bluuebunny/crossref_metadata_2025_split huggingface dataset:
76 Hepatorenal Syndrome Carries the Highest Risk of In-Hospital Mortality Among Hospitalized Patients With Primary Biliary Cholangitis
Authors: Galoosian Artin , Hirode Grishma , Wong Robert 
Published: October 2019

INTRODUCTION:
Primary biliary cholangitis (PBC) is an autoimmune and progressive cholestatic liver disease with significant morbidity and mortality. Hospitals with safety-net burden (SNB) provide an essential role to serving low-income and historically vulnerable populations. We aim to evaluate factors, including hospital SNB, associated with in-hospital mortality among hospitalizations with PBC.

METHODS:
Using the 2012–2014 National Inpatient Sample, we evaluated US adults hospitalized with PBC (using ICD-9 codes). Hospital SNB was defined as the percentage of hospitalizations among PBC with Medicaid or uninsured payer status per hospital, and was categorized into two groups: no SNB vs. any SNB. Between-group comparisons used chi-squared testing. Survey-weighted, adjusted multivariate logistic regression analysis was used to evaluate factors associated with in-hospital mortality.

RESULTS:
Among 7,364 hospitalizations with PBC (mean age 64.0 + 14.3y, 16.1% men, 70.3% non-Hispanic White), 65.3% were in no SNB and 34.7% were in low-high SNB hospitals. Crude in-hospital mortality was 4.15%, with no significant differences by hospital SNB. On adjusted regression, among the cirrhosis-related complications analyzed, the presence of ascites (OR 1.85, 95% CI 1.36–2.52, P < 0.001), hepatic encephalopathy (OR 2.32, 95% CI 1.75–3.08, P < 0.001) and hepatorenal syndrome (OR 7.58, 95% CI 5.12–11.2, P < 0.001) resulted in higher odds of in-hospital mortality compared to those without the respective complication present. Additionally, hospitalizations at urban teaching hospitals also had a higher odds of in-hospital mortality compared to rural hospitals (OR: 2.04, 95% CI: 1.20–3.46, P = 0.01).

CONCLUSION:
Hospitalizations with PBC with concomitant cirrhosis-related complications had significantly higher odds of in-hospital mortality. Specifically, PBC hospitalizations with hepatorenal syndrome were 7.6 times more likely to die during hospitalization. Urban teaching hospitals also had higher in-hospital mortality compared to rural hospitals.
81 Machine Learning Based Predictive Models Are More Accurate Than TNM Staging in Predicting Survival in Patients With Pancreatic Cancer
Authors: Das Amit , Ngamruengphong Saowanee 
Published: October 2019

INTRODUCTION:
Accurate prognostic prediction is important for treatment planning in patients with pancreatic cancer (PC). Although clinical and socioeconomic factors impact patient survival, traditional prognostic evaluation methods [e.g., TNM staging] do not incorporate these factors. A more accurate and comprehensive tool is needed. We evaluated machine learning (ML) based analytic models to predict survival of patients with PC using data from the Surveillance, Epidemiology, End-Results (SEER) database.

METHODS:
The SEER database was accessed to identify patients aged ≥18 yr. with histologically confirmed PC diagnosed between 2004–2015. Demographic, socioeconomic, clinical variables (AJCC stage, site, grade, and size of the tumor, treatment received, survival in months) were extracted and analyzed. Using ML software, an ensemble of predictive analytic models (Classification Tree-based, Bayesian net, Neural net, support vector, and K-nearest neighbor classifier) was built and trained using supervised learning algorithms for prediction of 1-year survival probability. Separate models were built using only baseline variables (A model) and including treatment-related variables [surgery, chemotherapy, and radiotherapy (B model)].

RESULTS:
Data on 42,673 patients with PC were used to develop the predictive models [Table 1; mean age, 67 yr.; 52% males; 80% white; stage I/II/III/IV/unknown: 6.0%/27.7%/10.3%/52.5%/3.5%; median survival (range): 6 (2–13) months with 78% surviving ≤12 months]. Ten independent prognostic variables were identified in multivariate Cox regression analysis: year of diagnosis, tumor stage/grade, presence of metastasis, age, tumor size, marital status, insurance status, US region, socio-economic factors, and these variables were entered into the ML models. Figure 1 shows the predictive importance of the different variables used in the two models. AUROC (Area Under the Receiver Operating Characteristics) of the A and B models in predicting 1-year survival probability were 0.804 (95% CI: 0.800–0.808) and 0.832 (95% CI: 0.828–0.836), respectively, which were both significantly higher that of the TNM staging system (AUROC = 0.696; 95%CI: 0.691–0.700); P < 0.0001; Figure 2).

CONCLUSION:
Using advanced ML techniques for analyzing a large dataset, we developed predictive models that accurately predicted the survival of patients with PC and were superior to the existing TNM staging system. These models may serve as an effective tool for prognostic evaluation of PC in clinical settings.
85 Trends in the Use of TPN Among Patients Admitted With Acute Pancreatitis
Authors: Pievsky Daniel , Kabaria Savan , Shulik Oleg 
Published: October 2019

INTRODUCTION:
Acute pancreatitis (AP) is a common condition impacting the gastrointestinal tract that accounts for a high amount of patient morbidity and mortality. It has long been recognized that enteral nutrition (EN) is the preferred feeding modality for patients with AP; however, parental nutrition (PN) has still been commonly used. In 2010 the Cochrane group published a meta-analysis showing the superiority of EN compared to PN in AP, but the first formal guidelines recommending against PN use in severe AP were not published until 2013. Our aim was to investigate the trends of PN use in AP and assess if the release of practice guidelines resulted in a change in clinical management.

METHODS:
We analyzed the National Inpatient Sample database for patients hospitalized with AP with and without PN from 2000 to 2014. Patients were identified using ICD 9 codes. Inclusion criteria were age ≥18, elective admission, and a primary diagnosis of AP. Trend models were fit to adjust for patient demographics, type of insurance, income quartile, Charlson Comorbidity Index, and hospital characteristics.

RESULTS:
Overall, 106,426 patients (3.41% of those hospitalized for AP) received PN. Baseline patient demographics, hospital characteristics, and insurance information are shown in Table 1. The trend of PN use by year in patients with AP can be seen in Table 2. Overall use has declined since 2007; however, the rate of decrease was greatest from 2011 to 2014, with a mean yearly decrease of 0.45%. While 55% of all patients who received PN were located at non-teaching hospitals, the percentage of hospital patients on PN was greater in teaching hospitals (3.84% vs. 3.12%, P < 0.0001). The yearly trend of PN use among teaching and non-teaching hospitals can be seen in Table 3. The mean yearly decrease in PN use from 2000 to 2014 is similar for teaching (0.18%) and non-teaching hospitals (0.17%). Since 2011, however, PN use for AP among teaching hospitals has been declining at a faster rate than among non-teaching hospitals (0.45% decrease vs. 0.41%).

CONCLUSION:
Use of PN for patients hospitalized with AP was significantly higher in teaching compared to non-teaching hospitals. This is likely due to the severity of AP treated at teaching hospitals. The greatest yearly decrease in the rate of PN use for AP was between 2011 and 2014, likely due to Cochrane meta-analysis published in 2010. Both teaching and non-teaching hospitals have decreased PN use in AP, as per published guidelines.
89 Opioid Dependence Among Chronic Pancreatitis Patients: A Trend Analysis of 15 Years
Authors: Twohig Patrick , Butt Muhammad , Gardner Timothy , Sandhu Dalbir S. 
Published: October 2019

INTRODUCTION:
Pain is a common symptom in chronic pancreatitis (CP) and has a significant impact on quality of life. Although a variety of pain management strategies exist, opioids are the most frequently used analgesic given their high oral bioavailability and activity at multiple neuropathic and visceral pain receptors. Limited data exists on the trends of opioid dependence in CP. Our aim is to characterize trends in opioid use in CP over the last 15 years.

METHODS:
We performed a retrospective analysis in the IBM Explorys database (1999–2018), a pooled, de-identified clinical database of over 63 million unique patients from 26 health care networks and 300 hospitals across the United States. At the time of analysis there were 63,656,680 patients. Patient populations were identified using SNOMED and ICD codes. Cochrane-Armitage testing analyzed trends in chronic opioid use among CP patients between 2004–2018. Subgroup analysis for gender, age, race, and insurance status were assessed.

RESULTS:
83,650 adult patients (>18 years old) had CP. 7,220 patients with CP were opioid dependent. The odds of being opioid dependent if diagnosed with chronic pancreatitis was 21.90 (P < 0.0001). Over the 15-year period, opioid dependence in chronic pancreatitis patients has significantly increased (2.25% to 4.35%; P < 0.0001). Most significant increase is noted among Medicaid (P = 0.0004) and Caucasian (P = 0.0001) patients.

CONCLUSION:
We present the first study to assess trends in opioid dependence among patients with CP over the last 15 years. Pain management is a critical component of treating CP. Multiple patient-dependent factors influence pain scores and opioid use in CP patients, including a history of alcohol use and psychological comorbidities. Side effects and opioid hyperalgesia significantly hinders their efficacy for long-term pain control.3 Pain exacerbation is the most common reason for hospitalization in CP, resulting in significant cost to the health care system.9 Opioid use and hypoalbuminemia are the biggest patient-specific risk factors for being hospitalized. Our results indicate that chronic opioid use in CP has increased in the last 15 years. Given the risks and side effects of opioids, along with recent legislation that more strictly regulates dispensation, finding alternative pain management techniques is essential in maintaining good quality of life for these patients.
100 Outcomes of Acute Pancreatic in Patients With and Without History of Cholecystectomy
Authors: Singh Amandeep , Sarmini Muhammad Talal , Alomari Mohammad , Sanaka Madhusudhan R. 
Published: October 2019

INTRODUCTION:
Acute pancreatitis (AP) has been shown to have a high mortality of up to 21%. But, data are lacking on the mortality and other outcomes in patients who underwent cholecystectomy. We aimed to assess the outcomes of AP in patients who had history of cholecystectomy versus who retained their gall bladder.

METHODS:
Using data from the National Inpatient Sample (NIS) database between 2002 and 2014, we identified patients who were diagnosed with AP using appropriate ICD 9 coding. Patients with AP were divided into two groups: with history of cholecystectomy (study group) and without history of cholecystectomy (control group). We then performed multivariate logistic regression analysis to compare the outcomes of AP between the two groups. Outcomes of interest included: inpatient mortality (IM), respiratory failure (RF) and acute kidney injury (AKI).

RESULTS:
A total of 1,094,214 total patients with AP were identified, of which 18,263 patients (1.67%) had history of cholecystectomy. Patients with cholecystectomy were older (53 vs 52), more likely to female (56.6% vs 49.9%) and less likely to be African American (11% vs 16.6%) than the control group (P < 0.001 for all). In addition, patients with cholecystectomy had less alcohol abuse (12.8% vs 22.8%, P < 0.001) but more likely to be obese (13.1% vs 9.4%) and smokers (23.1% and 19.4%) when compared to the control group (P < 0.001) (Table 1). Using Multivariate logistic regression, and after adjusting for potential cofounding factors including (age, race, gender, obesity, alcohol abuse, smoking and Elixhauser comorbidities), individuals in the cholecystectomy group had a lower rate of in-patient mortality (IM) (OR 0.21, 95%, CI: 0.16–0.28, P < 0.001), respiratory failure (RF) (OR 0.30, 95%, CI: 0.26–0.34, P < 0.001) and acute kidney injury (OR 0.58, 95%, CI: 0.54–0.63, P < 0.001) when compared to patients without cholecystectomy (Figure 1).

CONCLUSION:
Our study suggests that cholecystectomy in patients admitted with acute pancreatitis is associated with lower risk of IM, RF and AKI and should be considered in all patients admitted with acute pancreatitis.
110 Outcomes in Patients With Acute Pancreatitis and HIV Using the Nationwide Inpatient Sample Database
Authors: Patel Preet , Shaikh Amjad , Patel Pavan , Ahlawat Sushil 
Published: October 2019

INTRODUCTION:
Acute pancreatitis has been extensively studied, however the effect of HIV status on outcomes has yet to be described. Here, we aim to assess the effects of positive HIV status on the mortality and overall outcomes in patients hospitalized with acute pancreatitis.

METHODS:
Data between 2008 and 2014 from the Nationwide Inpatient Sample database was extracted. Inclusion criteria for both groups included patients with a primary diagnosis of acute pancreatitis using International Classification of Diseases, 9th Revision codes and age greater than 17. Exclusion criteria included all ICD-9 codes for chronic pancreatitis and malignant pancreatico-biliary disorders and indeterminate HIV status. The study group consisted of patients with a primary diagnosis of acute pancreatitis and a concurrent diagnosis of HIV. In-hospital mortality was compared between the two groups. Univariate and multivariate analyses were used to generate odds ratios. Elixhauser Comorbidity scores predicting mortality and readmission were calculated based on weighted scores from 29 different comorbidities. Scores were compared between the two groups using univariate analysis.

RESULTS:
There were a total of 295386 patients with acute pancreatitis and no HIV and 2580 patients with acute pancreatitis and HIV for hospitals in the United States between 2008 and 2014. There was no significant difference in hospital mortality between acute pancreatitis with HIV and acute pancreatitis with no HIV on univariate analysis. There was a significant difference in hospital mortality on multivariate analysis for the HIV vs non-HIV groups (OR = 1.751, P = 0.011). HIV patients had a significantly higher Elixhauser mortality (5.72 ± 9.7) and readmission (31.63 ± 18.772) scores as compared to non-HIV patients' mortality (4.46 ± 8.58) and readmission (14.39 ± 13.28) scores P < 0.001, indicated a higher rate of comorbidities.

CONCLUSION:
Patients with HIV that are admitted with acute pancreatitis have a significantly higher mortality than those without HIV. We suspect the additional mortality may be due to an increased rate of comorbidities among HIV patients as evidenced by the greater Elixhauser scores. The higher rate of comorbidities among patients with HIV may be explained by a higher rate of infections and relative immunocompromised status compared to the non-HIV patients.
120 Microscopic Colitis and Risk of Colon Adenomas: A Multicenter Retrospective Cohort Study
Authors: Kamboj Amrit K. , Zylberberg Haley , Lane Conor , Colbenson Gretchen , DeCuir Nicole , Lennon Ryan , Khanna Sahil , Lebwohl Benjamin , Pardi Darrell 
Published: October 2019

INTRODUCTION:
Microscopic colitis (MC) is a common cause of chronic watery diarrhea. Cross-sectional studies have suggested that patients with MC have a lower incidence of colon polyps compared to those without MC. However, existing literature is limited by a lack of longitudinal follow-up and the use of average-risk patients, rather than those with chronic diarrhea as controls. We aimed to further explore the association between MC and colon adenomas.

METHODS:
This retrospective cohort study included patients that underwent colonoscopy at Mayo Clinic (Rochester, MN) or Columbia University Medical Center (New York, NY) between 7/1/2006 and 12/31/2016. Consecutive cases with MC were identified using pathology databases at each center. Controls had chronic diarrhea, underwent colonoscopy, and did not have MC on biopsy. Cases and controls were matched 1:2 by age (±3 years), sex, and date of index colonoscopy (±6 months). Data was collected on demographics, tobacco and alcohol use, personal and family history of colon neoplasia, and presence of adenomas at the index or follow-up colonoscopies.

RESULTS:
The study included 376 patients with MC and 752 non-MC patients with chronic diarrhea. The median (range) age of patients was 64 (21, 88) years and 72% were female. Duration of follow-up was not significantly different between the 2 groups (total person years: cases 577, controls 972; P = 0.99) and 51 subjects had a new adenoma on follow-up. There were no significant differences in age, sex, alcohol use, family history of colon neoplasia, and personal history of inflammatory bowel disease between cases and controls. Patients with MC were more likely to be current tobacco users (10% vs. 6%, P = 0.02) and less likely to have a history of prior colon neoplasia (9% vs. 17%, P < 0.001). Patients with MC were significantly less likely to have colon adenomas at the time of their index colonoscopy (5% vs. 12%; odds ratio 0.36; 95% CI 0.21, 0.60; P < 0.001) after adjusting for tobacco use and history of prior lesions. However, when followed over time, there was no significant association between MC and risk of colon adenomas (Figure 1, P = 0.45) after adjusting for tobacco use, history of prior lesions, and presence of adenoma at index colonoscopy.

CONCLUSION:
Patients with MC are less likely to have colon adenomas at their index colonoscopy compared to those with chronic diarrhea without MC. However, when followed longitudinally, there appears to be no significant association between MC and risk of colon adenomas.
125 Underwater Versus Conventional Endoscopic Mucosal Resection for the Treatment of Colorectal Laterally Spreading Tumors: Results From an International, Multicenter, Randomized Controlled Trial
Authors: Hamerski Chris , Samarasena Jason , Lee David P. , Wang Andrew Y. , Strand Daniel , Amato Arnaldo , Watson Rabindra , Nett Andrew , Calitis Jona , Binmoeller Kenneth 
Published: October 2019

INTRODUCTION:
Safe and effective resection of large colonic polyps remains a challenge for the practicing endoscopist. Recently, an underwater technique for endoscopic mucosal resection (UEMR) has emerged as an alternative to conventional injection-assisted EMR (CEMR). While the effectiveness of UEMR technique seems to be borne out in several case series and retrospective analyses, prospective data regarding its performance against CEMR technique is lacking.

METHODS:
This study was a prospective international multicenter randomized controlled trial involving 4 tertiary referral centers, 3 in the US and 1 in Italy, in order to compare the outcomes and safety of UEMR versus CEMR technique for large colon polyps (15 mm or larger). Block randomization was used to assign patients to either the UEMR arm or CEMR arm. Primary outcome was the rate of curative resection, as documented by presence of residual neoplasia on 3–6 month surveillance colonoscopy. Secondary outcomes included resection time, total procedure time, en bloc resection rates, and adverse events.

RESULTS:
A total of 303 patients with 303 lesions were enrolled in this trial. 145 patients were randomized into the CEMR arm, and 158 patients were enrolled in the UEMR arm. Among those in the CEMR arm, 13 patients crossed over into the UEMR arm at the discretion of the performing endoscopist. Among those in the UEMR arm, 1 patient crossed over to the CEMR arm. At follow up, a total of 95 patients had surveillance colonoscopy performed in the CEMR arm, with residual neoplasia found in 16 of these patients (16.8%). In the UEMR arm, 118 patients followed up, with residual neoplasia found in 10 of these patients (8.5%) [P = 0.06] The resection time and total procedure time were found to be less in the UEMR arm and there was a significantly higher rate of en bloc resection achieved by UEMR versus CEMR (P < 0.01). There was no difference in the rate of adverse events.

CONCLUSION:
This large multicenter randomized study supports that UEMR technique is a safe and effective alternative to CEMR technique and should be considered a first line option in the management of large laterally spreading colorectal tumors.
132 Failure of Prescribing Bowel Regimens at Hospital Discharge for Patients on Opioid Medications
Authors: Moore Andrew , Kapil Anuja , Jones Sabrina K. , Lee Salina 
Published: October 2019

INTRODUCTION:
Opioid-induced constipation (OIC) is estimated to affect 40–80% of those on opioid therapy. Aside from added costs to the healthcare system, untreated constipation can cause adverse effects ranging from abdominal pain to more serious complications such as colonic perforation. No specific guidelines exist on the prescription of bowel regimens with opioid medications; however, expert opinion suggests that a bowel regimen should be prescribed with any opioid medication. The objective of this study was to evaluate the frequency of prescribing a bowel regimen with opioid medications on inpatient discharge medication reconciliations.

METHODS:
We identified all patients at an academic institution admitted on the general medical-surgical floors from the dates of 1/1–1/14/18. The discharge summaries of all patients admitted during the above time period were manually reviewed, and patients who were discharged on an opioid medication were identified. Of those patients, we identified those who were discharged on a bowel regimen and noted the specific regimen at discharge. No distinction was made between a new or prior prescription for opioid medication. We then calculated the percentage of patients who were discharged on an opioid medication with a bowel regimen.

RESULTS:
380 patients were admitted from 1/1–1/14/2018 on the general medical-surgical floors. Of those 380 patients, 12 were excluded due to chart restrictions and death during admission. Of the 368 patients remaining, 184 (50%) were male and 184 (50%) were female. 145 (39.4%) were discharged on an opioid. Of that population, only 72 (49.7%) were discharged on a bowel regimen. 116 of 145 were discharged on a single opioid regimen, and of those, 48 (41.4%) were discharged on a bowel regimen. 28 of 145 were discharged on dual opioid regimen, and of those, 23 (82.1%) were discharged on a bowel regimen.

CONCLUSION:
Despite the clear association of constipation with opioid use, more than half of patients discharged on an opioid medication were not prescribed a bowel regimen. Due to the wide-ranging complications of constipation and its economic burden, clear prescribing guidelines for bowel regimens with opioids need to be established. Within our institution, further research is to be conducted on developing a flagging system within the EMR at discharge to identify patients who are discharged on an opioid medication and to provide recommendation for the appropriate regimen for these patients.