Long-Term Follow-up of Disabled Patients With Chronic Pancreatitis: Evaluation of Clinical Characteristics, Outcomes, and Predictors.

BACKGROUND/AIMS: Patients with chronic pancreatitis (CP) often report a poor quality of life and may be disabled. Our study identifies clinical characteristics, predictors and outcomes in CP patients with disability. METHODS: A review of established CP patients followed in our Pancreas Center between January 1, 2016 and April 30, 2021. Patients were divided into 2 groups based on disability. Univariate analysis was performed to identify differences in demographics, risk factors, comorbidities, complications, controlled medications, and resource utilization. Multivariate analysis was conducted to identify predictors for disability. RESULTS: Out of 404 CP patients, 18% were disabled. These patients were younger (53.8 vs. 58.8, P =0.001), had alcoholic CP (54.1% vs. 30%; P <0.001), more recurrent pancreatitis (83.6% vs. 61.1%; P =0.001), chronic abdominal pain (96.7% vs. 78.2%; P =0.001), exocrine pancreatic insufficiency (83.6% vs. 55.5%; P <0.001), concurrent alcohol (39.3% vs. 23.3%; P =0.001) and tobacco abuse (42.6% vs. 26%; P =0.02), anxiety (23% vs. 18.2%; P <0.001), and depression (57.5% vs. 28.5%; P <0.001). A higher proportion was on opiates (68.9% vs. 43.6%; P <0.001), nonopiate controlled medications (47.5% vs. 23.9%; P <0.001), neuromodulators (73.3% vs. 44%; P <0.001), and recreational drugs (27.9% vs. 15.8%; P =0.036). Predictors of disability were chronic pain (OR 8.71, CI 2.61 to 12.9, P < 0.001), celiac block (OR 4.66, 2.49 to 8.41; P <0.001), neuromodulator use (OR 3.78, CI 2.09 to 6.66; P <0.001), opioid use (OR3.57, CI 2.06 to 6.31; P < 0.001), exocrine pancreatic insufficiency (OR3.56, CI 1.89 to 6.82; P <0.001), non-opioid controlled medications (OR 3.45, CI 2.01 to 5.99; P <0.001), history of recurrent acute pancreatitis (OR 2.49, CI 1.25 to 4.77; P <0.001), depression (OR 2.26, CI 1.79 to 3.01; P <0.001), and active smoking (OR1.8, CI 1.25 to 2.29; P <0.001). CONCLUSION: CP patients with disability have unique characteristics and predictors, which can be targeted to reduce disease burden and health care expenditure in this population.

Prospective evaluation of an emergency department protocol to prevent hospitalization in mild acute pancreatitis: Outcomes and predictors of discharge.

BACKGROUND: While acute pancreatitis (AP) contributes significantly to hospitalizations and costs, most cases are mild with minimal complications. In 2016, we piloted an observation pathway in the emergency department (ED) for mild AP and showed reduced admissions and length of stay (LOS) without increased readmissions or mortality. After 5 years of implementation, we evaluated outcomes of the ED pathway and identified predictors of successful discharge. METHODS: We reviewed a prospectively enrolled cohort of patients with mild AP presenting to a tertiary care center ED between 10/2016 and 9/2021, evaluating LOS, charges, imaging, and 30-day readmission, and assessed predictors of successful ED discharge. Patients were divided into two main groups: successfully discharged via the ED pathway ("ED cohort") and admitted to the hospital ("admission cohort"), with subgroups to compare outcomes, and multivariate analysis to determine predictors of discharge. RESULTS: Of 619 AP patients, 419 had mild AP (109 ED cohort, 310 admission cohort). The ED cohort was younger (age 49.3 vs 56.3,p < 0.001), had lower Charlson Comorbidity Index (CCI) (1.30 vs 2.43, p < 0.001), shorter LOS (12.3 h vs 116 h, p < 0.001), lower charges (mean $6768 vs $19886, p < 0.001) and less imaging, without differences in 30-day readmissions. Increasing age (OR: 0.97; p < 0.001), increasing CCI (OR: 0.75; p < 0.001) and biliary AP (OR: 0.10; p < 0.001) were associated with decreased ED discharge, while idiopathic AP had increased ED discharge (OR: 7.8; p < 0.001). CONCLUSIONS: After appropriate triage, patients with mild AP (age <50, CCI <2, idiopathic AP) can safely discharge from the ED with improved outcomes and cost savings.

Building a Quality Practice in Chronic Pancreatitis.

Chronic pancreatitis (CP) is a fibroinflammatory disorder that results in irreversible scarring to pancreatic parenchyma and presents with a myriad of symptoms including abdominal pain, nausea, weight loss, steatorrhea, and diabetes. Furthermore, patients with CP often have comorbid chemical dependencies to alcohol and tobacco, which can further complicate the management of CP. Recent literature proposes guidelines on how best to care for patients with CP and establishes requirements for centers of excellence. Here, we review the available data on endoscopic therapies, pain management, chemical dependency, and nutrition for patients with CP and propose quality metrics that may be used to establish a quality practice.

Comparison of Opioid-Based Patient-Controlled Analgesia with Physician-Directed Analgesia in Acute Pancreatitis: A Retrospective Cohort Study.

BACKGROUND: Patient-controlled analgesia (PCA) is commonly used for acute postoperative pain management. Clinicians may also use PCA in the management of acute pancreatitis (AP); however, there is limited data on its impact on patient outcomes. We aimed to characterize a cohort of patients receiving PCA therapy for pain management in AP compared to those patients receiving standard physician-directed delivery of analgesia. METHODS: We conducted a retrospective cohort study of adult patients admitted with AP at a tertiary care center from 2008 to 2018. Exclusion criteria included patients with chronic opioid use, chronic pancreatitis and pancreatic cancer. Primary outcomes include length of stay (LOS) and time to enteral nutrition. Secondary outcomes include proportion of patients discharged with opioid and complications. Multivariate regression analysis and t-test were used for analysis. RESULTS: Among 656 AP patients who met the criteria, patients receiving PCA (n = 62) and standard delivery (n = 594) were similar in admission pain score, Charlson Comorbidity Index, and pancreatitis severity. There were significantly greater proportion of women, Caucasians and nonalcoholics who received PCA therapy (p < 0.01) than standard delivery. Multivariate regression analysis revealed that patients in the PCA group have a longer LOS (7.17 vs. 5.43 days, p < 0.007, OR 1.03; 95% CI 1.01-1.07), longer time to enteral nutrition (3.84 days vs. 2.56 days, p = 0.012, OR 1.11; 95% CI 1.02-1.20), and higher likelihood of being discharged with opioids (OR 1.94; 95% CI 1.07-3.63, p = 0.03). CONCLUSION: The use of PCA in AP may be associated with poorer outcomes including longer LOS, time to enteral intake and a higher likelihood of being discharged with opioids.

Pre-existing, Concurrent/Early-Onset, and Late-Onset Diabetes in Chronic Pancreatitis: Do Outcomes Differ?

BACKGROUND/AIMS: Diabetes secondary to endocrine insufficiency in chronic pancreatitis (CP) may develop at any time during the disease course. We sought to evaluate the differences in clinical characteristics and outcomes in CP patients with pre-existing, early-onset, and late-onset diabetes. METHODS: We reviewed CP patients seen at our Pancreas Center during 2016-2021. We divided them into four groups: those without diabetes, with pre-existing diabetes, with early-onset diabetes, and with late-onset diabetes. We then compared clinical characteristics and outcomes. RESULTS: We identified 450 patients with CP: 271 without diabetes, 99 with pre-existing diabetes, 51 with early-onset diabetes, and 29 with late-onset diabetes. Early-onset diabetics were younger (54.1 vs 57.3 vs 62.5 vs 61.9 years), had more alcohol-related CP (45.1% vs 31.7% vs 32.3% vs 31%), had higher HbA1C levels (8.02% vs 5.11% vs 7.71% vs 7.66%), were more likely to be on insulin (78.4% vs 0% vs 48.4% vs 65.5%), and used more opioids (64.7% vs 43.9% vs 55.1% vs 44.8%) and gabapentinoids (66.7% vs 43.5% vs 48% vs 60.7%) compared to other groups (p < 0.05). Patients who developed diabetes after CP diagnosis had more exocrine insufficiency (72.4% vs 70.6% vs 65.7% vs 53.1%), anatomical complications, and interventions for pain control (p < 0.05). There was no difference in pancreatic cancer in the four groups. CONCLUSION: CP patients who are younger and use alcohol are at higher risk of having early-onset diabetes and have poorer glucose control compared other CP patients. Patients who develop diabetes after CP diagnosis have worse outcomes and use more resources.

Smoking Is Associated with Worse Clinical Outcomes in Chronic Pancreatitis.

BACKGROUND: Tobacco smoking is a known risk factor for progression of chronic pancreatitis (CP). AIM: We compare clinical outcomes of CP patients with current or former smoking with those who have never smoked. METHODS: We reviewed all patients with followed at our Pancreas Center from 2016 to 2021, comparing the demographics, clinical features, comorbidities, outcomes, and resource utilization between smokers and non-smokers. RESULTS: Of 439 CP patients, 283 were smokers (125 current, 158 former). Significantly more smokers were men (58.3% vs 40.4%), with alcoholic CP (45.5% vs 12.1%), chronic abdominal pain (77.7% vs 65.4%), anxiety and depression (22.6% vs 14.1% and 38.9% vs 23.1%), and with more local pancreatic complications [splanchnic vein thrombosis (15.7% vs 5.13%), pseudocyst (42.7% vs 23.7%), biliary obstruction (20.5% vs 5.88%)], exocrine pancreatic insufficiency (65.8% vs 46.2%), hospitalizations (2.59 vs 1.75 visits), and emergency department visits (8.96% vs 3.25%). Opioid and neuromodulator use were significantly higher (59.2% vs 30.3% and 58.4% vs 31.2%). Current smokers had worse outcomes than former smokers. Multivariate analysis controlling for multiple factors identified smoking as an independent predictor of chronic abdominal pain (OR 2.49, CI 1.23-5.04, p = 0.011), opioid (OR 2.36, CI 1.35-4.12, p = 0.002), neuromodulators (OR 2.55, CI 1.46-4.46, p = 0.001), and non-opioid-controlled medications (OR 2.28, CI 1.22-4.30, p = 0.01) use, as well as splanchnic vein thromboses (OR 2.65, CI 1.02-6.91, p = 0.045) and biliary obstruction (OR 4.12, CI 1.60-10.61, p = 0.003). CONCLUSION: CP patients who smoke or formerly smoked have greater morbidity and worse outcomes than non-smokers.

Myopericarditis following COVID-19 vaccination in adolescent triplets.

Multiple studies have reported myocarditis and pericarditis after the Pfizer-BioNTech coronavirus disease 2019 messenger ribonucleic acid vaccine. We describe male adolescent triplets who presented with myopericarditis within one week following vaccine administration.

The Impact of Prenatal Diagnosis on Clinical Outcomes of Isolated Vascular Rings From a Statewide Paediatric Cardiology Tertiary Service.

BACKGROUND: Vascular rings, including right aortic arch with aberrant left subclavian artery (RAA-ALSCA), double aortic arch (DAA) and pulmonary artery sling (PAS), are congenital anomalies that may cause airway and oesophageal compression. As prenatal detection has improved, literature comparing clinical outcomes of antenatally versus postnatally diagnosed cases continues to emerge. The aim is to define a statewide tertiary paediatric institution's clinical profile and outcomes of prenatal versus postnatally diagnosed isolated vascular rings. METHOD: A retrospective single-centre review of isolated RAA-ALSCA, DAA and PAS between 1 January 1999 and 31 December 2020 was conducted. Clinical characteristics, surgical and follow-up information were collected. Antenatal and postnatally diagnosed groups were compared. RESULTS: Out of 123 cases diagnosed with isolated vascular rings, 98 (79.7%) cases had RAA-ALSCA, 21 (17.1%) with DAA, 4 (3.3%) with PAS. The antenatal detection rate was 73.6% in the past decade; 20.3% had a genetic disorder, of which 48% had 22q11.21 microdeletion. Of prenatally diagnosed cases, 31.3% developed symptoms, commonly stridor and dysphagia, at a median age of 2.0 months (IQR 0.0-3.0), compared to a median age of diagnosis for the postnatal cohort of 9 months (IQR 1.0-40.7). Postnatally diagnosed cases were more likely to present with symptoms, primarily respiratory distress, than prenatally diagnosed cases (p=0.006). Fifty-nine (59) cases (50% antenatally diagnosed) required vascular ring division; 6.8% had residual symptoms following surgery. DISCUSSION: Antenatal diagnosis has improved and leads to better parental awareness and more timely, appropriate intervention. Postnatally diagnosed patients were older, more likely to be symptomatic, underwent more investigations and were commenced on more medications for symptom management prior to diagnosis. One in five cases of isolated vascular ring anomalies carried a genetic diagnosis, which has important implications on prenatal counselling and genetic testing.

Impact of recurrent acute pancreatitis on the natural history and progression to chronic pancreatitis.

BACKGROUND AND AIMS: It is believed that acute pancreatitis (AP), recurrent AP (RAP) and chronic pancreatitis (CP) represent stages of the same disease spectrum. We aimed to identify risk factors, clinical presentation and outcomes in patients with prior RAP who develop CP. METHODS: We retrospectively reviewed patients with CP who were seen at our Pancreas Center during 2016-2021. We divided them into two groups: with and without RAP (≥2 episodes of AP). We compared demographics, clinical presentation and resource utilization between the two groups. RESULTS: We identified 440 patients with CP, of which 283 (64%) patients had preceding RAP. These patients were younger (55.6 vs 63.1 years), active smokers (36% vs 20%) and had alcohol-related CP (49% vs 25%) compared to those without RAP and CP (p < 0.05). More patients with RAP had chronic abdominal pain (89% vs 67.9%), nausea (43.3% vs 27.1%) and exocrine pancreatic insufficiency (65.8% vs 46.5%) (p < 0.05). More patients with RAP used opioids (58.4% vs 32.3%) and gabapentinoids (56.6% vs 34.8%) (p < 0.05). They also had more ED visits resulting in an opioid prescription (9.68% vs 2%) and more CP flares requiring hospitalization (3.09 vs 0.87) (p < 0.05). CONCLUSION: Young age, smoking and alcohol use are seen in patients with RAP who progress to CP. These patients are highly symptomatic and use more healthcare resources, suggestive of an overall a more course compared to those patients who develop CP without preceding RAP. Early identification and counselling of these patients may slow down progression to CP.

Inpatient Alcohol Cessation Counseling Is Associated With a Lower 30-Day Hospital Readmission in Acute Alcoholic Pancreatitis.

BACKGROUND: Alcohol use is a common cause of recurrent acute pancreatitis. Thus, guidelines recommend providing alcohol prevention resources during hospitalization. There is limited data on the real-world implementation of this recommendation. We aimed to assess how often inpatients admitted with alcohol-induced acute pancreatitis (AAP) receive counseling and to determine the impact of counseling on readmissions for AAP. METHODS: We retrospectively studied patients admitted with AAP at a tertiary care center from 2008 to 2018. We compared demographics, clinical features, and outcomes in patients who did and did not receive counseling. Outcomes studied were the proportion of patients with AAP receiving counseling, and readmission rates for AAP at 30 days and 1 year. RESULTS: A total of 243 patients with AAP were identified, of which 115 had inpatient alcohol counseling (47%). Demographic data were comparable between the 2 groups. Fewer patients receiving alcohol counseling were readmitted at 30 days compared with patients not receiving counseling (19.3% vs. 31.2%, P =0.048). At 1 year, the 2 groups had similar readmission rates. On multivariate analysis, patients who received counseling were half as likely to be readmitted in 30 days compared with those who did not receive counseling [odds ratio=0.52 (0.27, 0.98), P =0.046]. CONCLUSIONS: We note that <50% of patients receive alcohol counseling. Patients receiving alcohol counseling were less likely to be readmitted at 30 days, inferring possible value in the intervention provided. Similar readmission rates at 1 year suggest that the single intervention may not have a durable effect on alcohol prevention.

Evaluating Outcomes and Misuse in Opioid-Dependent Chronic Pancreatitis Using a State-Mandated Monitoring System.

INTRODUCTION: Patients with chronic pancreatitis (CP) often require opioids for pain control. The goal of our study was to characterize opioid use in patients with CP in a real-life practice using a state-mandated online monitoring program and to assess outcomes compared to CP patients without opioid dependency. METHODS: CP patients seen in our Pancreas Center from 2016 to 2021 were divided into two groups-with and without chronic opioid use. Details of opioids and other controlled prescriptions were obtained by review of the Massachusetts Prescription Awareness Tool (MassPat). RESULTS: Of the 442 CP outpatients, 216 used chronic opioids. Patients with opioid use had significantly more recurrent acute pancreatitis (76.6% vs. 52.7%), concurrent alcohol use (11.2% vs. 5.8%), tobacco use (37.8% vs. 19.7%), anxiety (22.4% vs. 16.6%), depression (43.5% vs. 23.5%) and daily pain (59.8% vs. 24.8%) (p < 0.001). They also concurrently used more benzodiazepines (43.7% vs. 12.4%), gabapentinoids (66.4% vs. 31.1%) and medical marijuana (14.9% vs. 4.19%) (p < 0.001). They had more celiac plexus blocks (22.0% vs. 6.67%), surgery (18.3% vs. 8.89%) and more hospitalizations for CP flares (3.6 vs. 1.0 visits) (p < 0.001). Less than 13% patients received opioids by means of ED visits; 81.7% patients received their prescriptions from one facility and 75% received them at regular intervals. CONCLUSION: Opioid-dependent CP patients exhibit polypharmacy and have worse outcomes with higher resource utilization. The state-monitoring program ensures that the majority of patients receive opioids from a single facility, thereby minimizing misuse.

Hyperlipasemia in absence of acute pancreatitis is associated with elevated D-dimer and adverse outcomes in COVID 19 disease.

BACKGROUND: Coronavirus SARS-CoV-2 affects multiple organs. Studies have reported mild elevations of lipase levels of unclear significance. Our study aims to determine the outcomes in patients with COVID-19 and hyperlipasemia, and whether correlation with D-dimer levels explains the effect on outcomes. METHODS: Case-control study from two large tertiary care health systems, of patients with COVID-19 disease admitted between March 1 and May 1, 2020 who had lipase levels recorded. Data analyzed to study primary outcomes of mortality, length of stay (LOS) and intensive care utilization in hyperlipasemia patients, and correlation with D-dimer and outcomes. RESULTS: 992 out of 5597 COVID-19 patients had lipase levels, of which 429 (43%) had hyperlipasemia. 152 (15%) patients had a lipase > 3x ULN, with clinical pancreatitis in 2 patients. Hyperlipasemia had a higher mortality than normal lipase patients (32% vs. 23%, OR = 1.6,95%CI = 1.2-2.1, P = 0.002). In subgroup analysis, hyperlipasemia patients had significantly worse LOS (11vs.15 days, P = 0.01), ICU admission rates (44% vs. 66%,OR = 2.5,95%CI = 1.3-5.0,P = 0.008), ICU LOS (12vs.19 days,P = 0.01), mechanical ventilation rates (34% vs. 55%,OR = 2.4,95%CI = 1.3-4.8,P = 0.01), and durations of mechanical ventilation (14 vs. 21 days, P = 0.008). Hyperlipasemia patients were more likely to have a D-dimer value in the highest two quartiles, and had increased mortality (59% vs. 15%,OR = 7.2,95%CI = 4.5-11,P < 0.001) and LOS (10vs.7 days,P < 0.001) compared to those with normal lipase and lower D-dimer levels. CONCLUSION: There is high prevalence of hyperlipasemia without clinical pancreatitis in COVID-19 disease. Hyperlipasemia was associated with higher mortality and ICU utilization, possibly explained by elevated D-dimer.

Reducing Hospitalization in Mild Acute Pancreatitis: Results of Long-term Follow-up.

GOALS AND BACKGROUND: Acute pancreatitis (AP) is a common emergency department (ED) diagnosis, amounting to enormous costs. Our previous pilot study demonstrated the feasibility of reducing hospitalization using an ED-based observation pathway. In this follow-up study, we hypothesize that the pathway is durable in clinical practice, outside of research supervision, and patients can safely be managed without hospitalization. STUDY: We reviewed patients prospectively enrolled in the observation pathway after the end of the pilot study. We compared outcomes to patients enrolled in our pilot study and with a historic cohort of patients admitted with mild AP. Our primary outcome was hospitalization rate during the enrollment period and secondary outcomes included length of stay, 30-day readmissions, mortality, and health care utilization. RESULTS: Over a 2-year period 165 patients met criteria for AP with 118 (71.5%) having mild AP. Fifty-four of 118 patients (45.8%) were enrolled in the observation pathway and of these, 45 patients were discharged from the ED, reducing hospitalization by 31.2%, compared with pilot study (22.2%) and historic cohort (0%) (P<0.05). Median length of stay was shorter [19.9 (observation) vs. 72.0 h (historic cohort), P<0.01]. There were fewer radiographic examinations in the observation cohorts (pilot and current study) than in the historic cohort (P<0.05), with similar 30-day readmissions, and no reported deaths. CONCLUSIONS: This follow-up study demonstrates the durability of an observation-based pathway to manage mild AP outside of a research protocol and maintain its ability to reduce hospitalizations without affecting readmission rates or mortality.

Preventing Hospitalization in Mild Acute Pancreatitis Using a Clinical Pathway in the Emergency Department.

GOALS: We created an observation pathway with close outpatient follow-up for patients with mild acute pancreatitis (AP) to determine its effect on admission rates, length of stay (LOS), and costs. BACKGROUND: AP is a common reason for hospitalization costing $2.6 billion annually. Majority have mild disease and improve quickly but have unnecessarily long hospital stays. STUDY: We performed a pilot prospective cohort study in patients with AP at a tertiary-care center. In total, 90 patients with AP were divided into 2 groups: observation cohort and admitted cohort. Exclusion criteria from observation included end-organ damage, pancreatic complications, and/or severe cardiac, liver, and renal disease. Patients in observation received protocolized hydration and periodic reassessment in the emergency department and were discharged with outpatient follow-up. Using similar exclusion criteria, we compared outcomes with a preintervention cohort composed of 184 patients admitted for mild AP in 2015. Our primary outcome was admission rate, and secondary outcomes were LOS, patient charges, and 30-day readmission. RESULTS: Admitted and preintervention cohorts had longer LOS compared with the observation cohort (89.7 vs. 22.6 h, P<0.01 and 72.0 vs. 22.6 h, P<0.01). The observation cohort admission rate was 22.2% lower than the preintervention cohort (P<0.01) and had 43% lower patient charges ($5281 vs. $9279, P<0.01). Moreover there were significantly fewer imaging studies performed (25 vs. 49 images, P=0.03) in the observation cohort. There were no differences in readmission rates and mortality. CONCLUSIONS: In this feasibility study, we demonstrate that a robust pathway can prevent hospitalization in those with AP and may reduce resource utilization without a detrimental impact on safety.

Flail anterior tricuspid valve leaflet in a neonate: association with maternal antiphospholipid syndrome.

This brief report describes a case of flail anterior tricuspid valve leaflet in a neonate associated with maternal antiphospholipid syndrome. Fetal echocardiography at 27 weeks of gestation showed competent atrioventricular valves with biventricular echogenic chordae. Fetal distress was noted at delivery, and echocardiography showed a flail anterior leaflet of the tricuspid valve with severe regurgitation. Possible causation and implications of maternal antiphospholipid syndrome are discussed.

Impact of EGF, IL28B, and PNPLA3 polymorphisms on the outcome of allograft hepatitis C: a multicenter study.

Hepatitis C virus (HCV) infection is accelerated following liver transplantation (LT). Single nucleotide polymorphisms (SNPs) near the epidermal growth factor (EGF) (rs4444903), IL28B (rs12979860), and PNPLA3 (rs738409) loci are associated with treatment response, fibrosis, and hepatocellular carcinoma in non-transplant hepatitis C, but allograft population data are limited. We sought to determine the role of these SNPs in 264 patients with HCV who underwent LT between 1990 and 2008. Genotypes were determined from donor wedge/allograft biopsies and recipient explants. Cox proportional hazards model was used to assess time to cirrhosis, liver-related death, and retransplantation, adjusting for donor age and sustained virological response (SVR). Over a median follow-up of 6.3 yr, a trend toward increased progression to graft cirrhosis was observed among recipients of an EGF non-AA vs. AA donor liver (adjusted HR 2.01; 95% CI 0.93-4.34; p = 0.08). No other genotypes predicted cirrhosis development or graft survival. The CC IL28B variant in both recipients and donors was associated with increased rate of SVR (R-CC/D-CC 8/12[67%], R-non-CC/D-CC or R-CC/D-non-CC 23/52[44%], R-non-CC/D-non-CC 12/45[27%], p linear trend = 0.009). Recipient EGF, IL28B, and PNPLA3, and donor IL28B and PNPLA3 genotypes do not predict adverse outcomes in HCV LT recipients. A potential association exists between donor EGF genotype and cirrhosis.

Fellowship Colonoscopy Training and Preparedness for Independent Gastroenterology Practice.

GOALS: To objectively assess when gastroenterology (GI) fellows achieve technical competency to perform colonoscopy independently. BACKGROUND: New guidelines to assess the procedural competency of GI fellows in training have been developed. Although comprehensive, they do not account for the quality metrics to which independently practicing gastroenterologists are held. STUDY: We performed a prospective study examining consecutive colonoscopies performed by GI fellows from November 2013 through March 2014 at an academic medical center. Using a brief postprocedure questionnaire and the online medical record, we measured rates of independent fellow cecal intubation rate (CIR), insertion time to the cecum (cecal IT), and independent polypectomy rate. Our secondary outcomes were adenoma detection rate and polyp detection rate. RESULTS: A total of 898 colonoscopies performed by 10 GI fellows were analyzed. In the multivariate analysis, CIR [odds ratio (OR)=1.29, P=0.012], cecal IT (ß-coefficient=0.19, P=0.006), and rates of unassisted independent snare polypectomy (OR=1.36, P<0.001) all improved significantly with increased number of procedures performed (OR and ß-coefficient per 100 colonoscopies performed). After performing 500 colonoscopies, fellows achieved a mean CIR>90%, cecal IT between 7 and 10 minutes, and independent polypectomy rate of 90% with further improvement in cecal IT to <7 minutes, and independent snare polypectomy of >95% after 700 cases. CONCLUSIONS: Current procedural recommendations for fellowship training may underestimate the technical skill necessary for independent GI practice upon completion of fellowship. Technical proficiency in snare polypectomy may lag behind proficiency in cecal intubation.