Early assessment of pancreatic infections and overall prognosis in severe acute pancreatitis by procalcitonin (PCT): a prospective international multicenter study

Inflammatory mediators in the diagnosis and treatment of acute pancreatitis: pentraxin-3, procalcitonin and myeloperoxidase

INTRODUCTION

Acute pancreatitis (AP) is the third most common gastrointestinal disease at hospital admission. The etiology and pathogenesis of this disease are not completely clear. Our study was intended to determine the systemic levels of pentraxin-3 (PTX-3), myeloperoxidase (MPO), procalcitonin (PCT), and C-reactive protein (CRP) as prognostic parameters in early stages of AP. We also determined the effects of treatment on PTX-3, MPO, PCT and CRP levels in AP.

MATERIAL AND METHODS

The study group comprised 44 AP patients (22 male, 22 female; age: 49.3 ±16.9 years) referred to our outpatient clinic. Additionally, our investigation included a control group of 30 healthy volunteers (18 male, 12 female; age: 50.8 ±12.6 years).

RESULTS

Leukocytes, glucose, aspartate aminotransferase (AST (SGOT)), alanine aminotransferase (ALT (SGPT)), alkaline phosphatase (ALP), total and direct bilirubin levels were significantly higher in the AP group (p < 0.05, all). CRP, PTX-3, MPO and PCT were considerably higher in the AP group (p < 0.001, all), and after treatment, CRP, PTX-3, MPO and PCT levels were significantly lower (p < 0.001, all).

CONCLUSIONS

Our findings indicated that the CRP, PTX-3, MPO and PCT levels increase in patients with AP and hence these indicators can be used as diagnostic factors to predict inflammation severity in AP. It was revealed that after treatment, there were significant reductions in biomarker levels. However, further research is needed in order to understand how these biomarkers can help to monitor inflammatory responses in AP.

Risk factors and outcomes of infected pancreatic necrosis: Retrospective cohort of 148 patients admitted to the ICU for acute pancreatitis

Objective

The primary objective of this article is to identify risk factors for infected pancreatic necrosis (IPN) in patients admitted to the intensive care unit (ICU) for severe acute pancreatitis. We also described outcomes of IPN.

Background

Acute pancreatitis is common and associated with multiple, potentially life-threatening complications. Over the last decade, minimally invasive procedures have been developed to treat IPN.

Methods

We retrospectively studied consecutive patients admitted for severe acute pancreatitis to the ICUs of the Nantes University Hospital in France, between 2012 and 2015. Logistic regression was used to evaluate potential associations linking IPN to baseline patient characteristics and outcomes.

Results

Of the 148 included patients, 26 (17.6%) died. IPN developed in 62 (43%) patients and consistently required radiological, endoscopic, and/or surgical intervention. By multivariate analysis, factors associated with IPN were number of organ failure (OF) (for ≥ 3: OR, 28.67 (6.23-131.96), p < 0.001) and portosplenomesenteric venous thrombosis (OR, 8.16 (3.06-21.76)).

Conclusion

IPN occurred in nearly half our ICU patients with acute pancreatitis and consistently required interventional therapy. Number of OFs and portosplenomesenteric venous thrombosis were significantly associated with IPN. Early management of OF may reduce IPN incidence, and management of portosplenomesenteric venous thrombosis should be investigated.

Cortisol Outperforms Novel Cardiovascular, Inflammatory, and Neurohumoral Biomarkers in the Prediction of Outcome in Acute Pancreatitis

OBJECTIVES

The aims of this study were to assess whether copeptin, pro-atrial natriuretic peptide, proadrenomedullin, and cortisol are associated with disease severity in patients with acute pancreatitis (AP) and to compare their ability in predicting organ failure or death.

METHODS

From April 2011 to January 2015, 142 patients with AP were included in this prospective single-center study and observed for 4 days. Disease severity was rated by the Atlanta 1992 and 2012 criteria and organ failure by the modified Marshall score. The aforementioned laboratory markers, C-reactive protein, and procalcitonin were measured.

RESULTS

Patients with moderate to severe AP showed significantly higher plasma concentrations of all biomarkers than did those with mild AP. Overall, 30 organ failures or deaths occurred. All biomarkers except cortisol had only modest discriminatory ability, with areas under the receiver operating characteristic curve (AUCs) between 0.44 and 0.66. Cortisol showed an AUC of 0.78 compared with the Acute Physiology and Chronic Health Evaluation II score with an AUC of 0.75.

CONCLUSIONS

Cortisol was the best predictor of organ failure or death. All biomarkers were associated with disease severity to a similar degree as C-reactive protein, the criterion-standard marker in AP. Further studies are warranted to define their clinical role.

Utilizing Multiparameter Scores and Procalcitonin as Prognosis Markers for the Degree of Severity of Acute Pancreatitis

ABSTRACT: Aim: Corroborating the Ranson, Marshall, computer tomography severity index (EPIC score) multiparameter tests with the biological marker procalcitonin in order to establish the degree of severity of acute pancreatitis for therapeutic management and rate of complications. Material and method: 20 patients were surveyed, diagnosed with acute pancreatitis in the surgery clinic of the Military Emergency Hospital Dr. Ștefan Odobleja, between 2016-2017, with the aim of determining the clinical, etiological and severity diagnosis by corroborating the multiparameter scores with the plasma level of procalcitonin. Results: Following the use of multiparameter scores to identify the degree of severity of acute pancreatitis, we established that the best prediction is achieved by the Ranson score and the computer tomography severity index (EPIC score), with an accuracy of 90% . As for the values of the correlation coefficient, this was highly significant when correlating Ranson score and procalcitonin (r = 0.918). Other correlations were also highly significant, with values of r = 0.797 when correlating EPIC score and procalcitonin, and r = 0.736 when correlating Marshall score with procalcitonin. Conclusion: Our study achieved an early identification of the severe form of acute pancreatitis, by using the multiparameter tests and the biologic marker procalcitonin, allowing for the appropriate therapy to be implemented and thus decreasing the complication rate of this pathological entity. Levels of serum procalcitonin exceeded the normal limit of 2 ng/ml for 37.5% of the intermediate - severe form patients, and for 100% of the severe form patients. The levels of procalcitonin were highly correlated with the Ranson score, with a slightly lower correlation for the Marshall and EPIC scores.

Acute Pancreatitis: Etiology, Pathology, Diagnosis, and Treatment

Acute pancreatitis is a fascinating disease. In the United States, the two most common etiologies of acute pancreatitis are gallstones and excessive alcohol consumption. The diagnosis of acute pancreatitis is made with a combination of history, physical examination, computed tomography scan, and laboratory evaluation. Differentiating patients who will have a benign course of their pancreatitis from patients who will have severe pancreatitis is challenging to the clinician. C-reactive protein, pro-calcitonin, and the Bedside Index for Severity of Acute Pancreatitis appeared to be the best tools for the early and accurate diagnosis of severe pancreatitis. Early laparoscopic cholecystectomy is indicated for patients with mild gallstone pancreatitis. For patients who are going to have a prolonged hospitalization, enteral nutrition is preferred. Total parenteral nutrition should be reserved for patients who cannot tolerate enteral nutrition. Prophylactic antibiotics are not indicated for patients with pancreatic necrosis. Surgical intervention for infected pancreatic necrosis should be delayed as long as possible to improve patient outcomes.

Prognostic value of admission red blood cell distribution width in acute pancreatitis: a systematic review

BACKGROUND

Red blood cell distribution width (RDW) has been proved to be a strong prognostic marker in various diseases such as cardiovascular diseases, renal failure, viral hepatitis etc. But its prognostic value in acute pancreatitis (AP) remains controversial. The aim of this systematic review is to determine the prognostic value of RDW in AP.

METHODS

PubMed, Cochrane, Google scholar, and Web of Science were searched on March 2, 2017 to identify studies that investigated the association between RDW and the prognosis of AP. The eligible studies were reviewed and summarized.

RESULTS

In total, 2008 articles were screened. Seven studies were included in the final analysis. Five studies estimated the prognostic value of RDW using receiver operating characteristic (ROC) curve analysis, and multivariable analysis was performed in only four studies. The major design weaknesses of eligible studies are their retrospective design and some of potential confounding factors were not adjusted.

CONCLUSIONS

Current evidence and findings support that high admission RDW can be used as a biomarker to identify the AP patients who are at high risk of mortality. However, due to the weaknesses of available studies, further well-designed studies with large sample size and various outcome endpoints are needed to rigorously evaluate the prognostic value of RDW in AP.

Prediction of acute pancreatitis severity via the combined analysis of inflammatory biomarkers and coagulation parameters

Introduction. Timely assessment of severity of acute pancreatitis is needed to avoid severe systemic complications by making optimal therapeutic approach and correct prognosis of the disease. The aim of the study was to establish the role of several inflammatory biomarkers and coagulation parameters in prediction of AP severity, and also to propose a mathematical formula which allows their combined use for the same purpose. Material and Methods. The prospective study included 70 patients with AP. The patients were divided into groups: mild (group I), moderate (group II) and severe AP (group III). All patients were further classified into two groups: group A (mild AP) and group B (moderate and severe AP). Biochemical markers, inflammatory biomarkers and coagulation factors were tested in all patients. Results. Based on the results of Mann-Whitney,s test, it can be concluded that groups A and B are significant different from each other for CRP (p<0.05). Using the Wald’s stepwise forward method, a prediction model with CRP, PCT, D-dimer1, D-dimer3, fibrinogen1 and fibrinogen3 parameters as predictors of the severity of AP was obtained. The percentage of successful prediction of moderate or severe AP based on this model was 76.9%. The use of ROC analysis with the introduced linear combination from the logistic regression yielded equally good or even better results in the assessment of the severity of AP with the combined use of analyzed parameters. Conclusion. The combined analyses of biohumoral markers and coagulation parameters presented in the form a mathematical formula enabled a more accurate, rapid, rational and clinically available prediction of the severity of AP.

Early prediction of infected pancreatic necrosis secondary to necrotizing pancreatitis

To assess the association between the clinical parameters within 48 hours of admission and the occurrence of infected pancreatic necrosis (IPN) during the late phase of necrotizing pancreatitis (NP).All patients were divided into 2 groups, the IPN and non-IPN groups. The clinical data were retrospectively analyzed. Univariate and multivariate logistic regression analyses were performed to evaluate the relationship between clinical parameters and IPN secondary to NP. The performance of each independent variable was plotted by the receiver-operating characteristic (ROC) curve. Consequently, the cut-off level of each independent variable with its sensitivity and specificity was calculated.A total of 215 patients were enrolled in our study. Among them, 87 (40.5%) patients developed IPNs after a median of 13.5 (9.5-23.0) days from admission. Multivariate analysis indicated that the level of hematocrit (HCT) from 40% to 50% (P=.012, odds ratio (OR) = 2.407), HCT over 50% (P < .009, OR = 6.794), blood urea nitrogen (BUN) (P = .040, OR = 1.894), C-reactive protein (CRP) (P = .043, OR = 1.837), and procalcitonin (PCT) (P = .002, OR = 2.559) were independent risk factors of IPN secondary to NP. The ROC cures revealed that the area under the ROC (AUC) of the maximum level of HCT, BUN, CRP, and PCT within 48 hours of admission was 0.687, 0.620, 0.630, and 0.674 respectively. Furthermore, the combination of these 4 individual parameters contributes to a more preferable AUC of 0.789 with a sensitivity of 67.8% and specificity of 77.3%.The maximum levels of PCT, CRP, HCT, and BUN within 48 hours of admission are independent factors of IPN and their combination might accurately predict the occurrence of IPN secondary to NP.

Serum C-reactive protein, procalcitonin, and lactate dehydrogenase for the diagnosis of pancreatic necrosis

BACKGROUND

The treatment of people with pancreatic necrosis differs from that of people with oedematous pancreatitis. It is important to know the diagnostic accuracy of serum C-reactive protein (CRP), serum procalcitonin, and serum lactate dehydrogenase (LDH) as a triage test for the detection of pancreatic necrosis in people with acute pancreatitis, so that an informed decision can be made as to whether the person with pancreatic necrosis needs further investigations such as computed tomography (CT) scan or magnetic resonance imaging (MRI) scan and treatment for pancreatic necrosis started. There is currently no standard clinical practice, although CRP, particularly an increasing trend of CRP, is often used as a triage test to determine whether the person requires further imaging. There is also currently no systematic review of the diagnostic test accuracy of CRP, procalcitonin, and LDH for the diagnosis of pancreatic necrosis in people with acute pancreatitis.

OBJECTIVES

To compare the diagnostic accuracy of CRP, procalcitonin, or LDH (index test), either alone or in combination, in the diagnosis of necrotising pancreatitis in people with acute pancreatitis and without organ failure.

SEARCH METHODS

We searched MEDLINE, Embase, Science Citation Index Expanded, National Institute for Health Research (NIHR HTA and DARE), and other databases until March 2017. We searched the references of the included studies to identify additional studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. We also performed a 'related search' and 'citing reference' search in MEDLINE and Embase.

SELECTION CRITERIA

We included all studies that evaluated the diagnostic test accuracy of CRP, procalcitonin, and LDH for the diagnosis of pancreatic necrosis in people with acute pancreatitis using the following reference standards, either alone or in combination: radiological features of pancreatic necrosis (contrast-enhanced CT or MRI), surgeon's judgement of pancreatic necrosis during surgery, or histological confirmation of pancreatic necrosis. Had we found case-control studies, we planned to exclude them because they are prone to bias; however, we did not locate any. Two review authors independently identified the relevant studies from the retrieved references.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, including methodological quality assessment, from the included studies. As the included studies reported CRP, procalcitonin, and LDH on different days of admission and measured at different cut-off levels, it was not possible to perform a meta-analysis using the bivariate model as planned. We have reported the sensitivity, specificity, post-test probability of a positive and negative index test along with 95% confidence interval (CI) on each of the different days of admission and measured at different cut-off levels.

MAIN RESULTS

A total of three studies including 242 participants met the inclusion criteria for this review. One study reported the diagnostic performance of CRP for two threshold levels (> 200 mg/L and > 279 mg/L) without stating the day on which the CRP was measured. One study reported the diagnostic performance of procalcitonin on day 1 (1 day after admission) using a threshold level of 0.5 ng/mL. One study reported the diagnostic performance of CRP on day 3 (3 days after admission) using a threshold level of 140 mg/L and LDH on day 5 (5 days after admission) using a threshold level of 290 U/L. The sensitivities and specificities varied: the point estimate of the sensitivities ranged from 0.72 to 0.88, while the point estimate of the specificities ranged from 0.75 to 1.00 for the different index tests on different days of hospital admission. However, the confidence intervals were wide: confidence intervals of sensitivities ranged from 0.51 to 0.97, while those of specificities ranged from 0.18 to 1.00 for the different tests on different days of hospital admission. Overall, none of the tests assessed in this review were sufficiently accurate to suggest that they could be useful in clinical practice.

AUTHORS' CONCLUSIONS

The paucity of data and methodological deficiencies in the studies meant that it was not possible to arrive at any conclusions regarding the diagnostic test accuracy of the index test because of the uncertainty of the results. Further well-designed diagnostic test accuracy studies with prespecified index test thresholds of CRP, procalcitonin, LDH; appropriate follow-up (for at least two weeks to ensure that the person does not have pancreatic necrosis, as early scans may not indicate pancreatic necrosis); and clearly defined reference standards (of surgical or radiological confirmation of pancreatic necrosis) are important to reliably determine the diagnostic accuracy of CRP, procalcitonin, and LDH.

Soluble urokinase-type plasminogen activator receptor (suPAR) in patients with acute pancreatitis (AP) - Progress in prediction of AP severity

BACKGROUND

Soluble urokinase-type plasminogen activator receptor (suPAR) is a glycoprotein secreted during inflammation and infections. Moreover, increased levels of suPAR are observed after hypoxia and ischaemia. The aim of the study was to assess whether suPAR could represent a useful marker of acute pancreatitis (AP) severity.

PATIENTS AND METHODS

We have observed a cohort of 126 prospectively enrolled patients. Based on the presence of persistent organ failure (more than 48 h) and local complications (diagnosis of moderate AP [MSAP]), patients were classified into three groups: mild AP (MAP), moderate and severe AP (SAP). The blood samples were taken on admission for detecting suPAR concentrations.

RESULTS

AP was considered severe in 33 patients (26.2%), MSAP was found in 37 patients (29.4%), and MAP was found in 56 patients (44,4%). The AUC for SAP predicted by suPAR was 0.993. The calculated cut-off point for prognosis SAP is 4.75 ng/mL. The BISAP score of ≥3 for detection of SAP had sensitivity and specificity of 94.6% and 63.6%, respectively. The AUC for severity predicted by BISAP amounted to 0.916. Additionally, suPAR turned out to be a good predictor of fatal AP: for the cut-off point 7.05 ng/mL, the AUC was 0.917. The AUC for death prediction in AP patients based on the BISAP score ≥3 was 0.894.

CONCLUSIONS

suPAR concentration is a promising new diagnostic and prognostic indicator in SAP obtainable in the early stage of disease. Larger studies are recommended to evaluate this role further.

Procalcitonin in Crohn's disease with fever episodes, a variable to differentiate intra-abdominal abscess from disease flares

BACKGROUND

Crohn's Disease (CD) is a chronic inflammatory disease accompanied by many complications, such as intra-abdominal abscess (IAA). A frequent problem in CD is the discrimination of fever caused by exacerbated bowel inflammation or IAA.

METHODS

A total of 80 CD patients complaining with fever episodes were included prospectively. PCT, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white blood cell count (WBC) were evaluated on admission. IAA was identified based on image studies and response to antibiotic therapy by physicians blind to the serum PCT level. At last, correlation between serum PCT level and patients' disease activity was also investigated.

RESULTS

Sixteen patients were identified with IAA, which showed significantly higher serum PCT level when compared with those patients who have no IAA (0.505 ng/ml vs 0.112 ng/ml, p < 0.01). PCT is a better biomarker of IAA in CD patients compared with CRP, ESR and WBC (AUC = 0.954, 0.757, 0.771 and 0.554, respectively). And the cutoff value for PCT in differentiating patients with and without IAA was 0.35 ng/ml. Correlation between serum PCT level and CDAI score (r = 0.575) was weaker than that of CRP and ESR (r = 0.628 and 0.634 respectively), but stronger than that of WBC (r = 0.162).

CONCLUSION

PCT can be an additional marker for detecting IAA in CD patients with fever episodes, and may serve as a new serological marker of disease activity.

Acute pancreatitis following scoliosis surgery: description and clinical course in 14 adolescents

PURPOSE

Acute pancreatitis is a possible complication after scoliosis surgery. Although some risk factors have been documented in the literature, clinical description of pancreatitis diagnosis and ensuing course still remain very poor. The aim of this study was to describe characteristics of acute pancreatitis after scoliosis surgery.

METHODS

A descriptive, retrospective and single-center study of fourteen adolescents with postoperative acute pancreatitis after spine fusion surgery in scoliosis management between April 2003 and August 2012 was performed.

RESULTS

Acute pancreatitis occurred within 9.5 days (4-51) after surgery. Abdominal pain was atypical and was expressed in only half of the children. Ileus, nausea and vomiting were the most frequent signs. None of the acute pancreatitis cases was severe.

CONCLUSION

Acute pancreatitis is an early complication of scoliosis surgery. Clinical signs are atypical and non-severe and can induce misleading forms. Presence of delayed digestive problems should alert the clinician to the risk of pancreatitis in the aftermath of scoliosis surgery.

Procalcitonin levels predict infectious complications and response to treatment in patients undergoing cytoreductive surgery for peritoneal malignancy

BACKGROUND

Cytoreductive-surgery for peritoneal-malignancy (PM) involves extensive intra-abdominal surgery and a massive post-operative systemic-inflammatory-response (SIRS). It is often challenging to differentiate SIRS that are solely surgery-associated from those of post-operative infections. White-Cell-Counts (WCC) and C-Reactive-Protein (CRP) are routinely used as markers for infection, but are non-specific and their elevation is often delayed in PM cases. Other markers need to be evaluated to assist early identification/prediction of post-operative infections.

METHODOLOGY

Prospective evaluation of serum procalcitonin (PCT), CRP and WCC in 50 patients pre-operatively (Day0), and on post-operative days (POD) 1, 3 & 6, following cytoreductive-surgery with or without splenectomy.

RESULTS

Day0 PCT, CRP and WCC values were within normal limits, but increasing physiologically in post-operative period without infection, with noticeable higher PCT in splenectomized patients. In our cohort post-operative infections were diagnosed in 14 patients, often within 48 h. There was a trend for faster rise in serum PCT on POD1 compared to CRP and WCC, and faster PCT decline following appropriate therapy on POD3 and POD6 when infected cases were clinically resolving while WCC and CRP continued to rise, particularly in non-spelenectomised patients. The AUC on POD1 was significantly higher for PCT (0.689) vs. WCC (0.476) and CRP (0.477) (p = 0.04). Sensitivity, specificity, positive-predictive-value and negative-predictive-values for PCT ranged between (57%-100%), (22%-74%), (33%-47%) & (81%-100%), for CRP (28%-78%), (5.5%-86%), (18%-44.4%) & (40%-75.5%) and for WCC (14%-26.5%), (65.5-80.5%), (22%-25%), (67%-70%) respectively.

CONCLUSION

PCT, like WCC and CRP, needs to be interpreted with extreme cautions in the context of infections post-cytoreductive-surgery and should only be used in association with other clinical and investigational findings.

Efficacy of thymosin α1 and interferon α for the treatment of severe acute pancreatitis in a rat model

The present study aimed to investigate the effects of treatment with thymosin α1 (TA1) or interferon α (IFNα) following the establishment of severe acute pancreatitis (SAP) in rats. A total of 144 Sprague-Dawley rats were randomly divided into four groups. The rats in all four groups were celiotomized, and the rats in the control group were administered with an intravenous injection of saline. The three other groups were administered with 5% 1 ml/kg sodium taurocholate via the cholangiopancreatic duct. SAP group rats were administered with an intravenous injection of saline; TA1 group rats received 26.7 µg/kg TA1; and interferon α (INFα) group rats received 4.0×10⁵ U/kg IFNα. The rats were anesthetized and blood samples were collected from the animals 3, 12 and 24 h after surgery. The levels of T cell subsets, serum enzyme indicators, cytokines and procalcitonin (PCT) were measured. The general conditions of the rats were observed until sacrifice, and pancreatic and lung tissue samples were sampled for hematoxylin and eosin staining and histological scoring. The expression levels of aspartate transaminase, lactate dehydrogenase, α-amylase (AMY), P-type-amylase, lipase, PCT, tumor-necrosis factor α, interleukin (IL)-4, IL-5, and IL-18 in the TA1 and IFNα-treated rats were significantly lower, compared with those of the SAP rats within the first 24 h of model establishment (P<0.05). The TA1 and IFNα-treated rats exhibited significantly increased levels of CD3⁺, CD4⁺ and CD8⁺ T cells, and an increased ratio of CD4⁺/CD8⁺ cells, compared with SAP rats. Histological analysis revealed that the TA1 and IFNα-treated rats exhibited significantly ameliorated pancreas and lung damage, and mortality rates were reduced from 50.0% (6/12) to 25.0% (3/12) and 33.3% (4/12), respectively. The immunomodulatory agents TA1 and IFNα reduced acute inflammation, decreasing cell damage and enhancing immune function and survival rates in the SAP rats.

Laboratory markers predicting severity of acute pancreatitis

Acute pancreatitis (AP) is an inflammatory disease of highly variable severity, ranging from mild cases with low mortality to severe cases with high mortality. Numerous biomarkers have been studied as potential early predictors of the severity of this disease so that treatment can be optimally tailored to prevent complications. We aim to present and discuss the most relevant biomarkers for early severity assessment in AP that have been studied to date. We review the current literature on biomarkers that have been used to predict the severity in AP. C-reactive protein (CRP) is still considered to be the gold standard, with a cut-off value of 150 mg/ml 48 h after disease onset. Other markers, including procalcitonin (PCT) and interleukin 6 (IL-6) have been implemented in some hospitals, but are not used on a routine basis. Most other markers, including acute phase proteins (LBP, SAA, PTX3), cytokines (Il-8, TNF-a, MIF), activation peptides of pancreatic proteases (TAP, CAPAP, PLAP), antiproteases (AAT, a2M), adhesion molecules (ICAM-1, selectins, E-cadherin) and leukocyte-derived enzymes (PA2, PMN-E) have shown some promising results but have not been routinely implemented. Furthermore, new and interesting biomarkers (Copeptin, TRX-1, Ang-2, E-2) have shown good results, but more research is needed to determine if they could play a role in the future. Various reasons why new markers for disease severity have not been adopted in daily routine include low accuracy, cumbersome laboratory techniques and high cost. Despite these difficulties, research is still very active in finding new markers to predict the severity of AP.

Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015

BACKGROUND

Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines.

METHODS

A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines.

RESULTS

Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles.

CONCLUSIONS

The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.

Are there new approaches for diagnosis, therapy guidance and outcome prediction of sepsis?

Beside many efforts to improve outcome, sepsis is still one of the most frequent causes of death in critically ill patients. It is the most common condition with high mortality in intensive care units. The complexity of the septic syndrome comprises immunological aspects - i.e., sepsis induced immunosuppression - but is not restricted to this fact in modern concepts. So far, exact mechanisms and variables determining outcome and mortality stay unclear. Since there is no typical risk profile, early diagnosis and risk stratification remain difficult, which hinders rapid and effective treatment initiation. Due to the heterogeneous nature of sepsis, potential therapy options should be adapted to the individual. Biomarkers like C-reactive protein and procalcitonin are routinely used as complementary tools in clinical decision-making. Beyond the acute phase proteins, a wide bunch of promising substances and non-laboratory tools with potential diagnostic and prognostic value is under intensive investigation. So far, clinical decision just based on biomarker assessment is not yet feasible. However, biomarkers should be considered as a complementary approach.

Increased interleukin-23/17 axis and C-reactive protein are associated with severity of acute pancreatitis in patients

OBJECTIVE

The interleukin (IL)-23/IL-17 axis plays an important role in various inflammatory conditions but its function in acute pancreatitis (AP) is not well understood. The present study investigated the relationship between serum levels of IL-23, IL-17, and C-reactive protein (CRP) in patients and the severity of AP.

METHODS

Eighty-five patients with AP were categorized into mild group, moderately severe group, and severe group according to the revised Atlanta classification, 2012. Serum levels of IL-23 and IL-17 were measured by enzyme-linked immunosorbent assay in patients 48 hours after admission. The CRP levels of patients were also measured on admission and 48 hours after admission.

RESULTS

The serum levels of CRP of patients on admission and 48 hours after admission and levels of IL-23 and IL-17 of patients 48 hours after admission increased alone with the severity of AP, respectively (P < 0.01). The serum levels of IL-23 and IL-17 in the patients were correlated with CRP levels (r = 0.234, r = 0.552, P < 0.001, respectively).

CONCLUSIONS

The serum levels of IL-17, IL-23, and CRP are correlated with the severity of AP and represent valuable prognostic factors in the assessment of disease severity of patients with AP.

Alterations of serum cytokine levels and their relation with inflammatory markers in candidemia

The roles of CRP, PCT, serum amyloid A (SAA), and cytokines in the diagnosis of fungal infections have not yet been clearly demonstrated. This study aims to measure the serum levels of interleukin (IL)-23, IL-17, IL-1β, tumor necrosis factor (TNF)-α, IL-10, transforming growth factor (TGF)-β, C-reactive protein (CRP), procalcitonin (PCT), and serum amyloid A (SAA) in cases of candidemia and to compare them with those observed in cases of bacteremia. For this purpose, the serum cytokine levels from 50 patients with candidemia were compared with those of 14 patients with polymicrobial sepsis, 30 patients with bacteremia, and 27 healthy control subjects. The cytokine levels were studied using sandwich ELISAs according to the manufacturer protocol. The serum levels of TGF-β, IL-23, and IL-17 were found to be significantly higher in the candidemia group in comparison with the samples from those with bacteremia and healthy controls. The PCT and SAA levels were higher in samples from the group with bacteremia those from individuals with candidemia and the healthy control group. Assuming an IL-17 level threshold of >38.79 pg/ml, the sensitivity and specificity were 38% and 96.6%, respectively but considering an IL-23 threshold of >59.97 pg/ml, the sensitivity and specificity values were found to be 72% and 60%, respectively. The sensitivity and the specificity of the TGF-ß levels were found to be 85.71% and 53.33%, respectively, when the TGF-ß threshold is >560 pg/ml. PCT and SAA demonstrated a superior performance for the differentiation of candidemia and bacteremia. Our study demonstrates that IL-17, IL-23, TGF-ß, PCT, and SAA levels could be a diagnostic marker for candidemia.

The chemokine ligand CXCL16 is an indicator of bacterial infection in necrotizing pancreatitis

OBJECTIVES

Current guidelines tell us that intervention in severe necrotizing pancreatitis ought to be performed as late as possible. However, when pancreatic necrosis becomes infected, the necrotic tissue needs to be removed. Unfortunately, bacterial infection can only be proven by invasive methods.

METHODS

Necrotizing pancreatitis with sterile or infected necrosis was induced in mice. Mice serum samples were examined by antibody-based protein array. After identifying candidate proteins that showed strong regulation, the serum concentration of these proteins was examined by sandwich ELISA. Then, human serum samples were collected from patients with mild pancreatitis, severe pancreatitis with and without pancreatic necrosis and patients with microbiologically proven infection of pancreatic necrosis. These serum samples were then analyzed by sandwich ELISA.

RESULTS

In mice 6 proteins were strongly up-regulated and were further investigated by ELISAs. Of these proteins, CXCL16 and TRANCE (RANKL) concentrations were analyzed in human serum samples. CXCL16 and TRANCE were increased in patients with pancreatic necrosis and abdominal infection. Receiver operated characteristics showed that CXCL16 was superior in predicting infected pancreatic necrosis when compared to C-reactive protein and TRANCE.

CONCLUSIONS

Serum CXCL16 is increased in severe pancreatitis with infected pancreatic necrosis and identifies patients who benefit from surgical necrosectomy.

Role of inflammatory markers as predictors of laparotomy in patients presenting with acute abdomen

BACKGROUND

There is a need for an ideal indicator of surgery in patients presenting with acute abdomen. Several markers have been analysed, but the search still continues as none have proven effective. This study aimed to analyse and compare the predictive value of plasma procalcitonin (PCT) strip test in patients presenting with acute abdomen and identify a useful cut-off value to differentiate patients that would benefit with surgery from those that require conservative management.

METHODS

A prospective study was conducted in the department of general surgery from June 2012 to June 2013. Plasma PCT was estimated by the semi-quantitative strip test. The levels of plasma PCT and other routinely used markers of inflammation were analysed and compared.

RESULTS

Of the total of 58 patients, 44 patients (76%) were men with a mean age of 45 years. Forty patients required emergency surgical intervention. A plasma PCT value of >0.5 ng/mL at admission was 80% sensitive and 100% specific for predicting need for antibiotics in patients with acute abdomen that were managed conservatively. The mean plasma PCT value in the patients undergoing surgery (5.0-10.0 ng/mL) was significantly more than in those managed conservatively (0.5-2.0 ng/mL). Using receiver operating characteristic (ROC) curves a cut-off for plasma PCT of >5.0 ng/mL was 75% sensitive and 100% specific for considering surgical intervention in patients presenting with acute abdomen.

CONCLUSIONS

Plasma PCT (value >5 ng/mL) could be used as an adjunct to clinical examination to predict requirement of surgery in patients presenting with acute abdomen.

From moderately severe to severe hypertriglyceridemia induced acute pancreatitis: circulating miRNAs play role as potential biomarkers

The incidence of hypertriglyceridemia induced acute pancreatitis (HTAP) continues to rise in China. It has systemic complications and high mortality, making the early assessment of the severity of this disease even more important. Circulating microRNAs (miRNAs) could be novel, non-invasive biomarkers for disease progression judgment. This study aimed to identify the potential role of serum miRNAs as novel biomarkers of HTAP progression. HTAP patients were divided into two groups: moderately severe (HTMSAP) and severe (HTSAP), healthy people were used as control group. The serum miRNA expression profiles of these three groups were determined by microarray and verified by qRT-PCR. The functions and pathways of the targeted genes of deregulated miRNAs were predicted, using bioinformatics analysis; miRNA-mRNA network was generated. Moreover, the correlation between miR-181a-5p and pancreatitis metabolism related substances were studied and the serum concentration of inflammatory cytokines and miRNAs at different time points during the MSAP and SAP were investigated, respectively. Finally, the receiver operating characteristic (ROC) curve of miRNAs was studied. Significant changes in the serum concentration of the following miRNAs of HTAP patients (P<0.05) were discovered: miR24-3p, 361-5p, 1246, and 222-3p (constantly upregulated), and 181a-5p (constantly downregulated) (P<0.05). Bioinformatics analysis predicted that 13 GOs and 36 pathways regulated by overlap miRNAs were involved in glucose, fat, calcium (Ca++), and insulin metabolism (P<0.001). miRNA-mRNA network revealed that the overlap miRNAs targeted genes participating in pancreas metabolism and miR-181a-5p, the only downregulated miRNA, had good negative correlation with triglyceride (TG), total cholesterol (TC), and fast blood glucose (FBG), but a positive correlation with Ca++. When compared with inflammatory cytokines, the changes of all five overlap miRNAs were more stable. It was found that when used for evaluating the progression of HTAP, miRNAs showed good AUC. These data suggested that serum miRNAs have the potential to be excellent HTAP biomarkers.

Predictors of critical acute pancreatitis: a prospective cohort study

Critical acute pancreatitis (CAP) has recently emerged as the most ominous severity category of acute pancreatitis (AP). As such there have been no studies specifically designed to evaluate predictors of CAP. In this study, we aimed to evaluate the accuracy of 4 parameters (Acute Physiology and Chronic Health Evaluation [APACHE] II score, C-reactive protein [CRP], D-dimer, and intra-abdominal pressure [IAP]) for predicting CAP early after hospital admission. During the study period, data on patients with AP were prospectively collected and D-dimer, CRP, and IAP levels were measured using standard methods at admission whereas the APACHE II score was calculated within 24 hours of hospital admission. The receiver-operating characteristic (ROC) curve analysis was applied and the likelihood ratios were calculated to evaluate the predictive accuracy. A total of 173 consecutive patients were included in the analysis and 47 (27%) of them developed CAP. The overall hospital mortality was 11% (19 of 173). APACHE II score ≥11 and IAP ≥13 mm Hg showed significantly better overall predictive accuracy than D-dimer and CRP (area under the ROC curve-0.94 and 0.92 vs. 0.815 and 0.667, correspondingly). The positive likelihood ratio of APACHE II score is excellent (9.9) but of IAP is moderate (4.2). The latter can be improved by adding CRP (5.8). In conclusion, of the parameters studied, APACHE II score and IAP are the best available predictors of CAP within 24 hours of hospital admission. Given that APACHE II score is rather cumbersome, the combination of IAP and CRP appears to be the most practical way to predict critical course of AP early after hospital admission.

Role of heart rate variability in predicting the severity of severe acute pancreatitis

BACKGROUND

Infected pancreatic necrosis (IPN) and multiple organ dysfunction syndrome (MODS) are major complications of acute pancreatitis which determine disease severity and outcome.

AIMS

The aim of this study is to investigate the value of admission heart rate variability as a marker of IPN or MODS in severe acute pancreatitis (SAP) patients.

METHODS

Forty-one SAP patients within 72 h of symptoms onset were included in this prospective observational study. General demographics, laboratory data and the acute physiology and chronic health evaluation (APACHE) II scores were recorded at admission. 5-minute ECG signals were obtained at the same time for heart rate variability analyses to assess SAP severity.

RESULTS

The baseline heart rate variability measurements, levels of low frequency/high frequency (LF/HF) were significantly lower whereas high frequency norm (nHF) levels were significantly higher in patients who present with IPN and MODS or died (P < 0.01). Low frequency (LF) levels were lower in patients who present with IPN or MODS as compared to patients without these complications. Levels of low frequency norm (nLF) were lower in MODS and non-survival patients. nHF and LF/HF were good predictors of IPN and MODS, superior to procalcitonin. nHF and LF/HF were better than APACHE II in predicting IPN and LF/HF showed superiority over APACHE II in the prediction of MODS.

CONCLUSIONS

Admission heart rate variability is a good marker of IPN and MODS in SAP patients.

The role of organ failure and infection in necrotizing pancreatitis: a prospective study

OBJECTIVE

To clarify the roles of organ failure and infection in the outcome of necrotizing pancreatitis.

BACKGROUND

Results of previous cohort studies that focused on the roles of infection and organ failure in acute pancreatitis are controversial.

METHODS

In this study, we collected the medical records of 447 patients with necrotizing pancreatitis from January 2009 to June 2012. Data associated with organ failure and infection were analyzed.

RESULTS

The overall mortality rate was 13% (58/447). Intervention was performed in 223 of 447 patients. Among these 223 patients, 134 were confirmed to be with infected necrosis by a positive culture. The mortality rate was 15% (13/89) in the sterile necrosis group and 18% (24/134) in the infected necrosis group (P = 0.52). A multivariate analysis of death predictors indicated that bacteremia (odds ratio [OR] = 2.76, 95% confidence interval [CI], 1.23-5.46, P < 0.001), age (OR = 1.07, 95% CI, 1.03-1.11, P < 0.001), American Society of Anesthesiologists class (OR = 3.56, 95% CI, 1.65-7.18, P = 0.001), persistent organ failure in the first week (OR = 16.72, 95% CI, 7.04-32.56, P < 0.001), and pancreatic necrosis (OR = 1.73, 95% CI, 1.14-2.98, P = 0.008) were significant factors.

CONCLUSIONS

Among patients with necrotizing pancreatitis, the effects of organ failure on mortality are more critical than those of infection. Bacteremia, age, American Society of Anesthesiologists class, persistent organ failure in the first week, and pancreatic necrosis were identified as the predictors of mortality.

Update on procalcitonin measurements

Procalcitonin (PCT) is used as a biomarker for the diagnosis of sepsis, severe sepsis and septic shock. At the same time, PCT has also been used to guide antibiotic therapy. This review outlines the main indications for PCT measurement and points out possible pitfalls. The classic indications for PCT measurement are: (i) confirmation or exclusion of diagnosis of sepsis, severe sepsis, or septic shock, (ii) severity assessment and follow up of systemic inflammation mainly induced by microbial infection, and (iii) individual, patient adapted guide of antibiotic therapy and focus treatment. Using serially monitored PCT levels, the duration and need of antibiotic therapy can be better adapted to the individual requirements of the patient. This individualized approach has been evaluated in various studies, and it is recommended to be a part of an antibiotic stewardship program.

Procalcitonin Strip Test as an Independent Predictor in Acute Pancreatitis

Plasma procalcitonin (PCT) is a highly specific marker for the diagnosis of bacterial infection and sepsis. Studies have demonstrated its role in the setting of sepsis and acute pancreatitis. This study aims to analyze and compare the prognostic efficacy of plasma procalcitonin strip test in acute pancreatitis. A prospective study was conducted in the department of general surgery from June 2012 to June 2013. Plasma procalcitonin was estimated by the semiquantitative strip test. The study included a total of 50 patients diagnosed to have acute pancreatitis. Data was collected and statistically analyzed using SPSS version 17. Thirty-nine out of the 50 patients (78 %) were males with a mean age of 46.8 years (range, 25-78 years) and 25 patients (50 %) had ethanol-induced pancreatitis, while 13 patients (26 %) had gall stone pancreatitis. Plasma PCT values were found to correlate better than CRP levels and total leukocyte count with the total duration of hospitalization, ITU, and ICU stay, as well as with the progression to severe acute pancreatitis. A cut off for plasma PCT of >2 ng/mL was found to be 100 % sensitive and 100 % specific and a cut off for CRP of >19 mg/dL was 70 % sensitive and 65 % specific for predicting the progression to severe acute pancreatitis. Plasma PCT also correlated well with antibiotic requirement. A cut off value of >0.5 ng/mL for plasma PCT was 100 % sensitive and 80 % specific and a cut off value of >18 mg/dL for CRP was 86 % sensitive and 63 % specific for predicting antibiotic requirement. Plasma procalcitonin is an early and reliable prognostic indicator in acute pancreatitis. The procalcitonin strip test is a rapid test which is useful in analyzing prognosis in patients with acute pancreatitis.

Serum procalcitonin levels in patients with ankylosing spondylitis

AIM

Procalcitonin is a marker of bacterial and fungal infection and sepsis. The present study evaluated the relationship between serum procalcitonin levels and disease activity in patients with ankylosing spondylitis (AS).

METHOD

A total of 61 patients who met the 1984 New York criteria for AS were studied. Twenty-four age- and sex-matched healthy volunteers were recruited to this study as a control group. Disease activity was assessed by the Bath AS Disease Activity Index (BASDAI). The functional status of patients was evaluated by the Bath AS Functional Index (BASFI). Spinal mobility was measured by the Bath AS Metrology Index (BASMI). Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and serum procalcitonin levels were measured.

RESULTS

Thirty patients were on anti-tumor necrosis factor-alpha treatment and 31 patients were on conventional treatment. Seventeen (28%) of the AS patients were active (BASDAI > 4) and 44 (72%) of the AS patients were in remission. The median ESR was 14 (34-6) mm/h and 4 (7-2) mm/h (P < 0.001) for the patient and control groups, respectively. The median CRP level was 0.91 (2.72-0.37) mg/dL and 0.15 (0.25-0.07) mg/dL in the patient and control groups, respectively (P < 0.001). Median BASDAI, BASFI and BASMI scores for all AS patients were 3.6 (5.25-2.29), 2.5 (4.22-0.91) and 3 (5-1), respectively. Serum procalcitonin levels were normal (< 0.05 ng/mL) for all patients and controls.

CONCLUSION

Serum procalcitonin levels were not high in AS patients and controls, and the levels were independent of disease activity and medications. If bacterial or fungal infection is suspected in an AS patient, serum procalcitonin level may be useful for diagnosis.

Predictors of severe and critical acute pancreatitis: a systematic review

BACKGROUND

Persistent organ failure and infected pancreatic necrosis are major determinants of mortality in acute pancreatitis, but there is a gap in the literature assessing the best available predictors of these two determinants. The purpose of this review was to investigate the utility of predictors of persistent organ failure and infected pancreatic necrosis in patients with acute pancreatitis, both alone and in combination.

METHODS

We performed a systematic search of the literature in 3 databases for prospective studies evaluating predictors of persistent organ failure, infected pancreatic necrosis, or both, with strict eligibility criteria.

RESULTS

The best predictors of persistent organ failure were the Japanese Severity Score and Bedside Index of Severity in Acute Pancreatitis when the evaluation was performed within 48h of admission, and blood urea nitrogen and Japanese Severity Score after 48h of admission. Systemic Inflammation Response Syndrome was a poor predictor of persistent organ failure. The best predictor of infected pancreatic necrosis was procalcitonin.

CONCLUSIONS

Based on the best available data, it is justifiable to use blood urea nitrogen for prediction of persistent organ failure after 48h of admission and procalcitonin for prediction of infected pancreatic necrosis in patients with confirmed pancreatic necrosis. There is no predictor of persistent organ failure that can be justifiably used in clinical practice within 48h of admission.

[International multidisciplinary classification of acute pancreatitis severity: the 2013 Spanish edition]

OBJECTIVE

To develop a new classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of the published evidence, and worldwide consultation.

BACKGROUNDS

The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of specialist in pancreatic diseases, but are suboptimal because these definitions are based on the empiric description of events not associated with severity.

METHODS

A personal invitation to contribute to the development of a new classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists and radiologists currently active in the field of clinical acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global web-based survey was conducted, and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions.

RESULTS

The new classification of severity is based on the actual local and systemic determinants of severity, rather than on the description of events that are non-causally associated with severity. The local determinant relates to whether there is (peri) pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another, whereby the presence of both infected (peri) pancreatic necrosis and persistent organ failure has a greater impact upon severity than either determinant alone. The derivation of a classification based on the above principles results in four categories of severity: mild, moderate, severe, and critical.

CONCLUSIONS

This classification is the result of a consultative process among specialists in pancreatic diseases from 49 countries spanning North America, South America, Europe, Asia, Oceania and Africa. It provides a set of concise up to date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

Prognostic markers in acute pancreatitis

Acute pancreatitis has a mortality rate of 5-10%. Early deaths are mainly due to multiorgan failure and late deaths are due to septic complications from pancreatic necrosis. The recently described 2012 Revised Atlanta Classification and the Determinant Classification both provide a more accurate description of edematous and necrotizing pancreatitis and local complications. The 2012 Revised Atlanta Classification uses the modified Marshall scoring system for assessing organ dysfunction. The Determinant Classification uses the sepsis-related organ failure assessment scoring system for organ dysfunction and, unlike the 2012 Revised Atlanta Classification, includes infected necrosis as a criterion of severity. These scoring systems are used to assess systemic complications requiring intensive therapy unit support and intra-abdominal complications requiring minimally invasive interventions. Numerous prognostic systems and markers have been evaluated but only the Glasgow system and serum CRP levels provide pragmatic prognostic accuracy early on. Novel concepts using genetic, transcriptomic and proteomic profiling and also functional imaging for the identification of specific disease patterns are now required.

[Procalcitonin and C-reactive protein as early indicators of postoperative intra-abdominal infection after surgery for gastrointestinal cancer]

AIM

to evaluate the association between serum levels of procalcitonin and C-reactive protein, on the first 3 postoperative days, and the appearance of postoperative intra-abdominal infection.

METHOD

Prospective observational study including 67 patients operated on for colo-rectal, gastric and pancreatic cancer. Serum levels of procalcitonin and C-reactive protein were analyzed before surgery and daily until the third postoperative day. Values of procalcitonin (PCT) and C-reactive protein (CRP) were recorded as well as their accuracy for detection of postoperative intra-abdominal infection (PIAI).

RESULTS

The incidence of postoperative intra-abdominal infection was 13.4%. CRP serum levels at 72h, PCT serum levels at 24, 48 and 72h and the ratio between serum levels of CRP at 72hours and serum levels of CRP at 48hours (CRP D3/CRP D2) were significantly associated with the appearance of postoperative intra-abdominal infection. The highest sensitivity corresponded to PCT at 72hours (88.9%); the highest specificity and positive predictive value corresponded to the ratio CRP D3/CRP D2 (96.49% and 71.4%, respectively); the highest negative predictive value to procalcitonin at 72h and 24h.

CONCLUSIONS

Serum levels of PCT are significantly associated with the appearance of postoperative intra-abdominal infection. Sensitivity and predictive positive values are low, but negative predictive value is high, even at 24h after surgery.

Procalcitonin as a prognostic biomarker of severe sepsis and septic shock

OBJECTIVE

To evaluate the tendency of the plasma concentration and clearance of procalcitonin (PCT-c) as biomarkers of prognosis of patients with severe sepsis and septic shock, compared to another early prognosis marker, the number of SIRS criteria at sepsis diagnosis.

METHODS

We conducted a prospective, observational, cohort study, with patients with severe sepsis and septic shock. The serum procalcitonin was determined at diagnosis of sepsis and after 24 and 48 hours. Demographic data, APACHE IV, SOFA score on arrival, number of SIRS criteria at diagnosis, site of infection and microbiological results were recorded.

RESULTS

Twenty-eight patients were included, 19 clinical and nine surgical. In 13 (46.4%) the source of sepsis was pulmonary, abdominal in seven (25.0%), urinary in five (17.9%) and soft tissue in three cases (10.7%). Fifteen patients had severe sepsis and 13 septic shock. Overall mortality was 17.9% (five patients), three with septic shock. Twenty-eight PCT determinations were performed at sepsis diagnosis, 27 after 24 hours and 26 after 48 hours. The initial concentration was not significantly different between survivors and non-survivors groups, but the differences between the two groups after 24 and 48 hours were statistically significant. There was no difference in the number of SIRS criteria. The 24-hour procalcitonin clearance proved to be significantly higher in the group of survivors (-3.0 versus -300.0, p = 0.028). Although the 48-hour procalcitonin clearance has shown to be higher in the group of survivors when compared to non-survivors, the difference did not reach statistical significance.

CONCLUSION

Persistently high procalcitonin concentrations in plasma, as well as reduced 24-hours PCT clearence, were associated with a significant increase in mortality in patients with severe sepsis and septic shock.

Procalcitonin in abdominal exudate to predict prolonged postoperative ileus following colorectal carcinoma surgery

BACKGROUND

Prolonged postoperative ileus (PPOI) is a common problem after major abdominal surgery and can cause postoperative morbidity, extended hospitalization, as well as increased health care costs.

AIM

To investigate whether the levels of cytokines from abdominal exudate are predictive for early diagnosis of PPOI after colorectal surgery.

METHODS

One hundred patients who had undergone elective resection for carcinoma of the sigmoid or rectum were recruited. The abdominal exudate was obtained from a drain tube after surgery to examine the levels of C-reactive protein (CRP), procalcitonin (PCT), and tumor necrosis factor alpha (TNF-α). The relationship between cytokine levels on postoperative day 1, 3 and 5 and the occurrence of PPOI was analyzed.

RESULTS

Eight patients developed PPOI, which was diagnosed on postoperative day 10-15. PCT levels on postoperative day 1 and 3 were not significantly different between the 8 patients who developed PPOI and the 92 patients without PPOI. In contrast, PCT levels on day 5 were significantly higher in patients who developed PPOI than in patients without PPOI. The levels of CRP and TNF-α were irregular from day 1 to 5, and were not significantly different.

CONCLUSIONS

Increased PCT levels in abdominal exudate may predict PPOI in the early period following colorectal surgery.

Procalcitonin as a predictive marker for surgical site infection in elective colorectal cancer surgery

PURPOSE

Surgical site infection (SSI) is a frequent complication of elective surgery for colorectal cancer. The classical clinical markers of infection-elevations in white blood cell count, C-reactive protein (CRP) level, and body temperature-do not precisely predict SSI after elective colorectal resection. The objective of this study was to evaluate the efficacy of procalcitonin (PCT) as a tool for diagnosis of SSI in elective surgery for colorectal cancer.

METHODS

A total of 114 consecutive patients undergoing elective colorectal resection for cancer were evaluated. Routine blood samples, for determining PCT level, CRP plasma concentration, and white blood cell count, were obtained on postoperative days (POD) 1 and 3. Predictive values for each of the laboratory markers were examined.

RESULTS

SSI was diagnosed in 18 (15.7 %) of 114 patients. Patients with SSI exhibited significantly higher PCT levels (on PODs 1 and 3) and CRP levels (on POD 3) than did patients without SSI. According to receiver operating characteristic analysis, PCT showed the highest area under the curve (AUC) for predicting SSI on both PODs 1 and 3 (AUC, 0.76 and 0.77, respectively). Multivariate logistic regression analysis showed that PCT (on PODs 1 and 3) was an independent predictor for SSI (odds ratio = 14.41 and 9.79, respectively).

CONCLUSION

Serum PCT is more reliable laboratory marker for the early diagnosis of SSI after elective colorectal cancer surgery, compared with conventional inflammatory indicators. PCT could serve as an additional diagnostic tool for the early identification of SSI to improve clinical decision making.

Pancreatic stone protein predicts outcome in patients with peritonitis in the ICU

OBJECTIVE

To determine the value of pancreatic stone protein in predicting sepsis-related postoperative complications and death in the ICU.

DESIGN

A prospective cohort study of postoperative patients admitted to the ICU. Blood samples for analysis were taken within 3 hours from admission to the ICU including pancreatic stone protein, white blood cell counts, C-reactive protein, interleukin-6, and procalcitonin. The Mannheim Peritonitis Index and Acute Physiology and Chronic Health Evaluation II clinical scores were also determined. Univariate and multivariate analyses were performed to determine the diagnostic accuracy and independent predictors of death in the ICU [Clinicaltrials.gov, NCT01465711].

SETTING

An adult medical-surgical ICU in a teaching hospital in Germany.

PATIENTS

Ninety-one consecutive postoperative patients with proven diagnosis of secondary peritonitis admitted to the ICU were included in the study from August 17, 2007, to February 8, 2010.

INTERVENTIONS

Peripheral vein blood sampling.

MEASUREMENTS AND MAIN RESULTS

Univariate analysis demonstrated that pancreatic stone protein has the highest diagnostic accuracy for complications and is the best predictor for death in the ICU. Pancreatic stone protein had the highest overall efficacy in predicting death with an odds ratio of 4.0 vs. procalcitonin (odds ratio 3.2), interleukin-6 (odds ratio 2.8), C-reactive protein (odds ratio 1.3), and WBCs (odds ratio 1.4). By multivariate analysis, pancreatic stone protein was the only independent predictor of death.

CONCLUSIONS

In a population of patients with sepsis-related complications, serum-pancreatic stone protein levels demonstrate a high diagnostic accuracy to discriminate the severity of peritonitis and to predict death in the ICU. This test could be of value in the clinical diagnosis and therapeutic decision making in the ICU.

Could rising BUN predict the future development of infected pancreatic necrosis?

BACKGROUND

Infected (peri)pancreatic necrosis (IPN) in acute pancreatitis (AP) is associated with organ failure (OF) and high mortality. There are no established early markers of primary IPN. This study aimed to assess the association of simple parameters with primary IPN in AP.

METHODS

We retrospectively studied 281 patients with AP admitted to Mayo Clinic hospitals and identified those with microbiologically confirmed infections in (peri)pancreatic necrosis and collections. We defined primary IPN as infection of (peri)pancreatic necrotic tissue that developed before interventions. We recorded admission hematocrit, BMI, BUN, serum creatinine, SIRS score and development of persistent organ failure within 48 h of admission; and performed serial SIRS and BUN calculations for at least 48 h. We used univariate and multivariable analysis to assess associations and expressed results as odds ratio (OR)[95% CI].

RESULTS

27 (9.6%) patients developed IPN, of which 21 (77.7%) had primary IPN. 38.1% had Gram positive, 9.5% Gram negative and 52.3% mixed bacterial infections. Five (23.8%) of the patients with IPN had fungal infection. On univariate analysis, SIRS ≥ 2 at admission, rise in BUN by 5 mg/dL within 48 h of admission, persistence of SIRS for 48 h and development of persistent OF within 48 h of disease had significant association with development of primary IPN with OR (95% CI) of 4.12 (1.53-11.15), 10.25 (3.95-26.61), 1.19 (1.69-10.39) and 7.62 (2.58-21.25) [2-tailed p = 0.004, <0.0001, 0.002 and <0.0001] respectively. On multivariable analysis, only rise in BUN by 5 mg/dL within 48 h of admission was associated with primary IPN (p = 0.007).

CONCLUSIONS

Rising BUN within 48 h of admission can be used to predict development of primary IPN in AP.

Scoring of human acute pancreatitis: state of the art

BACKGROUND

Acute pancreatitis remains as one of the most difficult and challenging digestive disorder to predict in terms of clinical course and outcome. Every case has an individual course and therefore acute pancreatitis remains challenging and fascinating. Due to this variability, many different scoring systems have evolved during the last decades. Every scoring system has advantages and disadvantages. Not every scoring system is capable of assessing the clinical time course of the disease, some are only suitable for the time of initial presentation.

AIM

This paper will give an overview on the development of different widely used scoring systems and their performance in assessing severity and prognosis of acute pancreatitis.

CONCLUSION

Severity assessment means objective quantification of overall severity of illness. Early and reliable stratification of severity is required to decide best treatment of the individual patient, preparation for possible evolving complications or for referral to specialist centers. No single scoring system is able to cover the entire range of problems associated with treatment and assessment of acute pancreatitis. In our clinical experience, we recommend hematocrit upon admission, daily sequential organ failure assessment score and procalcitonin, C-reactive protein on day 3 and CT severity index beyond the first week. These scoring tools together with close clinical follow-up of the patient ultimately lead to an optimized treatment of this challenging disease.

Predictors of adverse outcomes in acute pancreatitis: new horizons

Acute pancreatitis (AP) continues to be a clinical challenge. The mortality of patients with AP with adverse outcomes like organ failure and infected necrosis can be as high as 43 %. Highly accurate predictors of adverse outcomes are necessary to identify the high-risk patients so that they can be meticulously monitored and managed. However, there are no ideal predictors till date. Over the past several years, a number of single- and multi-parameter predictors have been identified and tested for prediction of adverse outcomes in AP. Out of the different tools tested, blood urea nitrogen and the harmless acute pancreatitis score appears to be useful and feasible in the management of AP under Indian conditions. Other single-parameter predictors like serum creatinine, hematocrit, erythrocyte sedimentation rate, C-reactive protein, and D-dimer need to be put to further tests in high-quality prospective studies with large sample size at the community level. Multi-parameter prediction tools like the bedside index of severity of acute pancreatitis may not be appealing in day-to-day clinical practice.

Procalcitonin and C-reactive protein as early predictors of anastomotic leak in colorectal surgery: a prospective observational study

BACKGROUND

Although the early diagnosis of anastomotic leak is a key point in reducing its clinical consequences, in daily practice, anastomotic leak diagnosis is often late.

OBJECTIVE

The aim of this study was to determine whether procalcitonin and C-reactive protein are good predictors of anastomotic leak in colorectal surgery.

DESIGN

This is a prospective observational study.

SETTINGS

This study was conducted by a specialized colorectal multidisciplinary team of a tertiary teaching hospital.

PATIENTS

A series of 205 consecutive patients who underwent elective colorectal surgery in a specialized unit was prospectively analyzed. The following data were collected: demographic, surgical, ASA class, POSSUM, and morbidity. During the first 5 postoperative days, procalcitonin, C-reactive protein, leukocytes, platelets, and vital signs were evaluated daily.

INTERVENTIONS

Daily assessment of clinical variable and serological data were conducted in the first 5 postoperative days.

MAIN OUTCOME MEASURES

The primary outcome measure was the area under the curve at receiving operating characteristic curve analysis of the different variables in relation to the anastomotic leak.

RESULTS

Anastomotic leak was detected in 17 (8.3%) patients; 11(5.4%) of the patients had a major anastomotic leak (need for drainage or reoperation). None of the variables evaluated were shown to be reliable in the early detection of anastomotic leak, considering both minor and major (maximum area under the curve <0.80). In contrast, when considering only major anastomotic leaks, procalcitonin and C-reactive protein were reliable predictors on postoperative days 3 to 5 (p < 0.0001, area under the curve >0.80). The best combination was procalcitonin at postoperative day 5 (area under the curve = 0.86), with a cutoff of 0.31 ng/mL, resulting in a 100% sensitivity, 72% specificity, 100% negative predictive value, and 17% positive predictive value.

LIMITATIONS

Only symptomatic patients were investigated to rule out anastomotic leakage.

CONCLUSIONS

Procalcitonin and C-reactive protein are both reliable predictors of major anastomotic leak after colorectal resection, although procalcitonin is more accurate. Raised procalcitonin and C-reactive protein serum concentration on postoperative days 3 to 5 renders necessary a careful evaluation of the patient before discharge.

Increased admission serum estradiol level is correlated with high mortality in patients with severe acute pancreatitis

BACKGROUND

Sexual dimorphism in critical diseases has been documented. Severe acute pancreatitis is a disease with high mortality. We hypothesized that admission sex hormone levels may be used as an early predictor of outcome in these patients.

METHODS

A prospective cohort of patients with severe acute pancreatitis admitted to the intensive care unit for at least 48 h were enrolled (n = 62). Serum levels of estradiol, progesterone, and testosterone were determined on admission. The association of sex hormone levels and various disease severity scoring systems with patient outcome was analyzed.

RESULTS

There was no difference in overall mortality between the sexes. However, estradiol was significantly elevated in nonsurvivors (39 vs. 206 pg/mL, p < 0.001). The estradiol level was the best single-variable predictor of mortality (area under the curve 0.97), followed by the sequential organ failure assessment score, the multiple organ dysfunction score, and the acute physiology and chronic health care evaluation II (APACHE II) score. A serum estradiol level of 102 pg/mL was both sensitive and specific to predict mortality. There were no differences between survivors and non-survivors in terms of age, body mass index, or progesterone and testosterone levels.

CONCLUSIONS

Admission serum estradiol level is a good marker of disease severity and predictor of death in patients with severe acute pancreatitis.

Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation

OBJECTIVE

To develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation.

BACKGROUND

The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric description of occurrences that are merely associated with severity.

METHODS

A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions.

RESULT

The new international classification is based on the actual local and systemic determinants of severity, rather than description of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity-mild, moderate, severe, and critical.

CONCLUSIONS

This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

Role of early systemic inflammatory response in simultaneous pancreas-kidney transplantation

Pancreas grafts are susceptible to surgical complications mostly related to exocrine secretions and the low microcirculatory blood flow through the gland. During simultaneous kidney-pancreas transplantation, the systemic response depends on reperfusion of two organs acute graft pancreatitis, immunotherapy, coagulopathy, bleeding, and other factors. We performed a retrospective review of 10 adult simultaneous pancreas-kidney transplant patients to evaluate progression of early postoperative inflammation in the absence of infection. All patients were treated with four-drug therapy. We performed analyses of procalcitonin (PCT), C-reactive protein, serum creatinine, amylase, and lipase levels over the first 5 postoperative days. Relatively high peak PCT levels (maximum 130 ng/mL) were reached within 24 to 48 hours postoperatively followed by a moderate decrease. Consistent with this observation, the serum creatinine, amylase, and lipase levels decreased continuously to normal concentrations within the first week. The increased PCT levels seemed depend upon the surgical procedure and intraoperative events. PCT was superior to C-reactive protein to discriminate infection from inflammation in this setting. The dynamics of PCT levels, rather than absolute values, seemed to be important. Lack of a decrease in PCT levels after the peak, suggested an infectious complication or the development of sepsis. Monitoring and assessment of PCT levels may help in early recognition of infection and institution of therapy.

Correlation between procalcitonin and intra-abdominal pressure and their role in prediction of the severity of acute pancreatitis

BACKGROUND/AIMS

Early assessment of disease severity and vigilant patient monitoring are key factors for adequate treatment of acute pancreatitis (AP). The aim of this study was to determine the correlation of procalcitonin (PCT) serum concentrations and intra-abdominal pressure (IAP) as prognostic markers in early stages of AP.

METHODS

This prospective observational study included 51 patients, of which 29 had severe AP (SAP). Patients were evaluated with the Acute Physiology And Chronic Health Evaluation (APACHE II) score, C-reactive protein (CRP) and PCT serum concentrations and IAP at 24 h from admission. PCT was measured three times in the 1st week of disease and three times afterward, while IAP was measured daily. PCT and IAP values correlated with each other, and also compared with APACHE II score and CRP values.

RESULTS

PCT, IAP, CRP values and APACHE II score at 24 h after hospital admission were significantly elevated in patients with SAP. There was significant correlation between PCT and IAP values measured at 24 h of admission, and between maximal PCT and IAP values. Sensitivity/specificity for predicting AP severity at 24 h after admission was 89%/69% for APACHE II score, 75%/86% for CRP, 86%/63% for PCT and 75%/77% for IAP.

CONCLUSIONS

Increased IAP was accompanied by increased PCT serum concentration in patients with AP. PCT and IAP can both be used as early markers of AP severity.

Differential roles of inflammatory cells in pancreatitis

The incidence of acute pancreatitis per 100,000 of population ranges from 5 to 80. Patients suffering from hemorrhagic-necrotizing pancreatitis die in 10-24% of cases. 80% of all cases of acute pancreatitis are etiologically linked to gallstone disease immoderate alcohol consumption. As of today no specific causal treatment for acute pancreatitis exists. Elevated C-reactive protein levels above 130,mg/L can also predict a severe course of acute pancreatitis. The essential medical treatment for acute pancreatitis is the correction of hypovolemia. Prophylactic antibiotics should be restricted to patients with necrotizing pancreatitis, infected necrosis or other infectious complications. However, as premature intracellular protease activation is known to be the primary event in acute pancreatitis. Severe acute pancreatitis is characterized by an early inflammatory immune response syndrome (SIRS) and a subsequent compensatory anti-inflammatory response syndrome (CARS) contributing to severity as much as protease activation does. CARS suppresses the immune system and facilitates nosocomial infections including infected pancreatic necrosis, one of the most feared complications of the disease. A number of attempts have been made to suppress the early systemic inflammatory response but even if these mechanisms have been found to be beneficial in animal models they failed in daily clinical practice.

Comparison of serum procalcitonin with Ranson, APACHE-II, Glasgow and Balthazar CT severity index scores in predicting severity of acute pancreatitis

BACKGROUND/AIMS

The aim of this study is to assess serum procalcitonin (PCT) for early prediction of severe acute pancreatitis compared with multiple scoring systems and biomarkers.

METHODS

Forty-four patients with acute pancreatitis confirmed by radiological evidences, laboratory assessments, and clinical manifestation were prospectively enrolled. All blood samples and image studies were obtained within 24 hours of admission.

RESULTS

Acute pancreatitis was graded as severe in 19 patients and mild in 25 patients according to the Atlanta criteria. Levels of serum PCT were significantly higher in severe acute pancreatitis (p=0.001). The accuracy of serum PCT as a predicting marker was 77.3%, which was similar to the acute physiology and chronic health examination (APACHE)-II score, worse than the Ranson score (93.2%) and better than the Balthazar CT index (65.9%). The most effective cut-off level of serum PCT was estimated at 1.77 ng/mL (AUC=0.797, 95% CI=0.658-0.935). In comparision to other simple biomarkers, serum PCT had more accurate value (77.3%) than C-reactive protein (68.2%), urea (75.0%) and lactic dehydrogenase (72.7%). Logistic regression analysis revealed that serum PCT has statistical significance in acute severe pancreatitis. Assessment of serum PCT levels and length of hospital stay by simple linear regression analysis revealed effective p-value with low R square level, which could make only possibilty for affection of serum PCT to admission duration (r2=0.127, p=0.021).

CONCLUSIONS

Serum PCT was a promising simple biomarker and had similar accuracy of APACHE-II scores as predicting severity of acute pancreatitis.