bluuebunny/crossref_metadata_2025_split huggingface dataset:
61 Spontaneous Resolution of Biliary Obstruction in Patients With Acute Gallstone Pancreatitis and Acute Cholangitis: A Retrospective Study in a Single Medical Center
Authors: Mubder Mohamad I. , Hong Annie , Dhindsa Banreet , Saghir Syed , Makar Ranjit , Cross Chad , Ohning Gordon 
Published: October 2019

INTRODUCTION:
Spontaneous resolution of biliary obstruction has been reported in a high percentage of patients who present with gallstone acute pancreatitis (AP) and acute cholangitis (AC). Persistent biliary obstruction is associated with significant morbidity and requires urgent endoscopic intervention. Currently, the reported percentage of spontaneous resolution varies widely. Invasive intervention associated with its own risk and complication. Early identification of patients with spontaneous resolution of obstruction can help avoid unnecessary endoscopic intervention.

METHODS:
A retrospective chart review of patients admitted to University Hospital from June 2015 through Dec 2017 with a diagnosis of gallstone AP and AC. ICD-10 codes were used to identify the study cohort (K85.10, K85.11, K85.12, K85.90, K80.32, K80.33, K80.36, K80.37, K80.31). Inclusion criteria include patients with AP (exhibiting 2 out of 3 of abdominal pain, Lipase >3 times the upper limit of normal or features of pancreatitis on imaging with proof of obstruction on imaging) and AC (exhibiting fever, abdominal pain, and jaundice with proof of obstruction on imaging). Data were analyzed temporally using RM-ANOVA with each group as a between-subjects factor; all analyses were completed using SPSS (v. 25).

RESULTS:
Out of 398 patients reviewed, 114 patients were included. 35 patients (30%) demonstrated a stone on imaging and required intervention to relieve the obstruction. 17 (15%) patients showed stone on imaging and demonstrated the spontaneous passage of the stone via ERCP. 62 (54%) patients showed clinical suspicion of spontaneous passage on initial imaging with clinical improvement with or without intervention. No significant differences in characteristics, comorbidities or biochemical markers were identified.

CONCLUSION:
Data from this population-based cohort showed approximately 15% of stones demonstrated on imaging in AP and AC pass spontaneously without intervention. Unlike prior studies done in different populations, no significant difference was found in patients with demonstrated stone between those who required intervention and those who had a spontaneous passage that can help early recognition. A high percentage of patients (54%) showed clinical signs of spontaneous passage of the stone on admission.
65 Comparing Radiation Time in Radiology Technologist-Controlled Versus Endoscopist-Controlled Fluoroscopy During Endoscopic Retrograde Cholangiopancreatography
Authors: Bou-Abboud Matta Carine , Karb Daniel B. , Ahmad Dina , Chak Amitabh , Glessing Brooke , Faulx Ashley , Dumot John , Isenberg Gerard , Wong Richard C. , Smith Zachary L. 
Published: October 2019

INTRODUCTION:
The necessary use of fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) involves radiation exposure to the endoscopy staff and patients. Radiation technologists (RT) are formally trained to minimize exposure whereas endoscopists are not. The aim of this study was to primarily determine whether involvement of RT reduced fluoroscopy time and secondarily to identify independent predictors of increased fluoroscopy time during ERCP.

METHODS:
We conducted a retrospective review of ERCPs performed between August 2017–September 2018 within a single healthcare system. This system is unique in that it has 2 endoscopy units, both of which perform high-volume, high-level ERCPs. Four interventional endoscopists on faculty perform ERCPs at both centers. In one unit (site 1) the fluoroscopy units are controlled by the endoscopist and in the second (site 2) a RT controls it at the direction of the endoscopist. Procedure notes were reviewed for demographic and procedural data. Univariate analyses were used to assess differences among individual variables by site using Chi-squared and Mann-Whitney U test. Secondary comparisons included independent predictors of increased fluoroscopy time as assessed by multivariable linear regression. To minimize confounding, only ERCPs performed by endoscopists who work at both centers were analyzed.

RESULTS:
A total of 949 ERCPs were performed during the study period and 605 met inclusion criteria. Patient demographic and procedure characteristics are outlined in Table 1. There was no significant difference between fluoroscopy times in ERCPs that were RT-controlled (mean 372.7 seconds, st. dev. 391.5) versus endoscopist-controlled (334.2 seconds, st. dev 350.4). When controlling for confounding variables in the multivariable model, this difference remained statistically nonsignificant. Independent predictors of high fluoroscopy time in the multivariable model include trainee involvement, ERCP level 3 complexity, hilar biliary obstruction, technically unsuccessful ERCPs, stent placement, balloon or catheter dilation, mechanical and electrohydraulic lithotripsy, ductoscopy and outpatient procedures (Table 2).

CONCLUSION:
Involvement of a trained RT during ERCP does not decrease fluoroscopy time. Several other fixed and modifiable variables were independently associated with high fluoroscopy times, including trainee involvement. These results stress the importance of formal fluoroscopy education early in an interventional endoscopy fellowship.
67 Appraisal of Follow-up Protocols and Outcomes of High Risk Pancreatic Cancer Surveillance Programs: A Systematic Review and Meta-Analysis
Authors: Chhoda Ankit , Mukherjee Eric , Wattamwar Kapil , Kastrinos Fay , Farrell James J. 
Published: October 2019

INTRODUCTION:
Individuals with familial or genetic predisposition are at high risk of pancreatic cancer (PC) and undergo screening. After baseline imaging, these high-risk individuals (HRIs) undergo regular follow-up through cross-sectional imaging, endoscopic ultrasound (EUS), or a combination of these modalities. The follow-up of HRIs is largely based on guidelines, and the evidence and consensus for optimal imaging modality and screening intervals are scarce. The current study is the first systematic review appraising various follow-up strategies among HRIs screened for PC for the detection of new lesions and progression of preexisting abnormalities.

METHODS:
Prospective studies on PC surveillance were analyzed to determine the imaging intervals and predominant modality-Cross sectional imaging: CT or MRI, or Combined EUS and cross sectional imaging. The outcomes of interest included incidence of new lesions where baseline was normal and progression of screen-prevalent lesions, defined as pre-existing abnormalities at baseline imaging. Follow-up was quantified as per 1000 patient-years (pt-yrs). A random effect model was used to calculate cumulative effect measures. The systematic review was performed in adherence with PRISMA guidelines and a preregistered protocol (Figure 1).

RESULTS:
9 uncontrolled studies with 1438 subjects and 6274 pt-yrs of follow-up were analyzed; protocols included cross-sectional imaging (n = 4,4709 pt-yrs), or combined-EUS and cross sectional imaging (n = 5,1565 pt-yrs). HRIs with normal baseline were screened every 12 months, pooled radiologic incidence of 24.74 per 1000 pt-yrs [8.44–48.60, P < 0.01] and diagnostic rate of advanced pathology of 1.06 per 1000 pt-yrs [0–3.99, P < 0.08] (Figure 2). HRIs with screen-prevalent lesions were followed every 3–6 months and longer when stable, with cumulative progression rate of 19.47 per 1000 pt-yrs [1.05–52.98, P < 0.01], and that of advanced pathology-1.54 per 1000 pt-yrs [0–7.55, P < 0.01] (Figure 3). Subgroup analysis showed no significant difference in radiologic incidence or progression or in the histologic diagnosis of advanced pathologies between cross-sectional and combined follow-up protocols.

CONCLUSION:
Surveillance protocols exhibited significantly higher radiologic than histologic diagnostic rates. Though heterogeneity existed between studies, there was no significant difference in the diagnostic rates of incidence or progression between protocols employing predominately cross-sectional vs combined protocols of cross-sectional imaging and EUS.
68 Pancreatic Pseudocysts in Patients With Acute and Chronic Pancreatitis, Trends and Clinical Outcomes of Hospitalization: Insights From a National Inpatient Database
Authors: Mony Shruti , Bertran-Rodriguez Carlos E. , Shah Ishani 
Published: October 2019

INTRODUCTION:
Pancreatic pseudocysts are a known sequalae of both acute or chronic pancreatitis and are the most common cystic lesions of the pancreas, accounting for 75%–80% of such lesions. The etiology of which resembles the causes of pancreatitis and is more common after alcohol induced pancreatitis. Although the natural history of the diseases has become clearer with the advent of endoscopic ultrasound, there is limited information on its incidence and trends. The aim of our study was to review demographics and clinical characteristics of patients with pseudocysts and determine the recent trends of the rates of hospitalization and associated health care utilization in patients with pseudocysts related to both acute pancreatitis (AP) and chronic pancreatitis (CP).

METHODS:
A retrospective cross-sectional study of adults (≥18 years) admitted for pseudocyst management (n = 259332) during a five-year period (2010–2014) was performed using the Nationwide Inpatient Sample (NIS). Descriptive analyses were compared using t-test for continuous data and chi-square test for categorical data.

RESULTS:
Over the five-year period, the proportion of patients being admitted for pancreatic pseudocyst has been slowly been increasing (Figure 1) from 19.26 to 21.41 (P < 0.0003. Among the total population, the mean age at admission was 53.4 years, 59.4% were males. Patients with psueodcysts with AP were found to have more risk factors for being overweight and obese compared to CP patients (1.93, 8.9% vs 1.4 and 5.5%, P < 0.001). Overall, inpatient mortality was higher in the AP group (2.38% vs 1.64; P < 0.005); and was associated with a higher length of stay (mean 11.4 days vs 7.3 days). On multivariate analysis, advancing age, morbid obesity, comorbidities like ESRD, congestive heart failure, chronic lung disease, metastatic and pancreatic cancer were associated with increased mortality and length of stay in patients with pseudocysts and acute pancreatitis.

CONCLUSION:
Pancreatic pseudocysts due to acute pancreatitis is associated with an overall higher inpatient mortality, length of stay and cost of hospitalization compared to chronic pancreatitis. Advance age, morbid obesity, comorbidities like ESRD, congestive heart failure, chronic lung disease, metastatic and pancreatic cancer were associated with increased mortality and length of stay in patients with pseudocysts and acute pancreatitis.
69 NanoPac-2017-01 Mid-Study Report: Safety, Tolerability, and Preliminary Efficacy of Intracystic Submicron Particle Paclitaxel (SPP) for the Treatment of Mucinous Cysts
Authors: Othman Mohamed , Tabash Abdalaziz , Verco Shelagh , Verco James , Wendt Alison , diZerega Gere 
Published: October 2019

INTRODUCTION:
Pancreatic Mucinous cystic lesions (MCL) have significant potential for malignant transformation; delivery of SPP as a direct intratumoral injection confirmed SPP present at the delivery site for at least 100 days in a prior study; intracystic therapy with SPP may prevent progression to cancer without corresponding systemic toxicities.

METHODS:
Aim: To determine safety and preliminary efficacy of SPP for treatment of MCLs using endoscopic ultrasound Fine Needle Injection (EUS-FNI). Materials and Methods: Subjects with confirmed MCL, based on elevated intracystic CEA and cytology, receive intracystic SPP via EUS FNI at volumes equal to the aspirated cyst fluid volume in sequential cohorts at 6, 10, and 15 mg/mL in a standard “3+3” dose-escalation protocol. The highest dose with acceptable safety and tolerability profile, as determined by a DSMB, will proceed into the second phase of the study; 9 additional subjects will receive two injections of SPP (same dose) 12 weeks apart. Subjects are followed for 6 months for clinical endpoints including: safety and tolerability evaluations, physical examination findings and vital signs; pharmacokinetic analysis of systemic paclitaxel drug levels; and cyst volume response as reported by imaging at 3 and 6 months.

RESULTS:
Nine subjects have been enrolled to date; 5 have completed the study (1 injection). EUS, imaging, CEA and amylase concentration were consistent with branched duct IPMN cyst (BD-IPMN) or MCNs (Table 1). To date, no dose limiting toxicities, serious adverse events related to treatment, or clinically significant blood work (chemistry; hematology; coagulation) or urinalysis have been reported. Adverse events potentially related to SPP include mild, transient abdominal pain/discomfort in 4 subjects and nausea in 2 subjects. Systemic paclitaxel concentration did not exceed 1 ng/mL, and was undetectable at 2 weeks supporting retention of SPP at delivery site. Cyst volumes in 3 of 5 completed subjects reduced by month 6, 2 remained stable (Table 2).

CONCLUSION:
Intracystic SPP appears safe and tolerable when administered at 6, 10, and 15 mg/mL in a volume equal to that of aspirated cyst fluid. Minimal systemic study drug exposure is experienced. No patients developed pancreatitis. Intracystic SPP appears to prevent continued growth of the cysts and may reduce total cyst volume. Subject enrollment to the second phase (2 injections 12 weeks apart) is underway at 15 mg/mL.
73 Measuring Clinical Response to Lactated Ringer's vs. Normal Saline in Acute Pancreatitis: A Retrospective Study at a Community Hospital
Authors: Beattie Michael , Kopek Nathan 
Published: October 2019

INTRODUCTION:
Acute pancreatitis is the most common GI cause of U.S. hospital admissions, and the incidence is rising.1,2 Aggressive IV fluid resuscitation and pain control are the mainstay of therapy; with the therapeutic goal to resume diet as soon as safely possible, especially within the first 48–72 hours.3–6 Several studies and guidelines have suggested LR may provide anti-inflammatory benefits as measured by CRP and SIRS criteria.6–8 Despite an improvement in SIRS criteria, studies have shown no mortality benefit.9 The primary goal of this study was to compare NS vs LR with improved clinical response as the primary endpoint. Clinical response was measured by time to diet initiation upon ED presentation. Secondary goals examined if the timing to initiation of IV fluids led to improved clinical outcome regardless of fluid type, as this has not been examined in previous studies.

METHODS:
Data was abstracted for all adult patients 18 years of age or older with an admitting diagnosis of acute pancreatitis from 1/1/17–12/31/17. Primary fluid type was determined by reviewing medication and IV infusion orders and was calculated by length of time for which the fluid was administered. A subgroup analysis was performed comparing patients within groups based on their BISAP score (0–1, 2, >3). Time to initiation of diet was examined by calculating the difference from time of arrival to the ED to the time that diet was ordered. For the secondary endpoint, patients were compared based on timing of initial fluid administration (<2 hours from arrival versus >4 hours form arrival). To determine if there was a significant difference when comparing time to diet initiation, a student's t-test was utilized.

RESULTS:
Complete data was collected on 200 patients. NS was the primary fluid type in 77% and LR for 21.5%. Time to diet initiation was shorter for patients receiving NS in all subgroups. This finding was significant in patients with a BISAP score of 1 or below (Table 2). The data indicates that when fluids were initiated within two hours as compared to greater than four hours, diet was initiated 7.4 hours sooner (Table 3). Diet initiation was delayed in patients with a BISAP of 3 or greater in both the NS and LR group.

CONCLUSION:
Our study did not demonstrate any clinical difference in disease and symptomatic resolution based on fluid type. Time to fluid initiation may be more important than fluid choice. This should be studied further with larger populations.
74 Pain Modulatory Phenotypes Differentiate Chronic Pancreatitis Patients With Distinct Clinical Pain Profiles
Authors: Faghih Mahya , Philipps Anna E. , Larsen Isabelle M. , Drewes Asbjørn , Singh Vikesh , Yadav Dhiraj , Olesen Søren 
Published: October 2019

INTRODUCTION:
Pain is a common problem in patients with chronic pancreatitis (CP) and effective therapy remains a considerable challenge. Methods based on quantitative sensory testing (QST) provide information on pain modulation and have demonstrated promise in predicting future pain status and the efficacy of analgesics. The aims of this study were to evaluate the existence of CP subgroups with different pain modulatory phenotypes and to investigate associations with patients' clinical pain and psychological profiles.

METHODS:
This was a cross-sectional, multicentre study of CP outpatients. Patients fulfilled a number of questionaries' including the Brief Pain Inventory short form, the Hospital Anxiety and Depression Score as well as measures of Conditional and Situational Pain Catastrophising. Using a standardized QST protocol, we recorded pain detection thresholds (PDTs) to static muscle pressure stimulations at the “pancreatic dermatomes” on the upper abdomen and back and at three control areas. The ratio between pancreatic and control PDTs were calculated (PDT-index) to offset interindividual differences in absolute thresholds. The PDT-index was used in conjunction with repetitive pinprick stimulations (temporal summation) applied at the abdominal pancreatic dermatome to obtain a measure of segmental hyperalgesia. A conditioned pain modulation (CPM) paradigm was performed to investigate descending pain modulation. Patients were grouped based on normative QST reference values and questionnaire scores were compared across subgroups to investigate associations between patients' pain modulatory phenotypes and clinical pain and psychological profiles.

RESULTS:
A total of 91 patients were enrolled in the study. The mean age was 53.1 ± 12.7 y, 62% were men, and 65% had toxic etiology. Three distinct pain modulatory phenotypes were found: group 1 (n = 31) had normal pain modulation; group 2 (n = 17) had segmental sensitization; group 3 (n = 43) had widespread sensitization. Patients with widespread sensitization had higher pain score (P < 0.01) and lower QOL (P < 0.05) in comparison to segmental and normal. In contrast, psychological features were comparable across subgroups.

CONCLUSION:
CP patients with widespread sensitization have significantly higher levels of pain and lower QOL. QST characterizes the sensory profiles independently of the patient's psychological status and provides an unbiased proxy of pain processing. This information can be used for prognostication and tailoring of management strategies.
75 Calcifications and Moderate to Marked Ductal Changes Are Only Seen in Patients With Imaging Documented Acute Recurrent Pancreatitis
Authors: Faghih Mahya , Yahyapourjalaly Niloofar , Boortalary Tina , Fan Chris , Makary Martin , Kalloo Anthony , Afghani Elham , Khashab Mouen , Singh Vikesh 
Published: October 2019

INTRODUCTION:
Acute pancreatitis (AP) is often diagnosed on the basis of abdominal pain and elevations in pancreatic enzymes without abdominal imaging. However, neither pain nor enzyme elevations are specific for AP and recurrent presentations without confirmatory imaging may lead to a misdiagnosis of acute recurrent pancreatitis (ARP) and/or chronic pancreatitis (CP).

METHODS:
Adult patients with a diagnosis of ARP and/or CP between 2010–2019 were evaluated. All medical records and imaging studies from prior AP admissions were reviewed at our institution. Definite ARP was defined as ≥2 episodes of abdominal pain, elevated serum amylase and/or lipase ≥3X upper limit normal and abdominal imaging(s) showing changes or sequelae of AP. Probable ARP was defined as above but without any evidence of AP on abdominal imaging. Possible ARP was defined as ≥2 episodes of abdominal pain either with serum amylase and/or lipase levels that were normal or <3X ULN without any abdominal imaging showing AP. This was included as a category as referring physicians had diagnosed and managed these patients as ARP. The M-ANNHEIM criteria were used to define definite CP. Any patients with definite CP without a history of ARP were excluded.

RESULTS:
There were a total of 854 patients with ARP and/or CP with a mean age of 51.2 ± 14 years; 54.9% female; 75% white. There were 489 (57.2%) definite ARP, 162 (19%) probable ARP and 202 (23.7%) possible ARP with a similar mean duration of disease of 8.5 ± 7.8, 5.2 ± 4.1 and 6.8 ± 3.4 years, respectively. All patients were followed for a mean of 5.3 ± 2 years. Pancreatic calcification(s) and marked to moderate ductal changes were only seen in definite ARP. There were higher rates of exocrine insufficiency in definite ARP compared to probable and possible ARP (P = 0.005). Chronic opioid use was higher among the probable ARP compared to definite ARP and possible ARP (P < 0.001). All other characteristics including demographics, rates of alcohol use and smoking, diabetes and BMI similar between the 3 groups.

CONCLUSION:
Recurrent presentations of abdominal pain and pancreatic enzyme elevations without confirmatory changes of AP on imaging is problematic for the diagnosis of ARP as none of these patients developed definite changes of CP over the duration of disease and follow-up. This study highlights the nonspecific nature of abdominal pain and enzyme elevations for the diagnosis of AP and suggests that current diagnostic criteria may require revision.