Raimondo, Massimo

ObjectivesStudies suggest that adults diagnosed with celiac disease (CD) are at higher risk of developing acute pancreatitis (AP). The aim of this study is to explore the relationship between CD and AP in terms of inpatient prevalence, mortality, morbidity, and resource utilization in the past decade.MethodsRetrospective cohort study using the Nationwide Inpatient Sample (2007–2016). The primary outcome was the occurrence of AP in CD patients. Secondary outcomes were the trend in AP cases in CD patients, and mortality, morbidity, length of stay, and total hospital charges and costs.ResultsOf 337,201 CD patients identified, 7372 also had AP. The mean age was 53 years, 71% were women. The inpatient prevalence of AP in CD was 2.2% versus 1.2% in non-CD cohort (P< 0.01). Patients with CD displayed increased odds of having AP (adjusted odds ratio, 1.92;P< 0.01). Patients with AP and CD displayed lower odds of morbidity and mortality than non-CD patients with AP.ConclusionsThe inpatient prevalence of AP is higher in CD patients, and increased from 2007 to 2016. Patients with CD and AP displayed lower morbidity and mortality, which may suggest that they have a less severe form of AP or lower baseline comorbidity.

Objective The aim of the study was to compare incidence and outcomes of acute pancreatitis among advanced heart failure therapies. Methods Two retrospective cohorts are as follows: A, patients with heart failure presenting to our hospitals and B, the US National Inpatient Sample. Three groups were compared: left ventricular assist device (LVAD) recipients, transplant recipients, and controls who did not qualify for advanced therapies. Primary outcomes were pancreatitis incidence and mortality. Secondary outcomes included kidney failure, multiorgan failure, shock, and health care utilization. Results Cohort A included 1344 heart failure patients, and cohort B included 677,905 patients with acute pancreatitis. In cohort A, annual pancreatitis incidence was 6.7 cases per 1000 LVAD recipients, 4.1 per 1000 LVAD bridge-to-transplant, 2.3 per 1000 transplant recipients, and 3.2 per 1000 heart failure controls ( P = 0.03). Combined, the incidence was 5.6 per 1000 LVAD users and 2.7 in 1000 non-LVAD users (relative risk, 2.1; P = 0.009). In cohort B, increased mortality was seen in LVAD users, but not in transplant recipients. Left ventricular assist device patients had higher odds of kidney failure, multiorgan failure, shock, and intensive care. Conclusions Patients with LVAD have double risk of pancreatitis, worse clinical outcomes, and increased healthcare utilization. Studies elucidating the mechanisms behind pancreatic injury in advanced heart failure are suggested.

Abstract Background National guidelines recommend genomic profiling of tumor tissue to guide precision therapy. We compared the specimen adequacy for genomic profiling and yield of DNA between endoscopic ultrasound (EUS)-guided fine-needle biopsy (FNB) and EUS-guided fine-needle aspiration (FNA). Methods In our tandem, randomized controlled trial, consecutive patients undergoing EUS for evaluation of pancreatic masses underwent both conventional EUS-FNA with a 25-gauge needle and paired EUS-FNB (19 or 22-gauge needle), with the order randomized (EUS-FNA first followed by EUS-FNB, or vice versa). A minimum of one pass with each needle was obtained for histology. Second and third passes were performed to collect DNA. Specimens were evaluated by a cytopathologist blinded to the needle type. Specimen adequacy for genomic profiling was calculated based on FoundationOne clinical diagnostic (CDx) adequacy requirements. We compared the adequacy for genomic profiling DNA (quantity) and histology yields with both needles. Results Analysis included 50 patients (25 men; mean age 68 [standard deviation (SD) 13] years), with a mean lesion size of 38 (SD 17) mm; 37 lesions (74 %) were pancreatic ductal adenocarcinoma (PDAC). The mean DNA concentrations in PDAC by FNB and FNA needles were 5.930 (SD 0.881) µg/mL vs. 3.365 (SD 0.788) µg/mL, respectively (P = 0.01). The median standardized histology score per pass with EUS-FNB was 5 (sufficient for histology) and for EUS-FNA was 2 (enough for cytology). Specimen adequacy for genomic profiling and yield of DNA was significantly higher with FNB than with FNA needles. Conclusions In this study, adequacy for genomic profiling, DNA, and histology yield were considerably superior using an EUS-FNB needle compared with an EUS-FNA needle.

Abstract Background and study aims With newer imaging modalities, indications for use of endoscopic retrograde cholangiopancreatography (ERCP) have changed in the last decade. Despite advances in ERCP, paucity in recent literature regarding utilization and outcomes of ERCP exists. Thus, the aim of this study was to assess the inpatient use of ERCP, outcomes, and most common indications. Patients and methods Retrospective-cohort study using the Nationwide Inpatient Sample 2007–2016. All patients with ICD9–10CM procedural codes for ERCP were included. The primary outcome was the use of ERCP. Secondary outcomes included determining procedural specifics (stenting, sphincterotomy and dilation), complications (post-ERCP pancreatitis [PEP], bile duct perforation), hospital length of stay, total hospital costs and charges. Multivariate regression analysis was used to adjust for confounders. Results A total of 1,606,850 patients underwent inpatient ERCP. The mean age was 59 years (60 % female). The total number of ERCPs increased over the last decade. Patients undergoing ERCP in 2016 had greater odds of undergoing bile duct stent placement, pancreatic duct (PD) stenting, biliary dilation, pancreatic sphincterotomy, PEP and biliary perforation. Inpatient mortality decreased. Hospital charges increased, while length of stay (LOS) decreased. Conclusions The number of ERCPs increased in the past decade. Odds of therapeutic interventions and complications increased. The most common principal diagnoses were choledocholithiasis and gallstone-related AP. Hence, physicians must be aware to promptly diagnose and treat complications. These findings may reflect the increased case complexity and fact that ERCP continues to evolve into an increasingly interventional tool, contrasting from its former role as a predominantly diagnostic and gallstone extraction tool.

INTRODUCTION: Patients with Celiac disease (CD) are at increased risk of infections, as evidenced by increased prevalence of tuberculosis, influenza, and sepsis. Alterations in immunity and microbiota can contribute to this predisposition. Although the prevalence of Clostridium difficile infection (CDI) continues to increase in the US, there is little data on the association and outcomes in patients with CD. The aim of this study was to assess inpatient prevalence, outcomes and resource utilization of patients with CD and CDI in the US in the past decade. METHODS: Retrospective cohort study using the NIS 2007 to 2016. All patients with CD were included using ICD9-10CM codes. Cohorts were stratified for CDI coexistence. None were excluded. The primary outcome was determining the association of CD with CDI. Secondary outcomes were determining the CDI inpatient prevalence trend in the CD patients, as well as mortality, morbidity, length of hospital stay (LOS), total hospital charges and costs, which were adjusted for inflation using the Consumer Price Index. Multivariate regression was used to adjust for age, gender, income in patient zip code, Charlson Comorbidity Index, hospital region, location, size and teaching status. RESULTS: A total of 337,201 patients with CD were identified, of which 5,500 had associated CDI. Mean age was 55 years and 71% were female. The inpatient prevalence of CDI in patients with CD increased from 0.9/100,000 admissions in 2007 to 1.65/100,000 admissions in 2016. Patients with CD displayed increased adjusted odds (aOR:1.56, P < 0.01) of coexisting CDI compared to patients without CD. Patients with CD had lower odds of mortality, ICU, shock, multiorgan failure, hospital costs, charges, and LOS but increased odds of requiring TPN compared to the general population admitted population with CDI. CONCLUSION: Patients with CD had higher odds of CDI compared to non-CD patients, which could be attributed to CD-related gut mucosal integrity, immunological or microbiome alterations. The inpatient prevalence of CDI in patients with CD increased from 2007 to 2016. This may be a reflection of the general increase of CDI cases in the inpatient population and with improved CD diagnostic modalities. Patients with CD and CDI did show decreased morbidity/mortality and resource utilization, suggesting that the clinical course is less severe. Further studies should further assess the gut immunological and microbiome changes in CD to clarify potential factors associated with CDI.

OBJECTIVES: Pancreatic cystic lesions (PCLs) may be precancerous. Those likely to harbor high-grade dysplasia (HGD) or pancreatic cancer (PC) are targets for surgical resection. Current algorithms to predict advanced neoplasia (HGD/PC) in PCLs lack diagnostic accuracy. In pancreatic tissue and cyst fluid (CF) from PCLs, we sought to identify and validate novel methylated DNA markers (MDMs) that discriminate HGD/PC from low-grade dysplasia (LGD) or no dysplasia (ND). METHODS: From an unbiased whole-methylome discovery approach using predefined selection criteria followed by multistep validation on case (HGD or PC) and control (ND or LGD) tissues, we identified discriminant MDMs. Top candidate MDMs were then assayed by quantitative methylation-specific polymerase chain reaction on archival CF from surgically resected PCLs. RESULTS: Of 25 discriminant MDMs identified in tissue, 13 were selected for validation in 134 CF samples (21 cases [8 HGD, 13 PC], 113 controls [45 ND, 68 LGD]). A tree-based algorithm using 2 CF-MDMs ( TBX15 , BMP3 ) achieved sensitivity and specificity above 90%. Discrimination was significantly better by this CF-MDM panel than by mutant KRAS or carcinoembryonic antigen, with areas under the receiver operating characteristic curve of 0.93 (95% confidence interval: 0.86–0.99), 0.71 (0.57–0.85), and 0.72 (0.60–0.84), respectively. Cutoffs for the MDM panel applied to an independent CF validation set (31 cases, 56 controls) yielded similarly high discrimination, areas under the receiver operating characteristic curve = 0.86 (95% confidence interval: 0.77–0.94, P = 0.2). DISCUSSION: Novel MDMs discovered and validated in tissue accurately identify PCLs harboring HGD/PC. A panel of 2 MDMs assayed in CF yielded results with potential to enhance current risk prediction algorithms. Prospective studies are indicated to optimize and further evaluate CF-MDMs for clinical use.

Background Limited data exist regarding the effects of end-stage renal disease (ESRD) on acute pancreatitis (AP). This study aimed to evaluate the association between ESRD and outcomes and resource utilization of AP. Materials and methods The 2014 National Inpatient Sample database was used to identify all hospitalized patients with a principal diagnosis of AP. Propensity score matching was performed to create a matched cohort of ESRD and non-ESRD patients. The in-hospital mortality, morbidity, resource utilization and expenditures of AP in ESRD patients were compared to non-ESRD patients. Multivariate analysis was performed for further adjustment for potential confounders. Results Of 382 595 AP patients, 7380 ESRD patients and 8050 non-ESRD patients were created after propensity score matching. ESRD patients had more tendency to have hypercalcemia-related or AP-related to other/unspecified causes, whereas non-ESRD patients had more tendency to have alcohol-related, gallstone-related, and hypertriglyceridemia-related AP. In multivariate analysis, ESRD was associated with increased in-hospital mortality, increased length of hospital stay, and increased hospitalization costs and charges. No differences were observed in inpatient morbidity, imaging study use, and procedures performed during hospitalization. Conclusion In this large nationwide study using inpatient USA database, we demonstrate higher AP-related mortality, and resource utilization among ESRD patients when compared with non-ESRD patients.

Objective It is unclear whether endoscopic assessment of scars after colorectal endoscopic mucosal resection (EMR) has to include biopsies, even if endoscopy is negative. Vice versa, endoscopic diagnosis of recurrent adenoma may not require biopsy before endoscopic reinterventions. We prospectively analysed various endoscopic modalities in the diagnosis of recurrence following EMR. Design We conducted a prospective study of patients undergoing colonoscopy after EMR of large (≥20 mm) colorectal neoplasia. Endoscopists predicted recurrence and confidence level with four imaging modes: high-definition white light (WL) and narrow-band imaging (NBI) with and without near focus (NF). Separately, 26 experienced endoscopists assessed offline images. Results Two hundred and thirty patients with 255 EMR scars were included. The prevalence of recurrent adenoma was 24%. Diagnostic values were high for all modes (negative predictive value (NPV) ≥97%, positive predictive value (PPV) ≥81%, sensitivity ≥90%, specificity ≥93% and accuracy ≥93%). In high-confidence cases, NBI with NF had NPV of 100% (95% CI 98% to 100%) and sensitivity of 100% (95% CI 93% to 100%). Use of clips at initial EMR increased diagnostic inaccuracy (adjusted OR=1.68(95% CI 1.01 to 2.75)). In offline assessment, specificity was high for all imaging modes (mean: ≥93% (range: 55%–100%)), while sensitivity was significantly higher for NBI-NF (82%(72%–93%)%)) compared with WL (69%(38%–86%); p<0.001), WL-NF (68%(55%–83%); p<0.001) and NBI (71%(59%–90%); p<0.001). Conclusion Our study demonstrates very high sensitivity and accuracy for all four imaging modalities, especially NBI with NF, for diagnosis of recurrent neoplasia after EMR. Our data strongly suggest that in cases of high confidence negative optical diagnosis based on NBI-NF, no biopsy is needed to confirm absence of recurrence during colorectal EMR follow-up. A high confidence positive optical diagnosis can lead to immediate resection of any suspicious area. In all cases of low confidence, biopsy is still required. Trial registration number NCT02668198 .