chatila Ahmed , Bilal Mohammad , Siddiqui Mohamed Tausif , Al-Hanayneh Muhannad , Shah Aun R. , Desai Madhav , Wadhwa Vaibhav , Parupudi Sreeram , Casey Brenna W. , Krishnan Kumar , Hernandez-Barco Yasmin G. 
Published: October 2019

INTRODUCTION:
Opioid use disorder (OUD) has become a public health emergency in the United States. Patients with chronic pancreatitis (CP) are at high risk for opioid dependence due to chronic pain associated with the disease process. We aimed to evaluate the prevalence, impact and predictors of OUD in patients hospitalized with CP.

METHODS:
A retrospective cohort study was performed using the national inpatient sample (NIS) database from 2005–2014. Patients with a primary diagnosis of CP and OUD were included. OUD-related diagnosis were identified using previously published studies. The primary outcome was to evaluate the prevalence and trend of OUD in patients hospitalized with CP over time. Secondary outcomes were: i) to assess the impact of OUD on healthcare resource utilization, ii) identify predictors of OUD in hospitalized CP patients.

RESULTS:
A total of 176,857 CP patients were included, and OUD was present in 3.8% of patients. The prevalence of OUD in CP doubled from 2.7% in 2005 to 5.4% in 2014 (Figure 1). Patients with CP who had OUD were found to have higher mean length of stay (adjusted mean difference: 1.2 days (95% CI: 1.1–1.4), P < 0.001) and total hospitalization costs (adjusted mean difference: $1,936 (95% CI: 1590–2282), P < 0.001). Independent predictors of OUD in CP patients were obesity, presence of depression, and increased severity of illness (Table 1).

CONCLUSION:
OUD related diagnoses are increasing among patients with CP and are associated with increased healthcare resource utilization. Our study identifies an important group of patients at high-risk for OUD whose pain should be carefully managed.
97 Performance Comparison Between Endoscopic Ultrasound/endoscopic Retrograde Cholangiopancreatography and Intraoperative Cholangiography for Detecting Choledocholithiasis
Authors: Vyas Neil , Alshati Ali , Kosa Dimas , Shehzad Pir , Bhattarai Bikash , Bellapravalu Sharad , Nadir Abdul , Srinivasan Indu , Chuang Keng-Yu 
Published: October 2019

INTRODUCTION:
The diagnosis and management of choledocholithiasis have been evolving given multiple diagnostic modalities. One of these diagnostic modalities is intraoperative cholangiogram (IOC) which is typically performed during laparoscopic cholecystectomy for evaluation of choledocholithiasis. Our aim is to compare endoscopic ultrasound (EUS) to IOC in the accurate detection of a common bile duct stone using endoscopic retrograde cholangiopancreatography (ERCP) as gold standard for diagnosis.

METHODS:
A five-year retrospective single center study was performed for patients diagnosed with choledocholithiasis due to a positive IOC during laparoscopic cholecystectomy. These patients subsequently were tested with EUS and ERCP (Group 1). Analysis was also performed in which patients underwent IOC with subsequent ERCP without EUS (Group 2). We used ERCP as the gold standard to ascertain a percentage of true positives, true negatives, sensitivity, specificity and corresponding 95% exact confidence intervals. Demographic data and laboratory values (bilirubin and liver enzymes) prior to endoscopic procedure were also described.

RESULTS:
All of the 24 IOC positive patients (Group 1) were subjected to EUS and the majority of these patients underwent an ERCP. EUS detected 80% (8/10, 95% CI: 48.1–96.5) true positives and 92.3% (12/13, 95% CI: 67.5–99.6) true negatives among these IOC positive patients (Figure 1). 52 patients who underwent IOC and subsequent ERCP without EUS (Group 2). 43 of the 52 patients were positive to IOC. Nine IOC negative patients were examined with ERCP and 6 were negative. IOC detected 69.7% (30/43, 95% CI: 54.9–82.0) of true positives and 66.7% (6/9, 95% CI: 33.2–90.7) true negatives (Figure 1). With a sensitivity of 90.9% (95% CI: 75.7–98.1) and specificity of 31.6% (95% CI: 12.6–56.6), IOC resulted 30.2% (13/43, 95% CI: 18.0–46.1) false positives and 33.3% (3/9, 95% CI: 9.27–66.8) false negatives.

CONCLUSION:
Test performance of EUS in IOC-positive patients compared to test performance of IOC in patients not tested with EUS were comparable. However, with about a third of patients exposed to unnecessary ERCP, clinical practicality of IOC as the screening test is questionable. Large proportion of false positives is not desirable for a screening test with less than perfect sensitivity. Thus, EUS can help risk stratify patients and presumably avoid or minimize unnecessary ERCP risks to patients. Additional studies with large patient populations will be more conclusive.
101 The Effect of Disability on the Diagnosis and Treatment of Pancreatic Cancer in the Republic of Korea: A National Cohort Study
Authors: Choi Jongwook , Cho Byungha , Lee Jun Su , Kwon Hyeonwoo , Kim Seongmin , Park Seon Mee 
Published: October 2019

INTRODUCTION:
Pancreatic ductal adenocarcinoma (PC) is the fifth leading cause of cancer-related mortality and the eighth most common cancer in Korea. Korea has various national databases that can provide information regarding different health status factors, such as disability status, cancer, and delivery of health-care and associated medical costs. This study aimed to determine whether the diagnosis, treatment approach and prognosis of pancreatic cancer (PC) varied according to the presence, severity and type of disability.

METHODS:
Demographic, socioeconomic, and medical data were obtained from the National Disability Database, the Korean Central Cancer Registry, and the Korean National Health Insurance claims database. An age- and sex-matched cohort was established using a 1:3 ratio of 2,776,450 people with disabilities and 8,329,350 people without disabilities. Adult patients diagnosed with PC were subsequently selected from this cohort. Disabilities were categorized as physical, brain, communication, mental impairment, and affecting the major internal organs.

RESULTS:
The cohort included 12,402 patients with PC, with a significantly lower rate per 105 persons among people with disabilities than among people without disabilities (114.9 vs. 102.1, P < 0.0001). People with disabilities were more diagnosed PC at earlier age (P < 0.0091). Patients with disabilities had higher Charlson comorbidity index (1.47 vs. 2.00) and more below poverty line (5.8% vs. 13.3%) than those without disabilities. People with severe disabilities were diagnosed PC at earlier age, but less likely to undergo surgery (adjusted odds ratio 0.83, 95% confidence interval 0.77–0.96) or chemotherapy (0.81, 0.74–0.90) than those without disabilities. The overall and cancer specific mortality rates were higher in patients with disabilities than those without disabilities. This trend was more evident among patients with severe disabilities and in those with mental disorders.

CONCLUSION:
In Korea, people with disabilities generally have a lower rate of PC diagnosis, receive less intensive treatment, and have a lower survival rate than people without disabilities.
105 Are Race or Sex Associated With Mortality, Interventions, or Palliative Care Use in Pancreatic Cancer Patients? An Urban Center Experience, 2010–2017
Authors: Jamorabo Daniel S. , Renelus Benjamin D. , Gurm Hashroop , Bhesania Siddharth , Briggs William M. 
Published: October 2019

INTRODUCTION:
Treatment options for pancreatic cancer are well-established, but patients do not necessarily receive the same treatments for various reasons including unequal access to care, differences in medical literacy, or cultural barriers. We investigated whether or not disparities existed in the management of pancreatic cancer based on sex and race at our university-affiliated, urban hospital from 1/1/2010 through 12/31/2018.

METHODS:
We did a retrospective review of all pancreatic cancer cases diagnosed from 2010–2017 at our institution. We used Fisher's exact test to evaluate overall mortality and palliative care team involvement by patient sex and race. We used Cox proportional univariate regressions to compare survival following surgery, chemotherapy, and palliative care involvement based on sex, race, and age group (≤80 years old and >80 years old). Kaplan-Meier plots were used to determine mortality by sex, race, and age group.

RESULTS:
We identified 201 patients with biopsy-proven pancreatic cancer. Of those, 110 (54.7%) had died by date of last contact. We found no statistically significant difference in overall mortality based on sex, race, or age group. Chemotherapy did not confer a survival advantage, but we found an overall decrease in mortality following surgical intervention (HR 0.39, 95% CI 0.24–0.65; P = 0.0003) that was particularly evident in the first 1000 days following diagnosis (Figure 1). The palliative care team was involved in just 61/201 (30.3%) of cases with white patients being 70% less likely to have documented contact with the service compared to non-white patients (P = 0.004). Black patients had a higher likelihood than white patients of being seen by the palliative care team while hospitalized (OR 3.36, 95% CI 1.70–6.96; P = 0.0007).

CONCLUSION:
Sex and age group were not associated with differences in treatment. While surgical intervention appeared to be beneficial for the first three years following diagnosis, overall mortality after 1000 days was unchanged. Palliative care service has been underutilized across the cohort, despite there not being a long-term survival benefit with chemotherapy or surgery. White patients were less likely than black patients to be seen by our palliative care team, which could reflect a tendency to pursue more aggressive treatments or possibly decreased receptivity to palliative care involvement in this patient population. This discrepancy must be examined further through prospective or cross-sectional studies for clarification.
111 Clinical Utility of EUS-Guided Needle-Based Confocal Endomicroscopy of Pancreatic Cystic Lesions for Surgical Decision Making
Authors: Krishna Somashekar , Hart Phil , Luthra Anjuli K. , Porter Kyle , Papachristou George , Lara Luis , Conwell Darwin 
Published: October 2019

INTRODUCTION:
There is a need to assess the clinical impact of utilizing EUS-guided needle-based confocal endomicroscopy (nCLE) in the surgical management of PCLs. Hence, we sought to evaluate the concordance of diagnoses using the standard of care (SOC) clinical data with EUS-nCLE, and the impact on surgical resections of PCLs.

METHODS:
Subjects included consecutive patients enrolled in a prospective study (2015–2018) evaluating EUS-nCLE for the diagnosis of PCLs who underwent a clinically indicated EUS-FNA, along with EUS-nCLE. Data used to derive the SOC diagnosis included clinical history, cross-sectional imaging, EUS morphology, cyst fluid CEA, and cytology (based on hierarchical group assignment, Table 1). Decisions for patient management also involved multidisciplinary tumor board meetings. A final diagnosis of PCLs was defined for those with surgical histopathology or presence of established mutations in the cyst fluid (KRAS/GNAS: mucinous cyst, VHL: serous cystadenoma). The diagnostic concordance of EUS-nCLE alone with SOC was assessed.

RESULTS:
A total of 138 subjects with PCLs (mean cyst size 36.4 ± 15.7 mm) underwent SOC and EUS-nCLE. A final diagnosis was available in 93 subjects (surgical histopathology, n = 67, molecular markers in cyst fluid, n = 26). Diagnostic concordance was observed in 80 (86%) subjects, with a discordant nCLE diagnosis in the remaining 13 (14%) subjects. Among PCLs with discordant diagnoses (Table 2), EUS-nCLE was “clinically advantageous” in 11 subjects with successful downstaging of PCLs which were otherwise classified as mucinous by SOC, hence potentially preventing unwarranted surgery. In one subject, nCLE was “clinically advantageous” with successful upstaging of PCL (final diagnosis: IPMN), while SOC inaccurately classified the lesion as a non-mucinous PCL. EUS-nCLE was “clinically disadvantageous” in one subject (final diagnosis was mucinous cystic neoplasm) who were classified as a mucinous cyst by SOC, but nCLE did not reveal diagnostic image patterns.

CONCLUSION:
EUS-nCLE has a significant clinical impact by preventing at least one unwarranted pancreatic surgery for every ten subjects undergoing multimodality SOC evaluation. Hence EUS-nCLE should be considered for a comprehensive assessment of PCLs when FNA is being performed.