Impact of Ethno-racial Factors on Clinical Outcomes and Health Care Utilization in Chronic Pancreatitis.

BACKGROUND: Healthcare disparities adversely affect clinical outcomes in racial and ethnic minorities. Chronic pancreatitis (CP) is a complex disorder, and pressures for time and cost-containment may amplify the disparity for minorities in this condition. This study aimed to assess ethno-racial differences in the clinical outcomes of CP patients cared for at our institution. METHODS: This is a study of CP patients with available ethno-racial information followed at our pancreas center. We reviewed their demographics, comorbidities, clinical outcomes, and resource utilization: pain, frequent flares (≥ 2/year), local complications, psychosocial variables, exocrine, and endocrine insufficiency, imaging, endoscopic procedures, and surgeries. The outcomes underwent logistic regression to ascertain association(s) with covariates and were expressed as odds ratio (95% confidence intervals). RESULTS: Of the 445 CP patients, there were 23 Hispanics, 330 Non-Hispanic Whites, 47 Non-Hispanic Blacks, 16 Asian Americans, and 29 patients from Other/mixed races. Over a median follow-up of 7 years, no significant differences in the pain profile (p = 0.36), neuromodulator use (p = 0.94), and opioid use for intermittent (p = 0.34) and daily pain (p = 0.80) were observed. Frequent flares were associated with Hispanic ethnicity [2.98(1.20-7.36); p = 0.02], despite adjustment for smoking [2.21(1.11-4.41); p = 0.02)] and alcohol [1.88(1.06-3.35); p = 0.03]. Local complications (pseudocysts, mesenteric thrombosis, and biliary obstruction), exocrine and endocrine dysfunction, and healthcare resource utilization (cross-sectional imaging, endoscopic procedures, celiac blocks, or surgeries) were comparable across all ethno-racial groups. CONCLUSIONS: Although no significant differences in clinical outcomes, and health resource utilization were noted across ethno-racial groups, Hispanic ethnicity had significant association with CP flares. This study calls for further investigation of an understudied minority population with CP.

Prospective Evaluation of Sexual Dysfunction in Men With Chronic Pancreatitis: A Pilot Study.

OBJECTIVE: Our study aimed to determine the prevalence of sexual dysfunction (SD) and its association with quality of life (QOL) in men with chronic pancreatitis (CP). MATERIALS AND METHODS: Male patients with CP were prospectively enrolled in our pancreas center and completed the following 4 validated questionnaires: International Index of Erectile Function 5, Erectile Hardness Score, Pancreatitis Quality of Life Instrument, and Short Form Survey. Patients were classified as having mild, moderate, or severe SD based on review of questionnaires. RESULTS: Thirty patients were enrolled in the study, of which 18 patients had SD (mild in 9, moderate in 1, and severe in 8 patients). No significant differences were seen demographic or clinical characteristics in patients with and without SD. Patients with SD had more abdominal pain compared with those without SD (94.4% vs 83.3%, P = 0.001). No significant differences were noted in QOL metrics between the 2 groups. CONCLUSIONS: This pilot study shows that SD is present in 60% males with CP. No difference was noted in the QOL of patients with and without SD, albeit limited by our small sample size. Physicians caring for CP patients should routinely inquire for symptoms of SD and offer a urology referral if indicated.

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.

Natural history, clinical characteristics, outcomes, and long-term follow-up of pain-free chronic pancreatitis.

Background: Chronic pancreatitis (CP) is characterized by chronic abdominal pain and functional insufficiency. However, a small subset of patients with prior acute pancreatitis (AP) and/or underlying risk factors for developing CP may be pain-free at diagnosis and may have a different clinical course. We aimed to compare the clinical characteristics, outcomes, and healthcare utilization between CP patients with and without pain. Methods: Reviewed patients with established CP were followed in our Pancreas Center between January 2016 and April 2021. Patients without risk factors for developing CP and/or without AP prior to their diagnosis and only with incidental radiologic features of CP were excluded, so as to minimize confounding factors of pancreatopathy unrelated to CP. Patients were divided into painful and pain-free groups to analyze differences in demographics, outcomes, and healthcare utilization. Results: Of 368 CP patients, 49 (13.3%) were pain-free at diagnosis and had remained so for >9 years. There were no significant differences in body mass index, race, sex, or co-morbidities between the two groups. Pain-free patients were older at diagnosis (53.9 vs 45.7, P = 0.004) and had less recurrent AP (RAP) (43.8% vs 72.5%, P < 0.001) and less exocrine pancreatic insufficiency (EPI) (34.7% vs 65.7%, P < 0.001). Pain-free patients had less disability (2.2% vs 22.0%, P = 0.003), mental illness (20.4% vs 61.0%, P < 0.001), surgery (0.0% vs 15.0%, P = 0.059), and therapeutic interventions (0.0% vs 16.4%, P = 0.005) for pain. Conclusions: We described a unique subset of patients with underlying risk factors for CP and/or prior AP who were pain-free at diagnosis. They were older at diagnosis, had less EPI and RAP, and overall favorable outcomes with minimal resource utilization.

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.

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.

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.

The association of hourly second-stage documentation with cesarean delivery and maternal blood loss.

PURPOSE OF THE ARTICLE: Cesarean rates and maternal morbidity increase with the duration of the second stage of labor. We studied the effect of hourly evaluation and documentation during the second stage of labor on maternal and fetal outcomes. MATERIALS AND METHODS: We performed a retrospective cohort study of all women who delivered at our urban, tertiary care hospital and underwent a second stage of greater than 60 min between 1 June 2016 and 31 May 2019. There were 1498 patients with complete data. Four hundred forty patients had hourly evaluation and documentation throughout the second stage and 1058 did not. We performed t-tests, Chi-squared, and regression analyses to compare cesarean delivery rate, second-stage duration, quantitative blood loss, hemorrhage and blood transfusion rates, and fetal outcomes. We performed regression analyses to evaluate for independent effect of this intervention on each outcome. RESULTS: Patients with hourly evaluation and documentation had a decreased likelihood of cesarean delivery (8.2% vs. 20.3%, p < .001), shorter second-stage of labor (98.1 min vs. 177.5 min, p < .001), decreased quantitative blood loss (514.4 mL vs. 667.7 mL, p < .001), and hemorrhage rate (12.5% vs. 19.9%, p < .001). Hourly evaluation was associated with decreased transfusion rates (3.2% vs. 5.6%, p = .05) but was not related to the number of units transfused. Regression analyses confirmed the impact of hourly documentation when potential confounders were included. These differences in outcomes were also noted when evaluation was performed and documented within every 75 min. Hourly second-stage evaluation and documentation did not affect other maternal or infant morbidities. CONCLUSION: Hourly evaluation and documentation in the second stage was associated with decreased cesarean delivery rate, second-stage duration, quantitative blood loss, hemorrhage, and transfusion.

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.