Dual role for microbial short-chain fatty acids in modifying SIV disease trajectory following anti-α4β7 antibody administration

BACKGROUND

Human Immunodeficiency Virus (HIV)/Simian Immunodeficiency Virus (SIV) infection is associated with significant gut damage, similar to that observed in patients with inflammatory bowel disease (IBD). This pathology includes loss of epithelial integrity, microbial translocation, dysbiosis, and resultant chronic immune activation. Additionally, the levels of all-trans-retinoic acid (atRA) are dramatically attenuated. Data on the therapeutic use of anti-α4β7 antibodies has shown promise in patients with ulcerative colitis and Crohn's disease. Recent evidence has suggested that the microbiome and short-chain fatty acid (SCFA) metabolites it generates may be critical for anti-α4β7 efficacy and maintaining intestinal homeostasis.

MATERIALS AND METHODS

To determine whether the microbiome contributes to gut homeostasis after anti-α4β7 antibody administered to SIV-infected rhesus macaques, faecal SCFA concentrations were determined, 16S rRNA sequencing was performed, plasma viral loads were determined, plasma retinoids were measured longitudinally, and gut retinoid synthesis/response gene expression was quantified.

RESULTS

Our results suggest that anti-α4β7 antibody facilitates the return of retinoid metabolism to baseline levels after SIV infection. Furthermore, faecal SCFAs were shown to be associated with retinoid synthesis gene expression and rebound viral loads after therapy interruption.

CONCLUSIONS

Taken together, these data demonstrate the therapeutic advantages of anti-α4β7 antibody administration during HIV/SIV infection and that the efficacy of anti-α4β7 antibody may depend on microbiome composition and SCFA generation.

Association between neutrophil to high-density lipoprotein cholesterol ratio and disease severity in patients with acute biliary pancreatitis

BACKGROUND

The neutrophil to high-density lipoprotein cholesterol ratio (NHR) is independently associated with the severity of various diseases. However, its association with acute biliary pancreatitis (ABP) remains unknown.

METHODS

This study included 1335 eligible patients diagnosed with ABP from April 2016 to December 2022. Patients were divided into low- and high-NHR level groups using an optimal cut-off value determined utilizing Youden's index. Multivariate logistic regression analysis was used to investigate the correlation between NHR and ABP severity. Multivariate analysis-based limited restricted cubic spline (RCS) method was used to evaluate the nonlinear relationship between NHR and the risk of developing moderate or severe ABP.

RESULTS

In this study, multivariate logistic regression analysis indicated an independent association between NHR and ABP severity (p < .001). The RCS analysis showed a linear correlation between NHR and the risk of developing moderate or severe ABP (P for non-linearity > 0.05), and increased NHR was found to be independently associated with a more severe form of the disease.

CONCLUSIONS

Our study suggests that NHR is a simple and practical independent indicator of disease severity, serving as a potential novel predictor for patients with ABP.

Meropenem versus piperacillin-tazobactam for the treatment of pancreatic necrosis

PURPOSE

To date, there are three published guidelines discussing management of infected pancreatic necrosis (IPN) with conflicting recommendations. Specifically, The World Society of Emergency Surgery lists piperacillin-tazobactam as a treatment option in addition to meropenem and ciprofloxacin plus metronidazole. Piperacillin-tazobactam may serve as an effective carbapenem-sparing alternative. Although previous studies shed light on antimicrobial penetration data, there is a lack of clinical data comparing piperacillin-tazobactam to meropenem. The purpose of this study is to compare the efficacy of meropenem and piperacillin-tazobactam for the treatment of IPN.

METHODS

This was a multicenter, retrospective cohort study conducted across three institutions. Patients with IPN who received either meropenem or piperacillin-tazobactam from January 2015 to December 2020 were included. The primary composite outcome was the incidence of 90-day clinical failure, which encompassed 90-day all-cause mortality and 90-day intra-abdominal infection recurrence. Secondary outcomes included length of hospital stay, antimicrobial duration of therapy, and the need for surgical intervention.

RESULTS

We identified 229 patients with IPN that received either meropenem or piperacillin-tazobactam during hospital admission. After screening, 63 patients were included in the study. Incidence of 90-day clinical failure was observed in 33 % of the meropenem group and 50 % in the piperacillin-tazobactam group (OR, 1.98; 95 % CI 0.57 to 7.01, p = 0.259). The meropenem group had a lower incidence of 90-day infection recurrence in the piperacillin-tazobactam group (56 % vs 29 %, p = 0.047).

CONCLUSIONS

Piperacillin-tazobactam may be an efficacious carbapenem-sparing treatment alternative for infected pancreatic necrosis.

Mesenteric adipose tissue B lymphocytes promote intestinal injury in severe acute pancreatitis by mediating enteric pyroptosis

BACKGROUND

Visceral adipose tissue (VAT) has been linked to the severe acute pancreatitis (SAP) prognosis, although the underlying mechanism remains unclear. It has been reported that pyroptosis worsens SAP. The present study aimed to verify whether mesenteric adipose tissue (MAT, a component of VAT) can cause secondary intestinal injury through the pyroptotic pathway.

METHODS

Thirty-six male Sprague Dawley (SD) rats were divided into six different groups. Twelve rats were randomly divided into the SAP and control groups. We monitored the changes of MAT and B lymphocytes infiltration in MAT of SAP rats. Twelve SAP rats were injected with MAT B lymphocytes or phosphate buffer solution (PBS). The remaining twelve SAP rats were first injected with MAT B lymphocytes, and then with MCC950 (NLRP3 inhibitor) or PBS. We collected blood and tissue samples from pancreas, gut and MAT for analysis.

RESULTS

Compared to the control rats, the SAP group showed inflammation in MAT, including higher expression of tumor necrosis factor (TNF-α) and interleukin-6 (IL-6), lower expression of IL-10, and histological changes. Flow cytometry analysis revealed B lymphocytes infiltration in MAT but not T lymphocytes and macrophages. The SAP rats also exhibited intestinal injury, characterized by lower expression of zonula occludens-1 (ZO-1) and occludin, higher levels of lipopolysaccharide and diamine oxidase, and pathological changes. The expression of NLRP3 and n-GSDMD, which are responsible for pyroptosis, was increased in the intestine of SAP rats. The injection of MAT B lymphocytes into SAP rats exacerbated the inflammation in MAT. The upregulation of pyroptosis reduced tight junction in the intestine, which contributed to the SAP progression, including higher inflammatory indicators and worse histological changes. The administration of MCC950 to SAP + MAT B rats downregulated pyroptosis, which subsequently improved the intestinal barrier and ameliorated inflammatory response of SAP.

CONCLUSIONS

In SAP, MAT B lymphocytes aggravated local inflammation, and promoted the injury to the intestine through the enteric pyroptotic pathway.

Predicting the severity of acute pancreatitis: Current approaches and future directions

Acute pancreatitis (AP) is a sudden-onset inflammatory disease of the pancreas. The severity of AP is classified into mild, moderate, and severe categories based on the presence and persistence of organ failure. Severe acute pancreatitis (SAP) can be associated with significant morbidity and mortality. It requires early recognition for appropriate timely management. Prognostic scores for predicting SAP incorporating many clinical, laboratory, and radiological parameters have been developed in the past. However, all of these prognostic scores have low positive predictive value for SAP and some of these scores require >24 h for assessment. There is a need to develop biomarkers that can accurately identify patients at risk for SAP early in the course of the presentation. In this review, we aim to provide a summary of the most commonly utilized prognostic scores for AP and discuss future directions.

Gastrointestinal involvement in STEC-associated hemolytic uremic syndrome: 10 years in a pediatric center

BACKGROUND

The gastrointestinal (GI) tract represents one of the main targets of typical hemolytic uremic syndrome (HUS) in children. In this observational study, we tried to establish (1) the main features of GI complications during STEC-HUS and (2) the relationship between Escherichia coli serotypes and Shiga toxin (Stx) variants with hepatopancreatic involvement.

METHODS

A total of 79 STEC-HUS patients were admitted to our pediatric nephrology department between January 2012 and June 2021. Evidence of intestinal, hepatobiliary, and pancreatic involvements was reported for each patient, alongside demographic, clinical, and laboratory features. Frequency of gastrointestinal complications across groups of patients infected by specific E. coli serotypes and Stx gene variants was evaluated.

RESULTS

Six patients developed a bowel complication: two developed rectal prolapse, and four developed bowel perforation which resulted in death for three of them and in bowel stenosis in one patient. Acute pancreatitis was diagnosed in 13 patients. An isolated increase in pancreatic enzymes and/or liver transaminases was observed in 41 and 15 patients, respectively. Biliary sludge was detected in three, cholelithiasis in one. Forty-seven patients developed direct hyperbilirubinemia. Neither E. coli serotypes nor Shiga toxin variants correlated with hepatic or pancreatic involvement.

CONCLUSIONS

During STEC-HUS, GI complications are common, ranging from self-limited elevation of laboratory markers to bowel perforation, a severe complication with a relevant impact on morbidity and mortality. Hepatopancreatic involvement is frequent, but usually short-lasting and self-limiting.

MZB1 regulates cellular proliferation, mitochondrial dysfunction, and inflammation and targets the PI3K-Akt signaling pathway in acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a pathological condition characterized by the premature release and activation of trypsinogens and other enzyme precursors. In severe cases, the mortality rates are in the range of 20-30% and may even be as high as 50%. Though various prophylaxes are available for AP, the mechanism of its progression is unclear. Marginal zone B and B-1 cell-specific protein 1 (MZB1) is found in the endoplasmic reticulum (ER) where it is expressed exclusively in the B cells there. MZB1 promotes proliferation, inhibits apoptosis, invasion, and inflammation, and mitigates mitochondrial damage in cells. However, the importance of MZB1 in AP has not yet been determined.

METHODS

Differentially expressed genes (DEGs) between healthy pancreatic cells and those affected by AP were identified using datasets from Gene Expression Omnibus (GEO) datasets. Relative differences in MZB1 expression between normal and diseased tissues and cells were validated in vivo using a rat AP model induced with 4% (w/v) sodium taurocholate and in vitro using the AR42J rat pancreatic cell line exposed to caerulein (CAE). Cell Counting Kit-8 (CCK-8) and 5-ethynyl-2`-deoxyuridine (EdU) assays were performed to detect and compare normal and pathological cell proliferation. Flow cytometry was employed to assess and compare cellular apoptosis. Quantitative reverse transcription polymerase chain reaction (qRT-PCR) and western blot (WB) were applied to evaluate the apoptotic factors Bax and Bcl. The inflammatory factors interleukin (IL)-6 and IL-1β were quantified using Enzyme-linked immunosorbent assay (ELISA) and qRT-PCR techniques. Mitochondrial function was evaluated using assays for reactive oxygen species (ROS) and tetramethylrhodamine methyl ester (TMRM). WB and qRT-PCR were utilized to measure the expression levels of the PI3K-Akt signaling pathway, followed by a rescue experiment involving the inhibitor of wortmannin.

RESULTS

MZB1 was upregulated in the AP cases screened from the GEO datasets, the rat AP model, and the AR42J cells exposed to CAE. Overexpression of MZB1 enhanced the growth and supressed the cell death of AR42J cells while also activating the PI3K-Akt signaling pathway. MZB1 knockdown led to mitochondrial dysfunction and exacerbated inflammation. The rescue experiment demonstrated that MZB1 enhanced proliferation and inhibited apoptosis, mitochondrial dysfunction, and inflammation in pancreatic cells through the PI3K-Akt pathway.

CONCLUSIONS

AP cells and tissues exhibited markedly elevated levels of MZB1 expression compared to their healthy counterparts. MZB1 overexpression promoted proliferation and supressed apoptosis, mitochondrial dysfunction, and inflammation in pancreatic cells through the positive regulation of the PI3K-Akt signaling pathway.

Differences in glucose homeostasis and islet injury among diverse mice strains post acute pancreatitis

Diverse animal models have been used to study postpancreatitis diabetes mellitus (PPDM) development; however, no study has yet conducted a comparative analysis of the specific differences in glucose homeostasis and islet injury between these models. Therefore, we investigated the differences in pancreatic islet injury and glucose homeostasis among diverse strains in a cerulein-induced acute pancreatitis (AP) model to determine the appropriate animal model for PPDM. BALB/cJ, C57BL/6J, C57BL/6 N, and FVB/NJ mice were administered cerulein to induce AP. Serum amylase levels, pancreatic acinar injury, blood glucose homeostasis, islet function, and islet injury were measured and analyzed. All strains exhibited elevated amylase secretion post pancreatitis, and BALB/cJ, C57BL/6J, and C57BL/6 N mice exhibited sex-related differences. All strains exhibited pancreatic acinar injury post pancreatitis but mostly recovered within 15 days. Overall, glucose homeostasis remained balanced post pancreatitis in all strains compared to that in the control groups, except in FVB/NJ male and female mice, which exhibited an imbalance in glucose homeostasis on day 7 post pancreatitis. All the strains, except BALB/cJ mice, exhibited a decline in Homeostasis model assessment-β(HOMA-β) values post pancreatitis, with significant decrease in C57BL/6J females and FVB/NJ males. Islet size decreased post pancreatitis in all strains, except BALB/cJ mice. Pancreatic islet insulin secretion levels significantly decreased in male FVB/NJ mice post pancreatitis onset and did not recover within 15 days. Therefore, FVB/NJ male mice are a useful model for studying PPDM.

Qing Xia Jie Yi Formula granules alleviated acute pancreatitis through inhibition of M1 macrophage polarization by suppressing glycolysis

ETHNOPHARMACOLOGICAL RELEVANCE

Herbal formulas from Traditional Chinese Medicine are common and well-established practice for treating acute pancreatitis (AP) patients. However, little is known about their bioactive ingredients and mechanisms, such as their targets and pathways to inhibit inflammation.

AIM OF THE STUDY

This study aimed to evaluate the effect of Qing Xia Jie Yi Formula (QXJYF) granules on AP and discuss the molecular mechanisms involved.

MATERIALS AND METHODS

Major compounds in QXJYF granules were identified using UPLC-quadrupole-Orbitrap mass spectrometry (UPLC-Q-Orbitrap MS). The effect of QXJYF granules on experimental AP models both in vitro and in vivo, and detailed mechanisms were clarified. Two AP models were induced in mice by intraperitoneally injections of caerulein or L-arginine, and QXJYF granules were used to treat AP mice in vivo. Histological evaluation of pancreas and lung, serum amylase and lipase levels, serum inflammatory cytokines, inflammatory cell infiltration and macrophage phenotype were assessed. Bone marrow derived macrophages (BMDMs) were cultured and treated with QXJYF granules in vitro. BMDM phenotype and glycolysis levels were measured. Lastly, clinical effect of QXJYF granules on AP patients was verified. Predicted severe AP (pSAP) patients eligible for inclusion were assessed for enrollment.

RESULTS

Nine major compounds were identified in QXJYF granules. Data showed that QXJYF granules significantly alleviated AP severity both in caerulein and L-arginine-induced AP models in vivo, pancreatic injury and inflammatory cell infiltration, systematic inflammation, lung injury and inflammatory cell infiltration were all improved after QXJYF treatment. QXJYF granules significantly reduced M1 macrophages during AP both in vivo and in vitro; besides, the mRNA expression levels of M1 genes such as inos, Tnfα, Il1β and Il6 were significantly lower after QXJYF treatment in M1 macrophages. Mechanistically, we found that HK2, PFKFB3, PKM, LDHα levels were increased in M1 macrophages, but significantly decreased after QXJYF treatment. Clinical data indicated that QXJYF granules could significantly reduce CRP levels and shorten the duration of organ failure, thereby reducing the incidence of SAP and preventing pSAP patients from progressing to SAP.

CONCLUSION

QXJYF granules alleviated AP through the inhibition of M1 macrophage polarization by suppressing glycolysis.

Surgical cystogastrostomy: Is it still worthwhile?

The article by Ker et al explores the treatment of peripancreatic fluid collection (PFC). The use of percutaneous drainage, endoscopy, and surgery for managing PFC are discussed. Percutaneous drainage is noted for its low risk profile, while endoscopic cystogastrostomy is more effective due to the wider orifice of the metallic stent. Surgical cystogastrostomy is a definitive treatment with a reduced need for reintervention, especially for cases with extensive collections and significant necrosis. The choice of treatment modality should be tailored to individual patient characteristics and disease factors, considering the expertise available.

Acute pancreatitis in Turkey: Results of a nationwide multicenter study

BACKGROUND

Acute pancreatitis (AP) is the most common gastrointestinal disease requiring hospitalization, with significant mortality and morbidity. We aimed to evaluate the clinical characteristics of AP and physicians' compliance with international guidelines during its management.

METHODS

All patients with AP who were hospitalized at 17 tertiary centers in Turkey between April and October 2022 were evaluated in a prospective cohort study. Patients with insufficient data, COVID-19 and those aged below 18 years were excluded. The definitions were based on the 2012 revised Atlanta criteria.

RESULTS

The study included 2144 patients (median age:58, 52 % female). The most common etiologies were biliary (n = 1438, 67.1 %), idiopathic (n = 259, 12 %), hypertriglyceridemia (n = 128, 6 %) and alcohol (n = 90, 4.2 %). Disease severity was mild in 1567 (73.1 %), moderate in 521 (24.3 %), and severe in 58 (2.6 %) patients. Morphology was necrotizing in 4.7 % of the patients. The overall mortality rate was 1.6 %. PASS and BISAP had the highest accuracy in predicting severe pancreatitis on admission (AUC:0.85 and 0.81, respectively). CT was performed in 61 % of the patients, with the majority (90 %) being within 72 h after admission. Prophylactic NSAIDs were not administered in 44 % of the patients with post-ERCP pancreatitis (n = 86). Antibiotics were administered to 53.7 % of the patients, and 38 % of those received them prophylactically.

CONCLUSIONS

This prospective study provides an extensive report on clinical characteristics, management and outcomes of AP in real-world practice. Mortality remains high in severe cases and physicians' adherence to guidelines during management of the disease needs improvement in some aspects.

Pancreatic injury in patients treated with immune checkpoint inhibitors: a retrospective multicenterstudy

BACKGROUND

Immune checkpoint inhibitor-related pancreatic injury (ICI-PI) is a rare occurrence, which has not been reported in detail. We conducted a retrospective multicenter study to determine the clinical characteristics, risk factors, and treatment of ICI-PI.

METHODS

We reviewed the medical records of patients who received ICIs for malignant tumors between April 2014 and April 2019 at 16 participating hospitals. Patients with elevated pancreatic enzymes or pancreatitis were identified and classified using the Common terminology Criteria for Adverse Events (CTCAE) ver.5.0). The number of patients with pancreatic enzyme elevation was determined and those with pancreatic enzyme elevation of ≥ grade 3 according to CTCAE ver.5.0, or pancreatitis underwent detailed analysis for ICI-PI.

RESULTS

The study enrolled 1069 patients. Nineteen patients (1.8%) had ICI-PI, 5 (0.5%) of whom also had pancreatitis. Four patients had mild pancreatitis, whereas 1 patient had severe pancreatitis, culminating in death. Steroid therapy was administered to 7 of 19 patients, which led to ICI-PI improvement in 5 patients. On the other hand, ICI-PI improved in 9 of 12 patients who were not administered steroid therapy. Six of the 14 patients with ICI-PI improvement were rechallenged with ICI, and ICI-PI relapse occurred in only 1 patient (16.7%), which improved with ICI discontinuation and steroid therapy.

CONCLUSIONS

ICI-PI is a rare occurrence, with a low incidence of pancreatitis, which followed a very serious course in one patient. Although the benefit of steroid therapy for ICI-PI is unclear, ICI rechallenge is acceptable after improvement of ICI-PI without pancreatitis.

Is Contemporary Open Pancreatic Necrosectomy Still Useful In The Minimally Invasive Era?

BACKGROUND

Previous studies have shown that open pancreatic necrosectomy for infected pancreatic necrosis was associated with high morbidity and mortality. However, these results were mostly concluded from historical cohorts with traditional early necrosectomy in the absence of a minimally invasive step-up approach.

OBJECTIVE

To explore the value of contemporary open pancreatic necrosectomy for infected pancreatic necrosis in the minimally invasive era.

METHODS

A post hoc analysis was performed in a prospective maintained database of 320 patients with infected pancreatic necrosis from January 2011 to December 2022 at a large Chinese tertiary hospital.

RESULTS

A total of 320 patients with infected pancreatic necrosis received either a minimally invasive step-up approach (245, 76.6%) or open pancreatic necrosectomy (75, 23.4%), which included upfront open pancreatic necrosectomy (32, 10.0%) and salvage open pancreatic necrosectomy (43, 13.4%). Upfront open pancreatic necrosectomy was associated with similar morbidity and mortality rates but fewer surgical interventions compared with a minimally invasive step-up approach. However, salvage open pancreatic necrosectomy was associated with significantly higher mortality (48.8% vs 18.8%, P = .007), gastrointestinal fistula (44.2% vs 18.8%, P = .021), hemorrhage (48.8% vs 15.6%, P = .003), and intensive care unit stay (25 vs 7 days, P = .040) compared with upfront open pancreatic necrosectomy. Multivariate analysis suggested that multiple organ failure (hazard ratio = 5.1; 95% confidence interval, 1.4-18.2, P = .013) and synchronous critical acute pancreatitis (hazard ratio = 3.0; 95% confidence interval, 1.1-8.6, P = .040) were 2 independent risk factors of death for patients who received open pancreatic necrosectomy.

CONCLUSION

Patients undergoing upfront open pancreatic necrosectomy received fewer surgical interventions with comparable efficacy compared to the minimally invasive step-up approach. Salvage open pancreatic necrosectomy was potentially lifesaving, though it carried high morbidity and mortality. Multiple organ failure and synchronous critical acute pancreatitis were 2 independent risk factors of death for patients who received open pancreatic necrosectomy.

Machine learning improves early prediction of organ failure in hyperlipidemia acute pancreatitis using clinical and abdominal CT features

BACKGROUND

This study aimed to investigate and validate machine-learning predictive models combining computed tomography and clinical data to early predict organ failure (OF) in Hyperlipidemic acute pancreatitis (HLAP).

METHODS

Demographics, laboratory parameters and computed tomography imaging data of 314 patients with HLAP from the First Affiliated Hospital of Wenzhou Medical University between 2017 and 2021, were retrospectively analyzed. Sixty-five percent of patients (n = 204) were assigned to the training group and categorized as patients with and without OF. Parameters were compared by univariate analysis. Machine-learning methods including random forest (RF) were used to establish model to predict OF of HLAP. Areas under the curves (AUCs) of receiver operating characteristic were calculated. The remaining 35% patients (n = 110) were assigned to the validation group to evaluate the performance of models to predict OF.

RESULTS

Ninety-three (45.59%) and fifty (45.45%) patients from the training and the validation cohort, respectively, developed OF. The RF model showed the best performance to predict OF, with the highest AUC value of 0.915. The sensitivity (0.828) and accuracy (0.814) of RF model were both the highest among the five models in the study cohort. In the validation cohort, RF model continued to show the highest AUC (0.820), accuracy (0.773) and sensitivity (0.800) to predict OF in HLAP, while the positive and negative likelihood ratios and post-test probability were 3.22, 0.267 and 72.85%, respectively.

CONCLUSIONS

Machine-learning models can be used to predict OF occurrence in HLAP in our pilot study. RF model showed the best predictive performance, which may be a promising candidate for further clinical validation.

Association between serum triglyceride level and severity of acute biliary pancreatitis

BACKGROUND

Acute biliary pancreatitis (ABP) is the most common type of acute pancreatitis. However, the effect of serum triglyceride (TG) levels on the severity of ABP remains unclear. The aim of this study was to assess the correlation between serum TG levels and the severity of ABP.

METHODS

Data from 526 ABP patients was analyzed in this study. The patients were divided into normal and elevated groups according to the TG level measured within 24 h after admission, and the elevated group was further divided into mild, moderate, and severe elevated groups. The demographic data and clinical outcomes of each group were compared.

RESULTS

Of the 526 ABP patients, 394 were in the normal TG group and 132 were in the elevated TG group (36 mild, 57 moderate, and 39 severe). The elevated group was younger (51.5 ± 12.9 vs. 58.9 ± 13.9), predominantly male (66.7% vs. 45.2%), had more history of diabetes (22.7% vs. 12.4%) and hyperlipidemia (19.7% vs. 0.8%), and developed systemic inflammatory response syndrome (SIRS) (25.8% vs. 15.5%), persistent organ failure (POF) (11.4% vs. 2.8%), and local complications (62.9% vs. 42.1%) more frequently compared to the normal group (P < 0.05). The incidence of SIRS, POF, acute peripancreatic fluid collection (APFC), and acute necrotic collection (ANC) increased with increasing TG levels (Ptrend < 0.05). In multivariate analysis, TG was independently associated with POF, APFC, and ANC in increments of 100 mg/dl (P < 0.05), and there was a linear relationship between TG levels and POF, APFC, and ANC (non-linear P > 0.05, P overall <0.05). In addition, nonalcoholic fatty liver disease is not a risk factor for POF, ANC, and APFC in ABP patients.

CONCLUSIONS

Elevated serum TG levels were independently associated with more severe ABP. The incidence of POF, APFC, and ANC in ABP patients increased with the increase of TG levels, with a linear relationship.

Global, regional, and national burden of pancreatitis in older adults, 1990-2019: A systematic analysis for the global burden of disease study 2019

Background

To describe the past, present and future burden of pancreatitis in older adults, and to explore cross-national inequalities across socio-demographic index (SDI).

Methods

Data on pancreatitis in older adults, including mortality and disability-adjusted life years (DALYs) rates, were collected from the Global Burden of Disease (GBD) 2019 study. Temporal trends were measured using joinpoint analyses and predicted using a Bayesian age-period-cohort model. Additionally, the unequal distribution of the burden of pancreatitis in older adults was quantified.

Results

From 1990 to 2019, the number of deaths and DALYs due to pancreatitis in older adults has been increasing annually. However, in most regions of the world, age-standardized death rates (ASDR) and age-standardized DALYs rates have been declining. The burden of pancreatitis in older adults was highest in low SDI region, primarily affecting the population aged 65-74, with a greater burden on males than females. Furthermore, from 1990 to 2019, absolute and relative cross-national inequalities in pancreatitis among older adults have remained largely unchanged. It is projected that in the next 11 years, the number of deaths in older adults due to pancreatitis will continue to increase, but the ASDR is expected to decline.

Conclusion

Over the past 30 years, the ASDR and age-standardized DALYs rate of pancreatitis in older adults have shown a decline globally, but the absolute burden continues to increase. Cross-national health inequalities persist. Therefore, it is necessary to develop targeted intervention measures and enhance awareness among this vulnerable population regarding the risk factors associated with pancreatitis.

Circulating immune signatures in chronic pancreatitis with and without preceding acute pancreatitis: A pilot study

OBJECTIVE

To investigate profiles of circulating immune signatures in healthy controls and chronic pancreatitis patients (CP) with and without a preceding history of acute pancreatitis (AP).

METHODS

We performed a phase 1, cross-sectional analysis of prospectively collected serum samples from the PROspective Evaluation of Chronic Pancreatitis for EpidEmiologic and Translation StuDies (PROCEED) study. All samples were collected during a clinically quiescent phase. CP subjects were categorized into two subgroups based on preceding episode(s) of AP. Healthy controls were included for comparison. Blinded samples were analyzed using an 80-plex Luminex assay of cytokines, chemokines, and adhesion molecules. Group and pairwise comparisons of analytes were performed between the subgroups.

RESULTS

In total, 133 patients with CP (111 with AP and 22 without AP) and 50 healthy controls were included. Among the 80 analytes studied, CP patients with a history of AP had significantly higher serum levels of pro-inflammatory cytokines (interleukin (IL)-6, IL-8, IL-1 receptor antagonist, IL-15) and chemokines (Cutaneous T-Cell Attracting Chemokine (CTACK), Monokine induced Gamma Interferon (MIG), Macrophage-derived Chemokine (MDC), Monocyte Chemoattractant Protein-1 (MCP-1)) compared to CP without preceding AP and controls. In contrast, CP patients without AP had immune profiles characterized by low systemic inflammation and downregulation of anti-inflammatory mediators, including IL-10.

CONCLUSION

CP patients with a preceding history of AP have signs of systemic inflammatory activity even during a clinically quiescent phase. In contrast, CP patients without a history of AP have low systemic inflammatory activity. These findings suggest the presence of two immunologically diverse subtypes of CP.

Intravenous Hemin, a potential heme oxygenase-1 activator, does not protect from post-ERCP acute pancreatitis in humans: Results of a randomized multicentric multinational placebo-controlled trial

OBJECTIVE

Hemin, a heme oxygenase 1 activator has shown efficacy in the prevention and treatment of acute pancreatitis in mouse models. We conducted a randomized controlled trial (RCT) to assess the protective effect of Hemin administration to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in patients at risk.

METHODS

In this multicenter, multinational, placebo-controlled, double-blind RCT, we assigned patients at risk for PEP to receive a single intravenous dose of Hemin (4 mg/kg) or placebo immediately after ERCP. Patients were considered to be at risk on the basis of validated patient- and/or procedure-related risk factors. Neither rectal NSAIDs nor pancreatic stent insertion were allowed in randomized patients. The primary outcome was the incidence of PEP. Secondary outcomes included lipase elevation, mortality, safety, and length of stay.

RESULTS

A total of 282 of the 294 randomized patients had complete follow-up. Groups were similar in terms of clinical, laboratory, and technical risk factors for PEP. PEP occurred in 16 of 142 patients (11.3%) in the Hemin group and in 20 of 140 patients (14.3%) in the placebo group (p = 0.48). Incidence of severe PEP reached 0.7% and 4.3% in the Hemin and placebo groups, respectively (p = 0.07). Significant lipase elevation after ERCP did not differ between groups. Length of hospital stay, mortality and severe adverse events rates were similar between groups.

CONCLUSION

We failed to detect large improvements in PEP rate among participants at risk for PEP who received IV hemin immediately after the procedure compared to placebo.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov number, NCT01855841).

Factors affecting the time interval of endoscopic ultrasound-guided endoscopic necrosectomy of walled-off pancreatic necrosis: A retrospective single-center study in China

BACKGROUND AND AIM

Endoscopic ultrasound (EUS)-guided endoscopic necrosectomy is an effective and minimally invasive treatment for walled-off pancreatic necrosis (WON). This study investigated the factors affecting the time interval of EUS-guided WON necrosectomy.

METHODS

Patients who received EUS-guided necrosectomy in the Endoscopy Center of the First Affiliated Hospital of Chongqing Medical University in the past 5 years were retrospectively analyzed. Data including general information, etiology, blood biochemical indexes, physical signs, CT severity grade, location, size, solid necrotic ratio, type and number of stents, and immediate necrosectomy were collected to explore the relationships between these factors and the interval of endoscopic necrosectomy.

RESULTS

A total of 51 WON patients were included. No significant correlation has been noted between the endoscopic debridement interval and the following indexes, including the patients' general information, the etiology of pancreatitis, blood biochemical indexes (leukocyte count, neutrophil percentage, C-reactive protein), preoperative fever, and WON's location and size, type and number of stents, and whether immediate necrosectomy. However, there were significant differences between the debridement interval and the modified CT Severity Index (MCTSI) (p < 0.001), the solid necrotic ratio of WON (p < 0.001) before the intervention, postoperative fever (p = 0.038), C-reactive protein increasing (p = 0.012) and fever before reintervention (p = 0.024).

CONCLUSIONS

The EUS-measured solid necrotic ratio, the MCTSI, postoperative fever, C-reactive protein increase, and fever before reintervention in patients affect the time interval of EUS-guided endoscopic necrosectomy in WON patients. These five indicators may be promisingly effective in predicting and managing endoscopic necrosectomy intervals.

Incidence, implications and predictors of abdominal compartment syndrome in acute pancreatitis: A nationwide analysis

BACKGROUND

Acute pancreatitis (AP) often presents with varying severity, with a small fraction evolving into severe AP, and is associated with high mortality. Complications such as intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are intricately associated with AP.

OBJECTIVE

To assess the clinical implications and predictors of ACS in AP patients.

METHODS

We conducted a retrospective study using the National Inpatient Sample (NIS) database on adult AP patients, further stratified by the presence of concurrent ACS. The data extraction included demographics, underlying comorbidities, and clinical outcomes. Multivariate linear and logistic regression analyses were performed using STATA (v.14.2).

RESULTS

Of the 1,099,175 adult AP patients, only 1,090 (0.001%) exhibited ACS. AP patients with ACS had elevated inpatient mortality and all major complications, including septic shock, acute respiratory distress syndrome (ARDS), requirement for total parenteral nutrition (TPN), and intensive care unit (ICU) admission (P < 0.01). These patients also exhibited increased odds of requiring pancreatic drainage and necrosectomy (P < 0.01). Predictor analysis identified blood transfusion, obesity (BMI ≥30), and admission to large teaching hospitals as factors associated with the development of ACS in AP patients. Conversely, age, female gender, biliary etiology of AP, and smoking were found less frequently in patients with ACS.

CONCLUSION

Our study highlights the significant morbidity, mortality, and healthcare resource utilization associated with the concurrence of ACS in AP patients. We identified potential factors associated with ACS in AP patients. Significantly worse outcomes in ACS necessitate the need for early diagnosis, meticulous monitoring, and targeted therapeutic interventions for AP patients at risk of developing ACS.

Diarrhoea of unknown cause: medical treatment in a stepwise manner

The basic principle for the treatment of idiopathic diarrhoea (functional diarrhoea K59.1) is to delay transit through the gut in order to promote the absorption of electrolytes and water. Under mild conditions, bulking agents may suffice. With increasing severity, antidiarrhoeal pharmaceuticals may be added in a stepwise manner. In diarrhoea of unknown aetiology, peripherally-acting opioid receptor agonists, such as loperamide, are first-line treatment and forms the pharmaceutical basis of antidiarrheal treatment. As second-line treatment opium drops have an approved indication for severe diarrhoea when other treatment options fail. Beyond this, various treatment options are built on experience with more advanced treatments using clonidine, octreotide, as well as GLP-1 and GLP-2 analogs which require specialist knowledge the field.

Clinical diagnosis of psychiatric comorbidities, performance of screening tests and pattern of psychotropic medication use in patients with chronic pancreatitis

BACKGROUND

Psychiatric comorbidity measured by screening instruments is common in patients with chronic pancreatitis (CP) but whether this accurately reflects clinical diagnosis of psychiatric comorbidity is unknown and the prevalence of psychotropic medication prescription in CP remains largely unexplored.

METHODS

Adult patients (≥18 years) with definite CP were enrolled and completed the Hospital Anxiety and Depression Scale (HADS). Demographics, clinical characteristics and medications were retrieved from case report forms and the electronic health record (EHR). Clinical diagnosis of depression or anxiety was determined by presence of ICD-10 code or inclusion in the patient's EHR problem list or treatment plan. Comparisons were made between patients with and without clinical psychiatric comorbidity.

RESULTS

Total of 81 patients (48, 59.3% male; mean age 57.6 ± 14.3 years) were included. Clinical diagnoses of anxiety and depression were each noted in 47 (58%) patients, with overlap in 42 (51.9%). Compared to clinical diagnoses, the sensitivity and specificity of a positive screen for anxiety (HADS >7) were 76.6% and 91.2%; for depression 55.3% and 88.2%. Patients with anxiety and/or depression were more frequently female (51.9% v 20.7%), younger (53.6 v 64.9 years), and had alcohol etiology (51.9% v 27.6%) (all p < 0.01). In those with psychiatric comorbidity, 42 (80.8%) were prescribed psychotropic medication, most commonly gabapentinoid (24, 57.1%), selective serotonin reuptake inhibitor (n = 22, 52.4%) or benzodiazepine (n = 20, 47.6%).

CONCLUSIONS

Psychiatric comorbidities are common among CP patients and many receive psychotropic medications. Further studies are needed to evaluate the impact of these medications on CP symptoms.

Inhibition of Pck1 in intestinal epithelial cells alleviates acute pancreatitis via modulating intestinal homeostasis

Intestinal barrier dysfunction usually occurred in acute pancreatitis (AP) but the mechanism remains unclear. In this study, RNA sequencing of ileum in L-arginine-induced AP mice demonstrated that phosphoenolpyruvate kinase 1 (Pck1) was significantly up-regulated. Increased Pck1 expression in intestinal epithelial cells (IECs) was further validated in ileum of AP mice and duodenum of AP patients. In AP mice, level of Pck1 was positively correlated with pancreatic and ileal histopathological scores, serum amylase activity, and intestinal permeability (serum diamine oxidase (DAO), D-lactate, and endotoxin). In AP patients, level of Pck1 had a positive correlation with Ranson scores, white blood cell count and C-reactive protein. Inhibition of Pck1 by 3-Mercaptopicolinic acid hydrochloride (3-MPA) alleviated pancreatic and ileal injuries in AP mice. AP + 3-MPA mice showed improved intestinal permeability, including less epithelial apoptosis, increased tight junction proteins (TJPs) expression, decreased serum DAO, D-lactate, endotoxin, and FITC-Dextran levels, and reduced bacteria translocation. Lysozyme secreted by Paneth cells and mucin2 (MUC2) secretion in goblet cells were also partly restored in AP + 3-MPA mice. Meanwhile, inhibition of Pck1 improved intestinal immune response during AP, including elevation of M2/M1 macrophages ratio and secretory immunoglobulin A (sIgA) and reduction in neutrophils infiltration. In vitro, administration of 3-MPA dramatically ameliorated inflammation and injuries of epithelial cells in enteroids treated by LPS. In conclusion, inhibition of Pck1 in IECs might alleviate AP via modulating intestinal homeostasis.

Predictive value of machine learning for the severity of acute pancreatitis: A systematic review and meta-analysis

Background

Predicting the severity of acute pancreatitis (AP) early poses a challenge in clinical practice. While there are well-established clinical scoring tools, their actual predictive performance remains uncertain. Various studies have explored the application of machine-learning methods for early AP prediction. However, a more comprehensive evidence-based assessment is needed to determine their predictive accuracy. Hence, this systematic review and meta-analysis aimed to evaluate the predictive accuracy of machine learning in assessing the severity of AP.

Methods

PubMed, EMBASE, Cochrane Library, and Web of Science were systematically searched until December 5, 2023. The risk of bias in eligible studies was assessed using the Prediction Model Risk of Bias Assessment Tool (PROBAST). Subgroup analyses, based on different machine learning types, were performed. Additionally, the predictive accuracy of mainstream scoring tools was summarized.

Results

This systematic review ultimately included 33 original studies. The pooled c-index in both the training and validation sets was 0.87 (95 % CI: 0.84-0.89) and 0.88 (95 % CI: 0.86-0.90), respectively. The sensitivity in the training set was 0.81 (95 % CI: 0.77-0.84), and in the validation set, it was 0.79 (95 % CI: 0.71-0.85). The specificity in the training set was 0.84 (95 % CI: 0.78-0.89), and in the validation set, it was 0.90 (95 % CI: 0.86-0.93). The primary model incorporated was logistic regression; however, its predictive accuracy was found to be inferior to that of neural networks, random forests, and xgboost. The pooled c-index of the APACHE II, BISAP, and Ranson were 0.74 (95 % CI: 0.68-0.80), 0.77 (95 % CI: 0.70-0.85), and 0.74 (95 % CI: 0.68-0.79), respectively.

Conclusions

Machine learning demonstrates excellent accuracy in predicting the severity of AP, providing a reference for updating or developing a straightforward clinical prediction tool.

A new sight to acute pancreatitis through paracolic gutter exudation, a multicenter retrospective study

Objectives

Paracolic gutter exudation (PGE) may influence the severity of acute pancreatitis, but no study has explored it extensively. The objective of this study was to evaluate PGE for assessing the severity of disease.

Methods

We performed a retrospective analysis of 488 patients from three tertiary hospitals in Guangxi, China. General clinical information, severity, and clinical courses were recorded. The PGE score were classified as follows: 0 for no exudation, 1 for unilateral exudation, and 2 for bilateral exudation. We used ROC curves to assess the predictive value of the PGE score, and logistic regression analysis to determine risk factors associated with death, ICU admission, and the occurrence of MODS.

Results

This study included 352 patients with moderately severe acute pancreatitis (MSAP) and 136 patients with severe acute pancreatitis (SAP). Patients who had PGE experienced higher total hospitalization costs, longer hospital stays, a higher incidence of SAP, higher mortality rates, higher ICU admission rates, a higher incidence of MODS, and higher incidence of infections than those without (P < 0.05). Diagnostic efficacy in predicting severity in patients with MSAP and SAP increased after BISAP, MCTSI, modified Marshall, and SOFA scores combined with PGE score respectively. The PGE score of >1 is an independent risk factor for ICU admission and MODS occurrence. (P < 0.05).

Conclusion

The PGE provides reliable and objective information for assessing severity and clinical course of patients with MSAP and SAP.

A comparison of scoring systems and biomarkers to predict the severity of acute pancreatitis in patients referring to the emergency clinic

To investigate scoring systems and biomarkers for determining the severity and prognosis of acute pancreatitis (AP). Between January and July 2023, 100 patients with AP diagnosed and treated in the emergency department were included. AP was divided into 2 groups according to severity: mild AP and moderately severe AP (MSAP-SAP), according to the revised Atlanta Classification in 2012. Demographic characteristics, severity, intensive care unit (ICU) admission, white blood cell count (WBC), hematocrit, red cell distribution width from whole blood taken at admission and 48 hours later, C-reactive protein (CRP) and biochemistry values, Bedside Index for Severity in Acute Pancreatitis (BISAP), Pancreatitis Activity Scoring System (PASS), and harmless AP score scores were recorded retrospectively. Our variables, which were found to be significant in multiple logistic regression results, were found to increase MSAP-SAP expectation by 4.36-, 7.85-, 6.63 and 5.80 times in the presence of CRP > 47.10, WBC > 13.10, PASS > 0, and necrotizing computed tomography findings, respectively. It was detected that the risk factor which was found significant as a single variable affecting the ICU admission increased the risk of ICU requirement by 28.88 when PASS > 0, by 3.96 when BISAP > 1, and it increased the Atlanta score by 9.93-fold. We found that WBC and CRP values at the time of hospital admission and WBC, CRP, and red cell distribution width values after 48 had the highest accuracy in determining AP disease severity. BISAP, which was found to be significant in determining MSAP-SAP expectations, lost its significance in multiple logistic regression results, and PASS was found to be effective. The PASS is an important score in the clinical evaluation of patients with AP and in determining the need for ICU hospitalization.

Prediction of severe hypertriglyceridemia-associated acute pancreatitis using a nomogram based on CT findings and blood biomarkers

Hypertriglyceridemia is a common cause of acute pancreatitis (AP). Fatty liver, a manifestation of metabolic syndrome, is related to the severity of AP. The present study aimed to construct an accurate predictive model for severe AP (SAP) by combining the fatty liver infiltration on a computerized tomography (CT) scan with a series of blood biomarkers in patients with hypertriglyceridemia-associated AP (HTG-AP). A total of 213 patients diagnosed with HTG-AP were included in the present retrospective study. Clinical information and imageological findings were retrospectively analyzed. The model was constructed from independent risk factors using univariate analysis, the least absolute shrinkage and selection operator method. Subsequently, the data from the training group of 111 patients with HTG-AP was analyzed using logistic regression analysis. The efficacy of the model was verified using an external validation group of 102 patients through the receiver operating characteristic curve (ROC). Independent predictors, including serum calcium, C-reactive protein, lactate dehydrogenase and liver-to-spleen CT attenuation ratio (L/S ratio), were incorporated into the nomogram model for SAP in HTG-AP. The model achieved a sensitivity of 91.3% and a specificity of 88.6% in the training group. Compared with the Ranson model, the established nomogram model exhibited a better discriminative ability in the training group [area under the curve (AUC): 0.957] and external validation group (AUC: 0.930), as well as better calibration and clinical benefits. The present study demonstrates that the constructed nomogram based on CT findings and blood biomarkers is useful for the accurate prediction of SAP in HTG-AP.

Endoscopic papillectomy for synchronous adenoma of the major and minor duodenal papilla

OBJECTIVES

Synchronous adenomas of the major and minor duodenal papilla are seldom reported. The aim of this study was to describe the characteristics of synchronous major and minor papilla adenomas and to evaluate the safety and efficacy of endoscopic papillectomy (EP) for the management of the disease.

METHODS

Consecutive patients who underwent endoscopy for synchronous major and minor papilla adenomas from January 1, 2013 to August 31, 2023 were analyzed retrospectively. Patients' characteristics, clinical manifestations, laboratory, imaging and endoscopic findings were collected.

RESULTS

The nine patients with synchronous major and minor papilla adenomas had an average age of 50.78 ± 10.70 years. The diameter of major and minor papilla adenomas was 12.11 ± 3.41 mm and 6.11 ± 1.05 mm, respectively. Most major papilla adenomas had R0 horizontal margins (n = 8), while R0 vertical margins were achieved in all patients. While minor papilla adenomas were resected with both R0 horizontal and vertical margins in all patients. Post-EP bleeding was observed in one patient, which was classified as mild. Post-EP hyperamylasemia and pancreatitis was observed in two and four patients, respectively; the latter consisted of three with mild pancreatitis and one with severe pancreatitis. No perforation was observed. The mean follow-up duration was 9.22 ± 5.99 months. Histologically confirmed recurrence at the resection site was detected in one patient at 3 months after the procedure.

CONCLUSIONS

Synchronous major and minor papilla adenomas may not be as rare as previously speculated. EP may be an effective and safe alternative modality for their management.

Identifying novel acute pancreatitis sub-phenotypes using total serum calcium trajectories

BACKGROUND

Acute pancreatitis (AP) has heterogeneous clinical features, and identifying clinically relevant sub-phenotypes is useful. We aimed to identify novel sub-phenotypes in hospitalized AP patients using longitudinal total serum calcium (TSC) trajectories.

METHODS

AP patients had at least two TSC measurements during the first 24 h of hospitalization in the US-based critical care database (Medical Information Mart for Intensive Care-III (MIMIC-III) and MIMIC-IV were included. Group-based trajectory modeling was used to identify calcium trajectory phenotypes, and patient characteristics and treatment outcomes were compared between the phenotypes.

RESULTS

A total of 4518 admissions were included in the analysis. Four TSC trajectory groups were identified: "Very low TSC, slow resolvers" (n = 65; 1.4% of the cohort); "Moderately low TSC" (n = 559; 12.4%); "Stable normal-calcium" (n = 3875; 85.8%); and "Fluctuating high TSC" (n = 19; 0.4%). The "Very low TSC, slow resolvers" had the lowest initial, maximum, minimum, and mean TSC, and highest SOFA score, creatinine and glucose level. In contrast, the "Stable normal-calcium" had the fewest ICU admission, antibiotic use, intubation and renal replace treatment. In adjusted analysis, significantly higher in-hospital mortality was noted among "Very low TSC, slow resolvers" (odds ratio [OR], 7.2; 95% CI, 3.7 to 14.0), "moderately low TSC" (OR, 5.0; 95% CI, 3.8 to 6.7), and "Fluctuating high TSC" (OR, 5.6; 95% CI, 1.5 to 20.6) compared with the "Stable normal-calcium" group.

CONCLUSIONS

We identified four novel sub-phenotypes of patients with AP, with significant variability in clinical outcomes. Not only the absolute TSC levels but also their trajectories were significantly associated with in-hospital mortality.

Activin A signaling stimulates neutrophil activation and macrophage migration in pancreatitis

Acute Pancreatitis (AP) is associated with high mortality and current treatment options are limited to supportive care. We found that blockade of activin A (activin) in mice improves outcomes in two murine models of AP. To test the hypothesis that activin is produced early in response to pancreatitis and is maintained throughout disease progression to stimulate immune cells, we first performed digital spatial profiling (DSP) of human chronic pancreatitis (CP) patient tissue. Then, transwell migration assays using RAW264.7 mouse macrophages and qPCR analysis of "neutrophil-like" HL-60 cells were used for functional correlation. Immunofluorescence and western blots on cerulein-induced pancreatitis samples from pancreatic acinar cell-specific Kras knock-in (Ptf1aCreER™; LSL-KrasG12D) and functional WT Ptf1aCreER™ mouse lines mimicking AP and CP to allow for in vivo confirmation. Our data suggest activin promotes neutrophil and macrophage activation both in situ and in vitro, while pancreatic activin production is increased as early as 1 h in response to pancreatitis and is maintained throughout CP in vivo. Taken together, activin is produced early in response to pancreatitis and is maintained throughout disease progression to promote neutrophil and macrophage activation.

Investigating potential biomarkers of acute pancreatitis in patients with a BMI>30 using Mendelian randomization and transcriptomic analysis

BACKGROUND

Acute pancreatitis (AP) has become a significant global health concern, and a high body mass index (BMI) has been identified as a key risk factor exacerbating this condition. Within this context, lipid metabolism assumes a critical role. The complex relationship between elevated BMI and AP, mediated by lipid metabolism, markedly increases the risk of complications and mortality. This study aimed to accurately define the correlation between BMI and AP, incorporating a comprehensive analysis of the interactions between individuals with high BMI and AP.

METHODS

Mendelian randomization (MR) analysis was first applied to determine the causal relationship between BMI and the risk of AP. Subsequently, three microarray datasets were obtained from the GEO database. This was followed by an analysis of differentially expressed genes and the application of weighted gene coexpression network analysis (WGCNA) to identify key modular genes associated with AP and elevated BMI. Functional enrichment analysis was then performed to shed light on disease pathogenesis. To identify the most informative genes, machine learning algorithms, including Random Forest (RF), Support Vector Machine-Recursive Feature Elimination (SVM-RFE), and Least Absolute Shrinkage and Selection Operator (LASSO), were employed. Subsequent analysis focused on the colocalization of the Quantitative Trait Loci (eQTL) data associated with the selected genes and Genome-Wide Association Studies (GWAS) data related to the disease. Preliminary verification of gene expression trends was conducted using external GEO datasets. Ultimately, the diagnostic potential of these genes was further confirmed through the development of an AP model in mice with a high BMI.

RESULTS

A total of 21 intersecting genes related to BMI>30, AP, and lipid metabolism were identified from the datasets. These genes were primarily enriched in pathways related to cytosolic DNA sensing, cytokine‒cytokine receptor interactions, and various immune and inflammatory responses. Next, three machine learning techniques were utilized to identify HADH as the most prevalent diagnostic gene. Colocalization analysis revealed that HADH significantly influenced the risk factors associated with BMI and AP. Furthermore, the trend in HADH expression within the external validation dataset aligned with the trend in the experimental data, thus providing a preliminary validation of the experimental findings.The changes in its expression were further validated using external datasets and quantitative real-time polymerase chain reaction (qPCR).

CONCLUSION

This study systematically identified HADH as a potential lipid metabolism-grounded biomarker for AP in patients with a BMI>30.

Impact of Geospatial Food Access on Acute Pancreatitis Outcomes

BACKGROUND AND AIM

Food access is an important social determinant of health and refers to geographical and infrastructural aspects of food availability. Using publicly available data on food access from the United States Department of Agriculture (USDA), geospatial analyses can identify regions with variable food access, which may impact acute pancreatitis (AP), an acute inflammatory condition characterized by unpredictable outcomes and substantial mortality. This study aimed to investigate the association of clinical outcomes in patients with AP with geospatial food access.

METHODS

We examined AP-related hospitalizations at a tertiary center from January 2008 to December 2018. The physical addresses were geocoded through ArcGIS Pro2.7.0 (ESRI, Redlands, CA). USDA Food Access Research Atlas defined low food access as urban areas with 33% or more of the population residing over one mile from the nearest food source. Regression analyses enabled assessment of the association between AP outcomes and food access.

RESULTS

The study included 772 unique patients with AP residing in Massachusetts with 931 AP-related hospitalizations. One hundred and ninety-eight (25.6%) patients resided in census tracts with normal urban food access and 574 (74.4%) patients resided in tracts with low food access. AP severity per revised Atlanta classification [OR 1.88 (95%CI 1.21-2.92); p = 0.005], and 30-day AP-related readmission [OR 1.78(95%CI 1.11-2.86); p = 0.02] had significant association with food access, despite adjustment for demographics, healthcare behaviors, and comorbidities (Charlson Comorbidity Index). However, food access lacked significant association with AP-related mortality (p = 0.40) and length of stay (LOS: p = 0.99).

CONCLUSION

Low food access had a significant association with 30-day AP-related readmissions and AP severity. However, mortality and LOS lacked significant association with food access. The association between nutrition, lifestyle, and AP outcomes warrants further prospective investigation.

PD-L1 blockade in mitigating severe acute pancreatitis induced pancreatic damage through modulation of immune cell apoptosis

Acute pancreatitis (AP) is a prevalent gastrointestinal disorder. The immune response plays a crucial role in AP progression. However, the impact of immune regulatory checkpoint PD-L1 on severe acute pancreatitis (SAP) remains uncertain. Hence, this study aimed to examine the influence of PD-L1 on SAP. We assessed PD-L1 expression in neutrophils and monocytes obtained from SAP patients. We induced SAP in C57BL/6J mice, PD-L1 gene-deficient mice, and PD-L1 humanized mice using intraperitoneal injections of cerulein plus lipopolysaccharide. Prior to the initial cerulein injection, a PD-L1 inhibitor was administered. Pancreatic tissues were collected for morphological and immunohistochemical evaluation, and serum levels of amylase, lipase, and cytokines were measured. Flow cytometry analysis was performed using peripheral blood cells. The expression of PD-L1 in neutrophils and monocytes was significantly higher in SAP patients compared to healthy individuals. Likewise, the expression of PD-L1 in inflammatory cells in the peripheral blood of SAP-induced C57BL/6J mice was notably higher than in the control group. In mice with PD-L1 deficiency, SAP model exhibited lower pancreatic pathology scores, amylase, lipase, and cytokine levels compared to wild-type mice. PD-L1 deletion resulted in reduced neutrophil apoptosis, leading to an earlier peak in neutrophil apoptosis. Furthermore, it decreased early monocyte apoptosis and diminished the peak of T lymphocyte apoptosis. Within the SAP model, administration of a PD-L1 inhibitor reduced pancreatic pathology scores, amylase, lipase, and cytokine levels in both C57BL/6J mice and PD-L1 humanized mice. These findings suggest that inhibiting PD-L1 expression can alleviate the severity of SAP.

Gastro-Intestinal Symptoms in Palliative Care Patients

This review of the palliation of various gastro-intestinal (GI) symptoms encountered in cancer patients is by no means exhaustive. Frequent symptoms such as constipation, nausea and vomiting, bowel obstructions, ascites and bleeds will be discussed, focusing on their assessment and most importantly, how to control the associated symptoms. All of these symptoms and GI complications can significantly impact patients' quality of life (QOL) and should be treated as quickly and aggressively as possible.

The Use of Pre-Endoscopic Metoclopramide Does Not Prevent the Need for Repeat Endoscopy: A U.S. Based Retrospective Cohort Study

BACKGROUND

Peptic ulcer disease (PUD) can cause upper gastrointestinal bleeding (UGIB), often needing esophagogastroduodenoscopy (EGD). Second-look endoscopies verify resolution, but cost concerns prompt research on metoclopramide's efficacy compared to erythromycin.

METHODS

We analyzed the Diamond Network of TriNetX Research database, dividing UGIB patients with PUD undergoing EGD into three groups: metoclopramide, erythromycin, and no medication. Using 1:1 propensity score matching, we compared repeat EGD, post-EGD transfusion, and mortality within one month in two study arms.

RESULTS

Out of 97,040 patients, 11.5% received metoclopramide, 3.9% received erythromycin, and 84.6% received no medication. Comparing metoclopramide to no medication showed no significant difference in repeat EGD (10.1% vs. 9.7%, p = 0.34), transfusion (0.78% vs. 0.86%, p = 0.5), or mortality (1.08% vs. 1.08%, p = 0.95). However, metoclopramide had a higher repeat EGD rate compared to erythromycin (9.4% vs. 7.5%, p = 0.003), with no significant difference in transfusion or mortality.

CONCLUSIONS

The need to repeat EGD was not decreased with pre-EGD use of metoclopramide. If a prokinetic agent is to be used prior to EGD, erythromycin shows superior reduction in the need of repeat EGD as compared to metoclopramide.

Drug repurposing for cancer therapy

Cancer, a complex and multifactorial disease, presents a significant challenge to global health. Despite significant advances in surgical, radiotherapeutic and immunological approaches, which have improved cancer treatment outcomes, drug therapy continues to serve as a key therapeutic strategy. However, the clinical efficacy of drug therapy is often constrained by drug resistance and severe toxic side effects, and thus there remains a critical need to develop novel cancer therapeutics. One promising strategy that has received widespread attention in recent years is drug repurposing: the identification of new applications for existing, clinically approved drugs. Drug repurposing possesses several inherent advantages in the context of cancer treatment since repurposed drugs are typically cost-effective, proven to be safe, and can significantly expedite the drug development process due to their already established safety profiles. In light of this, the present review offers a comprehensive overview of the various methods employed in drug repurposing, specifically focusing on the repurposing of drugs to treat cancer. We describe the antitumor properties of candidate drugs, and discuss in detail how they target both the hallmarks of cancer in tumor cells and the surrounding tumor microenvironment. In addition, we examine the innovative strategy of integrating drug repurposing with nanotechnology to enhance topical drug delivery. We also emphasize the critical role that repurposed drugs can play when used as part of a combination therapy regimen. To conclude, we outline the challenges associated with repurposing drugs and consider the future prospects of these repurposed drugs transitioning into clinical application.

The Role of Hospital Characteristics in Clinical and Quality Outcomes for Gastrointestinal Bleeding in a National Cohort

INTRODUCTION

There is substantial variability in patient outcomes for gastrointestinal bleeding (GIB) across hospitals. This study aimed to identify hospital factors associated with GIB outcomes.

METHODS

This was a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for GIB from 2016 to 2018. These data were merged with the American Hospital Association Annual Survey data to incorporate hospital characteristics. We used generalized linear mixed-effect models to estimate the effect of hospital-level characteristics on patient outcomes after adjusting for patient risk factors including anticoagulant and antiplatelet use, recent GIB, and comorbidities. The primary outcome was 30-day mortality, and secondary outcomes included length of stay and a composite outcome of 30-day readmission or mortality.

RESULTS

Factors associated with improved GIB 30-day mortality included large hospital size (defined as beds >400, odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.97), greater case volume (OR 0.97, 95% CI 0.96-0.98), increased resident and nurse staffing (OR 0.88, 95% CI 0.83-0.94), and blood donor center designation (OR 0.93, 95% CI 0.88-0.99). Patients treated at a hospital with multiple advanced capabilities, such as availability of advanced endoscopy, advanced intensive care unit (ICU) capabilities (both a medical-surgical ICU and cardiac ICU), blood donor center, and liver transplant center, had a 22% reduction in 30-day mortality risk, compared with those hospitalized in a hospital with none of these services (OR 0.78, 95% CI 0.68-0.91). However, length of stay increased with additional services.

DISCUSSION

Patients hospitalized for GIB at hospitals with multiple advanced specialized capabilities have lower mortality but longer lengths of stay. Further research should examine the processes of care linked to these services that contribute to improved mortality in GIB.

Pancreatic Enzyme Use Reduces Pancreatitis Frequency in Children With Acute Recurrent or Chronic Pancreatitis: A Report From INSPPIRE

INTRODUCTION

Among children who suffer from acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP), acute pancreatitis (AP) episodes are painful, often require hospitalization, and contribute to disease complications and progression. Despite this recognition, there are currently no interventions to prevent AP episodes. In this retrospective cohort study, we assessed the impact of pancreatic enzyme therapy (PERT) use on clinical outcomes among children with pancreatic-sufficient ARP or CP.

METHODS

Children with pancreatic-sufficient ARP or CP in the INSPPIRE-2 cohort were included. Clinical outcomes were compared for those receiving vs not receiving PERT, as well as frequency of AP before and after PERT. Logistic regression was used to study the association between development of AP episodes after starting PERT and response predictors.

RESULTS

Among 356 pancreatic-sufficient participants, 270 (76%) had ARP, and 60 (17%) received PERT. Among those on PERT, 42% did not have a subsequent AP episode, during a mean 2.1 years of follow-up. Children with a SPINK1 mutation ( P = 0.005) and those with ARP (compared with CP, P = 0.008) were less likely to have an AP episode after starting PERT. After initiation of PERT, the mean AP annual incidence rate decreased from 3.14 down to 0.71 ( P < 0.001).

DISCUSSION

In a retrospective analysis, use of PERT was associated with a reduction in the incidence rate of AP among children with pancreatic-sufficient ARP or CP. These results support the need for a clinical trial to evaluate the efficacy of PERT to improve clinical outcomes among children with ARP or CP.

Laparoscopic Cholecystectomy vs Endoscopic Retrograde Cholangiopancreatography With Sphincterotomy in Elderly Patients With Acute Gallstone Pancreatitis

BACKGROUND

Gallstone pancreatitis (GSP) is common in elderly patients and carries worse outcomes. Laparoscopic cholecystectomy (LC) is recommended for prevention of recurrent GSP. In frail populations, an endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP-s) is an alternative. Management guidelines of GSP in the elderly are lacking. This study aimed to investigate and compare management strategies for GSP in the elderly.

MATERIALS AND METHODS

A retrospective comparison of outcome of patients aged ≥65 years with first presentation of GSP treated either with (1) LC only, (2) ERCP-s, (3) ERCP-S followed by LC, or (4) no intervention.

RESULTS

216 patients were included. Median age was 76 years (interquartile range 70-83). Most (80%, n = 172) had mild pancreatitis, whilst 12% (n = 26) had severe disease. 24% (n = 55) were treated with ERCP-s; 40% (n = 87) underwent LC alone; 11% (n = 23) had ERCP-s followed by LC; and 25% (n = 55) received no intervention. Patients without intervention were older (P < .001) and frailer (P < .001). The LC-only group had lower post-procedure re-admission rates of 6% (n = 5) compared to 27% (n = 14) for ERCP-s, 33% (n = 7) for ERCP-S + LC, and 31% (n = 17) for the no intervention group (P = .0001). Biliary cause mortality was highest in the no intervention group (n = 11, 20%).

CONCLUSION

Laparoscopic cholecystectomy represents the gold standard for elderly patients with GSP.

Scoping review of interventions to de-implement potentially harmful non-steroidal anti-inflammatory drugs (NSAIDs) in healthcare settings

OBJECTIVES

Potentially harmful non-steroidal anti-inflammatory drugs (NSAIDs) utilisation persists at undesirable rates worldwide. The purpose of this paper is to review the literature on interventions to de-implement potentially harmful NSAIDs in healthcare settings and to suggest directions for future research.

DESIGN

Scoping review.

DATA SOURCES

PubMed, CINAHL, Embase, Cochrane Central and Google Scholar (1 January 2000 to 31 May 2022).

STUDY SELECTION

Studies reporting on the effectiveness of interventions to systematically reduce potentially harmful NSAID utilisation in healthcare settings.

DATA EXTRACTION

Using Covidence systematic review software, we extracted study and intervention characteristics, including the effectiveness of interventions in reducing NSAID utilisation.

RESULTS

From 7818 articles initially identified, 68 were included in the review. Most studies took place in European countries (45.6%) or the USA (35.3%), with randomised controlled trial as the most common design (55.9%). Interventions were largely clinician-facing (76.2%) and delivered in primary care (60.2%) but were rarely (14.9%) guided by an implementation model, framework or theory. Academic detailing, clinical decision support or electronic medical record interventions, performance reports and pharmacist review were frequent approaches employed. NSAID use was most commonly classified as potentially harmful based on patients' age (55.8%), history of gastrointestinal disorders (47.1%), or history of kidney disease (38.2%). Only 7.4% of interventions focused on over-the-counter (OTC) NSAIDs in addition to prescription. The majority of studies (76.2%) reported a reduction in the utilisation of potentially harmful NSAIDs. Few studies (5.9%) evaluated pain or quality of life following NSAIDs discontinuation.

CONCLUSION

Many varied interventions to de-implement potentially harmful NSAIDs have been applied in healthcare settings worldwide. Based on these findings and identified knowledge gaps, further efforts to comprehensively evaluate the effectiveness of interventions and the combination of intervention characteristics associated with effective de-implementation are needed. In addition, future work should be guided by de-implementation theory, focus on OTC NSAIDs and incorporate patient-focused strategies and outcomes, including the evaluation of unintended consequences of the intervention.

The effect of serum triglyceride levels and different lipid-lowering methods on the prognosis of hypertriglyceridemic acute pancreatitis: a single-center 12-year retrospective study by propensity score matching

AIM

To investigate the impact of triglyceride on hypertriglyceridemic acute pancreatitis (HTG-AP) and different lipid-lowering methods on triglyceride-lowering efficiency and HTG-AP.

METHODS

The patients with HTG-AP from January 2012 to December 2023 in Civil Aviation General Hospital were analyzed, retrospectively. Patients were divided and compared according to whether their triglycerides were below 5.56 mmol/L at 48 and 72 h of admission. The patients were divided into control group, insulin group, and low molecular weight heparin (LMWH)+bezafibrate group based on the different methods of lipid-lowering. Propensity score matching (PSM) was employed to balance the baseline characteristics.

RESULTS

There was no correlation between the severity of HTG-AP and the triglyceride at admission. The incidence of severity, local complications, and persistent organ failure (POF) were significantly decreased in patients with 48-h and 72-h triglyceride attainment. Following PSM, the incidence of infectious pancreatic necrosis (IPN) (3.3% vs. 13.3%) was significantly reduced in insulin group compared with control group (p < .05). Compared with control group, LMWH + bezafibrate group had higher lipid reduction efficiency, and the incidence of IPN (0.9% vs. 10.1%) and POF (8.3% vs. 19.3%) was significantly decreased (p < .05). There was no significant difference in the efficiency of lipid-lowering, complications, and POF between LMWH + bezafibrate group and insulin group (p > .05).

CONCLUSION

The severity of HTG-AP is not associated with the triglyceride levels at admission. However, rapid reduction of triglyceride levels can lower the incidence of local complications and respiratory failure. Compared with conservative treatment, insulin and LMWH + bezafibrate can both reduce the incidence of IPN in patients with HTG-AP.

Infected pancreatic necrosis-Current trends in management

Acute necrotizing pancreatitis is a common gastrointestinal disease requiring hospitalization and multiple interventions resulting in higher morbidity and mortality. Development of infection in such necrotic tissue is one of the sentinel events in natural history of necrotizing pancreatitis. Infected necrosis develops in around 1/3rd of patients with necrotizing pancreatitis resulting in higher mortality. So, timely diagnosis of infected necrosis using clinical, laboratory and radiological parameters is of utmost importance. Though initial conservative management with antibiotics and organ support system is effective in some patients, a majority of patients still requires drainage of the collection by various modalities. Mode of drainage of infected pancreatic necrosis depends on various factors such as the clinical status of the patient, location and characteristics of collection and availability of the expertise and includes endoscopic, percutaneous and minimally invasive or open surgical approaches. Endoscopic drainage has proved to be a game changer in the management of infected pancreatic necrosis in the last decade with rapid evolution in procedure techniques, development of novel metal stent and dedicated necrosectomy devices for better clinical outcome. Despite widespread adoption of endoscopic transluminal drainage of pancreatic necrosis with excellent clinical outcomes, peripheral collections are still not amenable for endoscopic drainage and in such scenario, the role of percutaneous catheter drainage or minimally invasive surgical necrosectomy cannot be understated. In a nutshell, the management of patients with infected pancreatic necrosis involves a multi-disciplinary team including a gastroenterologist, an intensivist, an interventional radiologist and a surgeon for optimum clinical outcomes.

Cytokine Dynamics in Acute Pancreatitis: The Quest for Biomarkers from Acute Disease to Disease Resolution

Background: Acute pancreatitis (AP) is an inflammatory disease of the pancreas with incompletely known pathogenic mechanisms. This study aimed to explore the temporal changes in serum cytokines in patients with AP and to assess the association of these changes with disease severity. Methods: Fifty patients hospitalized with AP were enrolled, and their serum cytokine levels were analyzed at four different time points. A healthy control (HC) group of 30 outpatients was included. Results: AP patients showed increased levels of interleukin (IL)-6, IL-8, IL-10, vascular endothelial growth factor (VEGF), tumor necrosis factor (TNF)-alpha, and monocyte chemoattractant protein (MCP)-1 at admission when compared with HC. IL-6, VEGF, and EGF remained elevated 1 month after hospitalization and 6 months after discharge. Conclusions the Bedside Index of Severity in Acute Pancreatitis (BISAP) and severity classification of the revised Atlanta classification system, IL-6 and VEGF, determined 48 h after hospitalization, were the two cytokines consistently elevated in the most severe patients. Increased levels of IL-4, IL-6, IL-10, and TNF-alpha at admission and MCP-1 48 h after admission are also related to the length of hospital stay. Conclusions: Our study highlights the role cytokines play in the pathogenesis of AP and can be useful in the development of future drug trials for AP.

Analysis of immune cell infiltration characteristics in severe acute pancreatitis through integrated bioinformatics

The etiopathogenesis of severe acute pancreatitis (SAP) remains poorly understood. We aim to investigate the role of immune cells Infiltration Characteristics during SAP progression. Gene expression profiles of the GSE194331 dataset were retrieved from the GEO. Lasso regression and random forest algorithms were employed to select feature genes from genes related to SAP progression and immune responses. CIBERSORT was utilized to estimate differences in immune cell types and proportions and the relationship between immune cells and gene expression. We performed pathway enrichment analysis using GSEA to examine disparities in KEGG signaling pathways when comparing the two groups. Additionally, CMap analysis was executed to identify prospective small molecular compounds. The three hub genes (CBLB, JADE2, RNF144A) were identified that can predict SAP progression. Analysis of CIBERSORT and TISIDB databases has shown that there are significant differences in immune cell expression levels between the normal and SAP groups, and three hub genes (CBLB, JADE2, RNF144A) were highly correlated with multiple immune cells, regulating the characteristics of immune cell infiltration in the microenvironment. Finally, drug prediction through the Connectivity Map database suggested that compounds such as Entecavir, KU-0063794, Y-27632, and Antipyrine have certain effects as potential targeted drugs for the treatment of SAP. CBLB, JADE2, and RNF144A are hub genes in SAP, potentially playing important roles in SAP progression. This finding further broadens the understanding of the etiopathogenesis of SAP and provides a feasible basis for future research on diagnostic and immunotherapeutic targets for SAP.

Impact of therapeutic plasmapheresis on the duration of organ failure in patients with hypertriglyceridemia-associated acute pancreatitis

BACKGROUND

Plasmapheresis is widely used for severe hypertriglyceridemia-associated acute pancreatitis (HTG-AP) to remove excessive triglycerides from plasma. This study aimed to evaluate whether plasmapheresis could improve the duration of organ failure in HTG-AP patients.

METHODS

We analyzed a cohort of patients from a multicenter, prospective, long-running registry (the PERFORM) collecting HTG-AP patients admitted to the study sites within 72 h from the onset of symptoms. This study was based on data collected from November 2020 to March 2023. Patients who had organ failure at enrollment were involved in the analyses. The primary outcome was time to organ failure resolution within 14 days. Multivariable Cox regression model was used to evaluate the association between plasmapheresis and time to organ failure resolution. Directed acyclic graph (DAG) was used to identify potential confounders.

RESULTS

A total of 122 HTG-AP patients were included (median [IQR] sequential organ failure assessment (SOFA) score at enrollment, 3.00 [2.00-4.00]). Among the study patients, 46 underwent plasmapheresis, and 76 received medical treatment. The DAG revealed that baseline serum triglyceride, APACHE II score, respiratory failure, cardiovascular failure, and renal failure were potential confounders. After adjusting for the selected confounders, there was no significant difference in time to organ failure resolution between patients undergoing plasmapheresis and those receiving exclusive medical treatment (HR = 1.07; 95%CI 0.68-1.68; P = 0.777). Moreover, the use of plasmapheresis was associated with higher ICU requirements (97.8% [45/46] vs. 65.8% [50/76]; OR, 19.33; 95%CI 2.20 to 169.81; P = 0.008).

CONCLUSIONS

In HTG-AP patients with early organ failure, plasmapheresis was not associated with accelerated organ failure resolution compared to medical treatment but may be associated with more ICU admissions.

TRIAL REGISTRATION

The PERFORM study was registered in the Chinese Clinical Trial Registry (ChiCTR2000039541). Registered 30 October 2020.

Case Series of Endoscopic Papillary Balloon Dilation for Children with Common Bile Duct Stones and a Review of the Literature

Background: Endoscopic sphincterotomy (EST) has been employed for the endoscopic treatment of common bile duct stones (CBDSs) and has been reported to have a high success rate for stone removal. However, EST is associated with a risk of bleeding, perforation, and sphincter of Oddi function disruption. To avoid these risks, endoscopic papillary balloon dilation (EPBD) is an option for CBDS. Sphincter of Oddi function preservation decreases long-term biliary infection and gallstone recurrence. EPBD may have advantages in children who require a long follow up. However, there have been few reports on pediatric cases, particularly in infants. Methods: From September 2017 to December 2023, we performed EPBD for four pediatric CBDSs. The patients were aged from 5 months to 8 years, including two infants aged 5 and 6 months. Furthermore, we reviewed the stone removal rate and complications of 545 ESTs performed at high-volume centers and 13 EPBD-reported cases in children with CBDSs. Results: CBDSs of all patients who underwent EPBD in our institution were successfully removed. No bleeding or perforation was noted; pancreatitis was observed in three patients. In an analysis of 545 ESTs in children, the stone removal rate was high, ranging from 83% to 100% (mean 96%). The incidence of pancreatitis was 0-9.6% (mean 4.4%), and the grade of pancreatitis was almost mild. The bleeding frequency was 1.3-5.4% (mean 2.7%). With regards to the grade of bleeding, seven cases were mild (64%) and four were moderate (36%). Compared with adults who underwent EST, the frequencies of pancreatitis and bleeding were almost equal in children; however, in children, once bleeding occurs, it has a higher risk of leading to blood transfusion. Stone removal via EPBD in children has a 100% success rate. Pancreatitis was responsible for all complications were related; its frequency was 46% (6/13 patients, including five mild cases and one moderate case), which is higher than that of EST and adult cases who underwent EPBD. In most children with pancreatitis, pancreatic enzyme levels returned to normal within 2-3 days following EPBD, and no severe cases caused by EPBD were reported. Conclusions: CBDS removal via EPBD in children has a high success rate with very low risk of bleeding and perforation. Although pancreatitis frequently occurs, most cases are mild. Sphincter of Oddi function preservation via EPBD is expected to prevent long-term stone recurrence and biliary tract infection, and EPBD is considered to be an effective method for CBDS removal in children.

The integration of single-cell and bulk RNA-seq atlas reveals ERS-mediated acinar cell damage in acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a clinically common acute abdominal disease, whose pathogenesis remains unclear. The severe patients usually have multiple complications and lack specific drugs, leading to a high mortality and poor outcome. Acinar cells are recognized as the initial site of AP. However, there are no precise single-cell transcriptomic profiles to decipher the landscape of acinar cells during AP, which are the missing pieces of jigsaw we aimed to complete in this study.

METHODS

A single-cell sequencing dataset was used to identify the cell types in pancreas of AP mice and to depict the transcriptomic maps in acinar cells. The pathways' activities were evaluated by gene sets enrichment analysis (GSEA) and single-cell gene sets variation analysis (GSVA). Pseudotime analysis was performed to describe the development trajectories of acinar cells. We also constructed the protein-protein interaction (PPI) network and identified the hub genes. Another independent single-cell sequencing dataset of pancreas samples from AP mice and a bulk RNA sequencing dataset of peripheral blood samples from AP patients were also analyzed.

RESULTS

In this study, we identified genetic markers of each cell type in the pancreas of AP mice based on single-cell sequencing datasets and analyzed the transcription changes in acinar cells. We found that acinar cells featured acinar-ductal metaplasia (ADM), as well as increased endocytosis and vesicle transport activity during AP. Notably, the endoplasmic reticulum stress (ERS) and ER-associated degradation (ERAD) pathways activated by accumulation of unfolded/misfolded proteins in acinar cells could be pivotal for the development of AP.

CONCLUSION

We deciphered the distinct roadmap of acinar cells in the early stage of AP at single-cell level. ERS and ERAD pathways are crucially important for acinar homeostasis and the pathogenesis of AP.

Acute Pancreatitis in Pregnancy: A Propensity Score Matching Analysis and Dynamic Nomogram for Risk Assessment

BACKGROUND

Acute pancreatitis is easily confused with abdominal pain symptoms, and it could lead to serious complications for pregnant women and fetus, the mortality was as high as 3.3% and 11.6-18.7%, respectively. However, there is still lack of sensitive laboratory markers for early diagnosis of APIP and authoritative guidelines to guide treatment.

OBJECTIVE

The purpose of this study was to explore the risk factors of acute pancreatitis in pregnancy, establish, and evaluate the dynamic prediction model of risk factors in acute pancreatitis in pregnancy patients.

STUDY DESIGN

Clinical data of APIP patients and non-pregnant acute pancreases patients who underwent regular antenatal check-ups during the same period were collected. The dataset after propensity matching was randomly divided into training set and verification set at a ratio of 7:3. The model was constructed using Logistic regression, least absolute shrinkage and selection operator regression, R language and other methods. The training set model was used to construct the diagnostic nomogram model and the validation set was used to validate the model. Finally, the accuracy and clinical practicability of the model were evaluated.

RESULTS

A total of 111 APIP were included. In all APIP patients, hyperlipidemic pancreatitis was the most important reason. The levels of serum amylase, creatinine, albumin, triglyceride, high-density lipoprotein cholesterol, and apolipoprotein A1 were significantly different between the two groups. The propensity matching method was used to match pregnant pancreatitis patients and pregnant non-pancreatic patients 1:1 according to age and gestational age, and the matching tolerance was 0.02. The multivariate logistic regression analysis of training set showed that diabetes, triglyceride, Body Mass Index, white blood cell, and C-reactive protein were identified and entered the dynamic nomogram. The area under the ROC curve of the training set was 0.942 and in validation set was 0.842. The calibration curve showed good predictive in training set, and the calibration performance in the validation set was acceptable. The calibration curve showed the consistency between the nomogram model and the actual probability.

CONCLUSION

The dynamic nomogram model we constructed to predict the risk factors of acute pancreatitis in pregnancy has high accuracy, discrimination, and clinical practicability.

Clinical and Economic Implications of Interventions in Pancreatic Fluid Collections: An Assessment From a National Claims Database

OBJECTIVE

To compare clinical and economic implications of percutaneous and endoscopic treatment approaches in patients with pancreatic fluid collections (PFCs).

MATERIALS AND METHODS

This is a retrospective claims analysis of Medicare beneficiaries who underwent inpatient endoscopic or percutaneous PFC drainage procedures (2016-2020). We performed longitudinal analysis of claims for all-cause mortality and rehospitalization during 180-day follow-up. Main outcome was mortality. Other outcomes were rehospitalization and direct costs.

RESULTS

A total of 1311 patients underwent endoscopic (n = 727) or percutaneous (n = 584) drainage. Percutaneous as compared with endoscopic approach was associated with higher mortality (23.08% vs 16.7%, P = 0.004), rehospitalization (58.9% vs 53.3%, P = 0.04), and mean direct hospital costs ($37,107 [SD = $67,833] vs $27,800 [SD = $43,854], P = 0.004). On multivariable analysis, percutaneous drainage (adjusted hazard ratio [HR], 1.38; 95% confidence interval [CI], 1.02-1.86; P = 0.039), older age (hazard ratio [HR], 1.04; 95% CI, 1.01-1.04; P < 0.001), intensive care unit stay (HR, 1.02; 95% CI, 1.01-1.03; P < 0.001), and multiple comorbidities (HR, 1.07; 95% CI, 1.05-1.09; P < 0.001) were significantly associated with mortality. Percutaneous drainage (adjusted odds ratio [OR], 1.30; 95% CI, 1.04-1.63; P = 0.027) and older age (OR, 0.98; 95% CI, 0.97-0.99; P < 0.001) were significantly associated with rehospitalizations.

CONCLUSIONS

As percutaneous drainage may be associated with higher mortality, rehospitalization, and costs, when requisite expertise is available, endoscopy should be preferred for treatment of PFC amenable to such an approach. Randomized trials are required to validate these findings.