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Chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP) in pediatric patients are strongly associated with genetic mutations and lead to pan-parenchymal disease refractory to medical and endoscopic treatment. Our aim was to assess pain resolution and glucose control in patients with CP and ARP following total pancreatectomy with islet auto-transplantation (TPIAT). We retrospectively analyzed prospectively collected clinical data of 12 children who developed CP and ARP and underwent TPIAT when 21 years old or younger at the University of Chicago between December 2009 and June 2020. Patients with recurrent or persistent abdominal pain attributed to acute or chronic pancreatic inflammation and a history of medical interventions attempted for the relief of pancreatic pain were selected by a multi-disciplinary team for TPIAT. We followed patients post-operatively and reported data for pre-TPIAT, post-operative day 75, and yearly post-TPIAT. All 12 patients experienced complete resolution of pancreatic pain. The overall insulin-independence rate after 1 year was 66% (8/12) and 50% (3/6) at 4 years. Shorter duration of CP/ARP pre-TPIAT, higher mass of islets infused, and lower BMI, BMI percentile, and BSA were associated with insulin-independence post-TPIAT. TPIAT is a viable treatment option for pediatric patients with CP and ARP. Pediatric patients undergoing TPIAT for CP achieved resolution of pancreatic-type pain and reduced opioid requirements. The majority were able to achieve insulin-independence which was associated with lower pre-TPIAT BMI and higher islet mass transplanted (i.e., over 2000 IEQ/kg), the latter of which can be achieved by earlier TPIAT. Treatment study, Level IV.

Total pancreatectomy with islet autotransplantation (TPIAT) is an effective treatment option for non-diabetic patients with intractable chronic pancreatitis. The outcome and potential benefits for pre-diabetic and diabetic patients are less well established. Thirty-four patients underwent TPIAT were retrospectively divided into 3 groups according to pre-operative glycemic control: diabetes mellitus (DM) (n = 5, 15%), pre-DM (n = 11, 32%) and non-DM (n = 18, 54%). Pre-operative fasting c-peptide was detectable and similar in all 3 groups. Islet yield in the DM group was comparable to pre-DM and non-DM groups (median islet equivalents [IEQ] was 191,800, 111,800, and 232,000 IEQ, respectively). Patients received islet mass of over the target level of 2000 IEQ/kg in pre-DM and DM at lower but clinically meaningful rates compared to the non-DM group: 45% (5/11) and 60% (3/5) for a combined 50% (8/16) rate, respectively, compared to 83% (15/18) for the non-DM group. At 1 year, fasting c-peptide and HbA1c did not differ between DM and pre-DM groups but c-peptide was significantly higher in non-DM. Islet transplantation failed (negative c-peptide) only in 1 patient. Pre-operatively, all patients experienced pancreatic pain with daily opioid dependence in 60% to 70%. Pancreatic-type pain gradually subsided completely in all groups with no differences in other painful somatic symptoms. Diabetic patients with measurable pre-operative c-peptide can achieve similar benefit from TPIAT, with comparable outcomes to pre-diabetic and non-diabetic patients including pain relief and the metabolic benefit of transplanted islets. Not surprisingly, endocrine outcomes for diabetic and pre-diabetics patients are substantially worse than in those with normal pre-operative glucose control.

Aim: The neutropenic diet is commonly prescribed to cancer patients with neutropenia with the goal of reducing infections. However, multiple randomized trials have proved no benefit with neutropeni...

Primary pancreatic lymphoma (PPL) is an extranodal manifestation of non-Hodgkin lymphoma originating in the pancreas, which constitutes1% of all pancreatic neoplasms. Because of the rarity of the disease, most data on PPL are derived from case reports and small case series. To provide better insight into the epidemiology, treatment, and outcomes of these patients, we conducted an analysis of patients with PPL from the Surveillance, Epidemiology and End Results (SEER) database, which is presented in this study.Patients with PPL were identified using the International Classification of Disease for Oncology, third edition histology codes for lymphoma (9590/3-9734/3), with pancreas (C25.0-C25.9) listed as the primary disease site. We collected data on patient demographics, year of diagnosis, primary tumor site, histology, first line of treatment received, and survival until death or last follow-up for the period 1973-2014.Overall, 835 patients were included. The median (range) age of the study population was 67 (2 to 98) years. The median (95% confidence interval) overall survival for the cohort was 53 (37 to 73) months. On univariable analyses, age, stage, and use of chemotherapy were statistically associated with improved overall survival. Besides these factors, white race was associated with improved cause-specific survival on multivariable analysis.This large population-based series describes PPL in detail. Younger age, white race, early stage, and initial treatment with chemotherapy are associated with improved survival in patients with PPL.

Background and study aims Endoscopic ultrasound (EUS)-guided tissue sampling is the standard of care for diagnosing solid pancreatic lesions. While many two-way comparisons between needle types have been made in randomized controlled trials (RCTs), it is unclear which size and type of needle offers the best probability of diagnosis. We therefore performed a network meta-analysis (NMA) to compare different sized and shaped needles to rank the diagnostic performance of each needle. Methods We searched MEDLINE, EMBASE and Cochrane Library databases through August, 2020 for RCTs that compared the diagnostic accuracy of EUS fine-needle aspiration (FNA) and biopsy (FNB) needles in solid pancreatic masses. Using a random-effects NMA under the frequentist framework, RCTs were analyzed to identify the best needle type and sampling technique. Performance scores (P-scores) were used to rank the different needles based on pooled diagnostic accuracy. The NMA model was used to calculate pairwise relative risk (RR) with 95 % confidence intervals. Results Review of 2577 studies yielded 29 RCTs for quantitative synthesis, comparing 13 different needle types. All 22G FNB needles had an RR > 1 compared to the reference 22G FNA (Cook) needle. The highest P-scores were seen with the 22G Medtronic FNB needle (0.9279), followed by the 22G Olympus FNB needle (0.8962) and the 22G Boston Scientific FNB needle (0.8739). Diagnostic accuracy was not significantly different between needles with or without suction. Conclusions In comparison to FNA needles, FNB needles offer the highest diagnostic performance in sampling pancreatic masses, particularly with 22G FNB needles.

Background Obesity is a major public health challenge, and recent literature sheds light on the concept of “normalization” of obesity. Objective We aimed to study the worldwide pattern of web-based information seeking by public on obesity and on its related terms and topics using Google Trends. Methods We compared the relative frequency of obesity-related search terms and topics between 2004 and 2019 on Google Trends. The mean relative interest scores for these terms over the 4-year quartiles were compared. Results The mean relative interest score of the search term “obesity” consistently decreased with time in all four quartiles (2004-2019), whereas the relative interest scores of the search topics “weight loss” and “abdominal obesity” increased. The topic “weight loss” was popular during the month of January, and its median relative interest score for January was higher than that for other months for the entire study period (P Conclusions Despite a worldwide increase in the prevalence of obesity, its popularity as an internet search term diminished over time. The reason for peaks in months should be explored and applied to the awareness campaigns for better effectiveness. These patterns suggest normalization of obesity in society and a rise of public curiosity about image-related obesity rather than its medical implications and harm.

Introduction: Total pancreatectomy with islet autotransplantation (TPIAT) is an effective treatment option for nondiabetic patients with intractable chronic pancreatitis. The outcome and potential benefits for prediabetic and diabetic patients are less well established. Method: Thirty-four patients underwent TPIAT were retrospectively divided into 3 groups according to pre-operative glycemic control: diabetes mellitus (DM) (n=5, 15%), Pre-DM (n=11, 32%) and Non-DM (n=18, 54%). Results: Preoperative fasting c-peptide was detectable and similar in all 3 groups. Islet mass in the DM group was comparable to Pre-DM and Non-DM groups: (median 191,800), 111,800 and 232,000, respectively). Patients received islet mass of over the target level of 2,000 IEQ/kg in Pre-DM and DM at lower but clinically meaningful rates compared to the Non-DM group 45% (5/11) and 60% (3/5) for a combined 50% (8/16) rate, respectively, compared to 83% (15/18) for the non-DM group. At 1 year, fasting c-peptide and HbA1c did not differ between DM and Pre-DM groups but c-peptide was significantly higher in Non-DM. Islet transplantation failed (negative c-peptide) only in one patient. Preoperatively, all patients experienced pancreatic pain with daily opioid dependence in 60-70%. Pancreatic-type pain gradually subsided completely in all groups with no differences in other painful somatic symptoms. Conclusions: Patients with diabetes and measurable preoperative c-peptide can achieve similar benefit from TPIAT, with comparable outcomes to prediabetic and nondiabetic patients including pain relief. Not surprisingly, endocrine outcomes for diabetic and prediabetic patients are substantially worse than in those with normal preoperative glucose control. Disclosure P.J. Bachul: None. P. Borek: None. R. Anteby: None. L. Basto: None. L. Perea: None. K. Golab: None. L. Wang: None. M.L. Tibudan: None. A. Perez-Gutierrez: None. M. Komorniczak: None. S. Nagpal: None. A.C. Lucander: None. M. Dimitrov: None. J. Fung: None. J.B. Matthews: None. P. Witkowski: None.

The majority of patients with pancreatic ductal adenocarcinoma (PC) display either impaired fasting glucose/glucose intolerance or overt diabetes. However, the pathophysiologic basis of this association remains largely unexplained.In this case-control study we aimed to study the morphological changes in the islets of patients with PC, compared to control patients with and without type 2 diabetes mellitus (T2DM). T2DM controls and PC cases had a lower β-cell area and average islet size and density compared to non-T2DM controls (p 0.05).Compared to both T2DM and non-T2DM controls, mean α-cell area was significantly lower and β/α-ratio was higher in PC cases (p 0.05). Furthermore, whereas islets in T2DM controls were characterized by disrupted islet architecture and presence of islet amyloid aggregates, islet composition in PC islets was not significantly different compared to non-T2DM controls (p 0.05 vs. Control).Our data shows that PC is associated with a unique pattern of islet pathology characterized by preserved architecture, absence of amyloid aggregates, and relative α-cell loss indicating that distinct mechanisms are likely involved in the pathophysiology of islet failure in PC-induced DM. Insights into the mechanisms mediating β-cell failure in PC can be important for our understanding of pathophysiology of PC.

There is lack of consensus on post-operative surveillance for resected non-invasive intraductal papillary neoplasms (IPMNs). In this study we explored risk factors for subsequent PC in patients with MD-IPMN undergoing partial pancreatectomy. We searched the Mayo Clinic surgical pathology database for all cases of resected MD-IPMN between 1997 and 2014. Cases with histologically confirmed main pancreatic duct involvement either isolated or in a mixed pattern with branch-duct involvement were included. Outcomes of PC in the remnant pancreas, and death related to MD-IPMN were assessed with survival analyses (Kaplan–Meier and Cox regression). Among the 179 patients with resected MD-IPMN the incidence of concomitant PC and high-grade dysplasia (HGD) in the resected specimen was 23 and 14%, respectively. The mean duration of follow-up was 4.31 years (range 0.12–13.5 years). Excluding 28 subjects who either underwent initial total pancreatectomy or partial pancreatectomy with surgical margins positive for PC/HGD, the 5-year incidence of subsequent PC was 12%, including 60.6% and15.6% in those with initial PC and HGD, respectively. The 10-year incidence of PC was 21.2% overall, 60.6% for PC, 38.3% for HGD, and 3.0% for LGD. Risk of subsequent PC was significantly higher for those with initial PC compared with HGD (HR = 4.95, 95% CI: 1.63–15.03, p = 0.005 and for HGD compared with LGD (HR = 11.30, 95% CI: 1.55–82.26, p = 0.017). Patients with MD-IPMN with PC or HGD undergoing segmental pancreatectomy are at higher risk of subsequent PC and may benefit from post-operative surveillance. The post-operative surveillance intervals in resected MD- IPMNs need to be tailored based on dysplasia grade.

OBJECTIVES: Human pancreatic polypeptide (HPP) is a hormone secreted by the ventral pancreas. While postprandial HPP levels have been studied in chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDAC), there are limited data on fasting HPP in these diseases. METHODS: Fasting serum HPP was measured in the following groups of patients: CP with diabetes mellitus (DM) (n = 16), CP without DM (n = 34), PDAC with new-onset DM (n = 50), PDAC without DM (n = 49), new-onset type 2 DM (n = 50), and controls without DM (n = 49). Sixty-six had type 3c DM (CP with DM, n = 16; PDAC with new-onset DM, n = 50). RESULTS: Median fasting HPP levels (in picograms per milliliter) were similar among all groups. Median (interquartile range) HPP levels in new-onset type 2 DM (n = 50; 288.3 [80.1–1072.1]) were similar to those in type 3c DM (n = 66; 242.3 [64.9–890.9]) (P = 0.71). In PDAC (n = 99), HPP values were similar in pancreatic head (n = 75) versus body/tail (n = 24) tumors (245.3 [64.3–1091.3] vs 334.7 [136.1–841.5]; P = 0.95), regardless of DM. CONCLUSIONS: Fasting HPP levels are similar in CP, PDAC, and controls regardless of glycemic status.

The incidence of colorectal cancer in the United States has decreased substantially in individuals aged 50 and older. In contrast, it is increasing in young adults. The polyp characteristics on baseline and follow-up colonoscopy in young adults are not well characterized. We describe the polyp characteristics on baseline and follow-up colonoscopy in adults 40 years and determined factors associated with the occurrence of metachronous, advanced neoplasia or high-risk (HR) polyp features. We compared the occurrence of metachronous advanced neoplasia in young adults with those 50 years and older to assess whether postpolypectomy surveillance guidelines seem appropriate for polyp-bearing adults less than age 40 years.Patients 40 years of age with1 polyp removed on colonoscopy followed by a postpolypectomy colonoscopy were eligible. The primary outcome was the occurrence of advanced neoplasia or HR polyp features on follow-up colonoscopy. Secondary endpoints included factors associated with metachronous advanced neoplasia in young adults. The occurrence of metachronous advanced neoplasia in young adults was compared with a cohort of patients aged 50 years and older.Included were 128 patients with a mean age of 34.9 years; 124 patients (97%) had adenomas and 7% had sessile serrated polyps (SSPs). Advanced neoplasia was seen in 35% of patients at baseline. The median follow-up time was 33.6 months. Metachronous advanced neoplasia was identified in 7% of patients on follow-up colonoscopy. Baseline factors associated with metachronous advanced neoplasia included the presence of an SSP (hazard ratio, 7.8; 95% CI, 1.09-56.3; P = .041) with a trend in those with advanced neoplasia (hazard ratio, 3.4; 95% confidence interval, .89-12.8; P = .072). The occurrence of metachronous advanced neoplasia did not differ between the young and older cohorts (7% vs 12.2%, P = .58); however, young adults were less likely to have HR polyp features on follow-up (8.6% vs 20.3%, P = .008).More than 1 in 3 adults 40 years old undergoing colonoscopy had advanced neoplasia on baseline colonoscopy. The occurrence of metachronous advanced neoplasia in young adults is similar to older adults and appears to be associated with the size, pathology, and number of baseline polyps. Our data suggest young polyp-bearing adults may undergo postpolypectomy colonoscopy at intervals currently recommended by national guidelines. Confirmation in larger studies is warranted.

This case report describes an 83-year-old woman with multiple comorbidities who presented with melena and coffee-ground emesis with diagnostic studies evident for a large prepyloric gastrointestinal stromal tumor. She underwent combined laparoendoscopic transgastric resection surgery for the tumor, performed by a team of gastroenterologist and thoracic surgeon with a successful outcome. The case and videos in this report provide a descriptive demonstration of the steps leading up to the surgical intervention followed by a step-by-step illustration of the combined surgical technique, thus highlighting the importance of multidisciplinary approach for optimal treatment of prepyloric gastrointestinal stromal tumor.

Nonalcoholic fatty liver disease (NAFLD) is likely to replace Hepatitis C as the leading cause of cirrhosis resulting in liver transplantation (LT) within a few years. Unfortunately, due to the lack of established guidelines for the screening of NAFLD in high-risk populations, many patients present with portal hypertension complications as their first manifestation of NAFLD require a LT evaluation. We aimed to investigate what proportion of patients who underwent LT for NAFLD-cirrhosis had knowledge of their liver disease prior to presenting with portal hypertension complications and to identify differences in clinical parameters between those with and without knowledge of preexisting NAFLD.Consecutive patients who underwent LT for NAFLD-cirrhosis at a tertiary referral center were included in the study. Demographic and clinical data at the time of the first LT evaluation visit were collected, and patient knowledge of previous NAFLD was documented. Ascites, variceal bleeding, hepatic encephalopathy, and thrombocytopenia leading to diagnosis of underlying cirrhosis were considered as the presenting symptoms of portal hypertension. A p 0.05 was considered statistically significant.A total of 124 subjects who received LT for NAFLD-cirrhosis were included, 58 % (n = 72) were male. At the time of the first LT evaluation visit, 60 % had diabetes, the mean body mass index was 33.2 [28.6, 37.6] kg/m(2), and the mean Model for End-Stage Liver Disease (MELD) score was 14.0 [11.0, 19.0]. More importantly, 85/124 patients (68.5 %) had no knowledge of preexisting NAFLD prior to presentation with symptoms of portal hypertension. The presenting symptoms were new-onset ascites in 61 %, hepatic encephalopathy in 25 %, variceal bleeding in 18 %, thrombocytopenia in 9 %, and other in 9 % (non-exclusive). Patients with no prior knowledge of NAFLD were less likely to have a diagnosis of hypercholesterolemia (30 vs. 50 %, p = 0.035) and had a trend toward having higher MELD scores at the time of the first LT evaluation visit (15 vs. 13.5, p = 0.05) and presenting with encephalopathy (25 vs. 10 %, p = 0.06) compared to those with previous knowledge of NAFLD diagnosis.The majority of patients undergoing liver transplant evaluation for NAFLD-cirrhosis are not aware of underlying NAFLD until they present with features of portal hypertension. New guidelines should consider screening for NAFLD in certain high-risk groups as more effective treatments for NAFLD are emerging.

62 Background: Multiple studies have reported an increasing incidence of colorectal cancer (CRC) in young( < 45 years)adults.However, the impact of race on the incidence, tumor location and survival in adults < 45 years with CRC has not been explored. Methods: Using Surveillance,Epidemiology and End Results database,we identified patients with CRC and abstracted data on patient demographics,tumor location and survival between 1973-2014, and compared these variables in patients 18-44 years with those > 45 years. Cases where CRC was not the first/only malignancy were excluded.Categorical variables were compared using the Chi-square test and overall survival was analyzed using Kaplan-Meier method. Results: Overall, 453,019 patients were included (27, 352 < 45,and 425,667 >45 years). 81.7% among those > 45 years were caucasian, as compared to 74.3% < 45 years of age. Among those < 45, 14.3% were black, 10.3% were Asian/Pacific Islander (API) and 1.1% were American Indian/Alaska Native (compared to 10.1%, 7.5% and 0.6% respective in adults > 45) (p < 0.0001*) (Table). 73.1% of those < 45 had left sided disease (descending, sigmoid colon and rectum) as compared to 60.1% in those > 45 (p < 0.0001*).Survival was poorer for non-white patients (black, API and AI) (94 months, 95%CI 90-100) as compared to white patients (153 months, 95%CI 145-161) overall, and individually for the < 45 and >45 years subgroups as well. Conclusions: Racial distribution in patients with CRC differs significantly among patients < 45 as compared to older adults,with incidence in young American Indian/Alaska Natives approaching 2 times that of older adults,and 1.5 times in young Blacks and Asian/Pacific Islanders.Non-white races have poorer survival across all age groups.With rates of CRC rising sharply in young adults, underlying reasons for these differences require further investigation to better channelize efforts for education and screening. [Table: see text]

Since its first description in the 1960s from the United States, IgG4-SC has been increasingly recognized and reported from around the world. It is the most common extrapancreatic manifestation of type 1 autoimmune pancreatitis and is possibly associated with an accelerated development of secondary biliary cirrhosis if diagnosis is delayed. Obstructive jaundice and constitutional symptoms are the main presenting symptoms, similar to hilar cholangiocarcinoma and primary sclerosing cholangitis, which are the most important differential diagnoses of IgG4-SC. Endoscopy is critical to rule out malignancy. While steroids are the mainstay of initial treatment, and most patients respond rapidly, there is a very high likelihood of relapse, especially in patients with proximal biliary strictures. Initiation of immunomodulators or rituximab may be required to maintain long-term remission. In this chapter we will describe the epidemiology, diagnosis, clinical presentation, and management of IgG4-SC based on studies primarily from the United States.

Background and aims Annular pancreas (AnnP) is a rare congenital abnormality that results from the presence of a complete or partial ring of pancreatic tissue surrounding the descending portion of the duodenum. While the clinical presentation and management of AnnP in neonates and infants has been well described, the complete spectrum of clinical presentation of AP in adults is not very clear. We aimed to describe the clinical spectrum of presentation and management of adult patients with AnnP. Methods Using the electronic medical record, we identified 198 patients with radiologically and/or surgically confirmed AnnP evaluated at Mayo Clinic between 1995 and 2017. Results The mean age of the study population at diagnosis was 55.1 (±18.3) years (60% female). 60% of patients did not have symptoms attributable to pancreatic disease at the time of diagnosis and were diagnosed incidentally. Computed tomography (CT) was the most common modality (64%) of diagnosis. Among symptomatic patients, abdominal pain (50%), duodenal obstruction (31%) and acute pancreatitis (16%) were the most common symptoms (non-exclusive). While most patients with duodenal obstruction required surgery, all patients with acute pancreatitis could be managed conservatively in the absence of competing indications for intervention. Conclusion AnnP may remain asymptomatic well into adulthood and be incidentally detected on abdominal imaging done for other indications. While surgery remains the mainstay of treatment in patients presenting with duodenal obstruction, a majority of these adult symptomatic patients with AnnP, including those with acute pancreatitis require no further treatment.

Background & Aims Identifying metabolic abnormalities that occur before pancreatic ductal adenocarcinoma (PDAC) diagnosis could increase chances for early detection. We collected data on changes in metabolic parameters (glucose, serum lipids, triglycerides; total, low-density, and high-density cholesterol; and total body weight) and soft tissues (abdominal subcutaneous fat [SAT], adipose tissue, visceral adipose tissue [VAT], and muscle) from patients 5 years before the received a diagnosis of PDAC. Methods We collected data from 219 patients with a diagnosis of PDAC (patients) and 657 healthy individuals (controls) from the Rochester Epidemiology Project, from 2000 through 2015. We compared metabolic profiles of patients with those of age- and sex-matched controls, constructing temporal profiles of fasting blood glucose, serum lipids including triglycerides, cholesterol profiles, and body weight and temperature for 60 months before the diagnosis of PDAC (index date). To construct the temporal profile of soft tissue changes, we collected computed tomography scans from 68 patients, comparing baseline (>18 months before diagnosis) areas of SAT, VAT, and muscle at L2/L3 vertebra with those of later scans until time of diagnosis. SAT and VAT, isolated from healthy individuals, were exposed to exosomes isolated from PDAC cell lines and analyzed by RNA sequencing. SAT was collected from KRAS+/LSLG12D P53flox/flox mice with PDACs, C57/BL6 (control) mice, and 5 patients and analyzed by histology and immunohistochemistry. Results There were no significant differences in metabolic or soft tissue features of patients vs controls until 30 months before PDAC diagnosis. In the 30 to 18 months before PDAC diagnosis (phase 1, hyperglycemia), a significant proportion of patients developed hyperglycemia, compared with controls, without soft tissue changes. In the 18 to 6 months before PDAC diagnosis (phase 2, pre-cachexia), patients had significant increases in hyperglycemia and decreases in serum lipids, body weight, and SAT, with preserved VAT and muscle. In the 6 to 0 months before PDAC diagnosis (phase 3, cachexia), a significant proportion of patients had hyperglycemia compared with controls, and patients had significant reductions in all serum lipids, SAT, VAT, and muscle. We believe the patients had browning of SAT, based on increases in body temperature, starting 18 months before PDAC diagnosis. We observed expression of uncoupling protein 1 (UCP1) in SAT exposed to PDAC exosomes, SAT from mice with PDACs, and SAT from all 5 patients but only 1 of 4 controls. Conclusions We identified 3 phases of metabolic and soft tissue changes that precede a diagnosis of PDAC. Loss of SAT starts 18 months before PDAC identification, and is likely due to browning. Overexpression of UCP1 in SAT might be a biomarker of early-stage PDAC, but further studies are needed.

Background : Microspherophakia is characterized by lenticular myopia, late development of lens dislocation, shallow anterior chamber and angle-closure glaucoma. If it is associated with angle closure glaucoma, the management can be challenging. Objective : To report the management of a case of bilateral secondary angle closure glaucoma with isolated microspherophakia and right subluxated lens in a middle aged lady. Case : A 47-year-old female presented with bilateral secondary angle closure glaucoma with isolated microspherophakia, right subluxated lens and left operated trabeculectomy. The patient`s best corrected log mar visual acuity improved from 1.0 to 0.2 and intraocular pressure (IOP) decreased from 24.9mm of Hg to lower teens following lensectomy with scleral ?xation of posterior chamber intraocular lens in the right eye. The left eye IOP remained in mid teens without medication in two year follow up. Conclusion : This case demonstrates that microspherophakia should be ruled out even in middle aged patients presenting as angle closure glaucoma. The possibility of thickened cornea must be kept in mind requiring an IOP correction. Lensectomy with scleral ?xation of posterior chamber IOL provides a satisfactory recovery of visual acuity and IOP control. Though in this patient, the lens was held in position by posterior synechiae in the left eye, future stability of zonules needs to be monitored.

Dear Editor, We read with great interest, the recent article by Ling et al. who hypothesized that following the launch of a campaign for a medical condition, information seeking behavior pertaining to the condition would increase as well1. They used data from Google Trends (Google Inc., CA) on 4 different diseases (including Colon Cancer) to conclude that the use of infoveillance shows promise as an alternative and inexpensive solution for disease surveillance and health care campaign evaluation. Cancer awareness has massively benefitted from rapid growth of internet and mass media and the evolution of social marketing strategies around the promotion of healthcare2,3. This has resulted in the development of cancer oriented societies, websites, public campaigns and specifically earmarked Cancer Awareness Months (CAMs) directed at changing public attitudes towards prevention, screening, treatment and informed decision making. However, despite the significant impact of cancer awareness on screening of preventable cancers4, the impact of CAMs on cancer-related internet search activity has not been well studied. Breast (BC), Lung (LC) and Colorectal Cancers (CRC) are the leading causes of cancer incidence and mortality among women 5 and have their respective CAMs during October, November and March respectively 6. Using Google Trends, a public web facility of Google Inc. based on Google Search, we compared the relative frequency of search of terms ‘Breast Cancer’,‘Lung Cancer’ and ‘Colon Cancer’ between 1st January 2004 and 31st January 2017 (n=158 months). The program assigns a reference value of 100 for the point of maximum popularity from among the search terms, and provides relative monthly scores for all terms, which we termed interest scores (IS). IS were then compared among cancers for the overall period (n=158 months) and specifically during their CAMs (n=13 months). Within each cancer, IS were then compared during the CAMs (n=13 months) as compared to the remaining months (n=145 months). Parametric and non-parametric analyses were carried out (wherever applicable) using ANOVA and Kruskal-Wallis tests respectively. A p-value of

Portal hypertension leading to gastric polyposis has rarely been reported. More common gastric manifestations of portal hypertension are portal hypertensive gastropathy and gastric antral vascular ectasia (GAVE). We report a case of a patient in whom portal hypertension manifested as bleeding gastric polyps leading to transfusion-dependent iron deficiency anemia.

BACKGROUND & AIMS: Of subjects with new-onset diabetes (based on glycemia) over the age of 50 years, approximately 1% are diagnosed with pancreatic cancer within 3 years. We aimed to develop and validate a model to determine risk of pancreatic cancer in individuals with new-onset diabetes. METHODS: We retrospectively collected data from 4 independent, non-overlapping cohorts of patients (n=1561) with new-onset diabetes (based on glycemia; data collected at date of diagnosis and 12 months before) in the Rochester Epidemiology Project, from January 1, 2000 through December 31, 2015 to create our model. The model weighed scores for the 3 factors identified in the discovery cohort to be most strongly associated with pancreatic cancer (64 patients with pancreatic cancer and 192 with type-2 diabetes): change in weight, change in blood glucose, and age at onset of diabetes. We called our model enriching new-onset diabetes for pancreatic cancer (END-PAC). We validated the locked-down model and cutoff score in an independent population-based cohort of 1096 patients with diabetes; of these 9 patients (.82%) had pancreatic within 3 years of meeting the criteria for new-onset diabetes. RESULTS: In the discovery cohort the END-PAC model identified patients who developed pancreatic cancer within 3 years of onset of diabetes with an area under the receiver operating characteristic curve value of 0.87; a score of ≥3 identified patients who developed pancreatic cancer with 80% sensitivity and specificity. In the validation cohort, a score of ≥3 identified 7/9 patients with pancreatic cancer (78%), with 85% specificity; the prevalence of pancreatic cancer in subjects with score of ≥3 (3.6%) was 4.4-fold more than in patients with new-onset diabetes. A high END-PAC score in subjects who did not have pancreatic cancer (false positives) was often due to such factors as recent steroid use or different malignancy. An END-PAC score 6 months before a diagnosis of pancreatic cancer. CONCLUSIONS: Based on change in weight, change in blood glucose, and age at onset of diabetes, we developed and validated a model to determine risk of pancreatic cancer in patients with new-onset diabetes, based on glycemia (the END-PAC model). An independent, prospective study is needed to further validate this model, which could contribute to early detection of pancreatic cancer.

Over the course of the last 2 decades our knowledge of autoimmune pancreatitis has increased exponentially. In this review, we summarize the clinical presentation, diagnosis and treatment of AIP, to better allow general gastroenterologists and primary care providers to consider AIP as a as a rare but important cause of painless obstructive jaundice and recurrent acute pancreatitis. While steroids remain the mainstay of first line therapy, a number of patients with type 1 AIP require immunomodulators or rituximab to maintain remission; recommendations on the management of relapses continue to evolve.

e18940Background: Neutropenic Diet (ND) is commonly recommended and widely practiced for cancer patients with neutropenia with the goal of reducing infections. However, multiple randomized trials s...

240 Background: Colorectal and Pancreatic cancers have high mortality with about 50,000 patients dying from each annually. Cancer awareness months (CAMs) have been earmarked by cancer societies to change public attitudes towards prevention, screening and treatment of various cancers. Awareness campaigns lead by these societies have benefited significantly from readily available Internet access and growing social media. Internet search activity has been used as a surrogate tool to gauge public interest and awareness. We aimed to assess if cancer awareness months impact internet search activity for these cancers. Methods: Using Google Trends, a public web facility of Google Inc. based on Google Search, we compared the relative frequency of search of terms ‘Colon Cancer’ and ‘Pancreatic Cancer’ between 1st January 2004 and 31st December 2016 (n=156 months). The program assigns a reference value of 100 for the point of maximum popularity from among the search terms, and provides relative monthly scores for all terms, which we termed relative interest scores (RIS). Within each cancer, the median RIS was then compared for their respective awareness months (n=13; March for CRC and November for PC) to the to the remaining months (n=143). Results: The median (IQR) RIS for CRC was significantly higher for CRC during its CAM:54 (51-63) as compared to other months:47 (44-50); p=0.0001. However, there was no significant difference in the median RIS for PC during its CAM: 33 (27.5-35.5) as compared to other months: 31 (27-33); p=0.43. The point of maximum popularity during the study period (i.e. RIS 100), and other peaks in search volume for PC corresponded to significant news events associated with PC, and PC search volumes surpassed CRC in those months. Conclusions: Ongoing campaigns for CRC awareness appear to be effective in increasing internet search activity during its respective CAM. While differences could be due to established CRC screening guidelines, other reasons behind the success of CRC awareness campaigns should be adopted by PC as awareness campaigns for the two cancers are otherwise similar.