Predictors of severe and critical acute pancreatitis: a systematic review

Construction and validation of a nomogram for predicting survival in elderly patients with severe acute pancreatitis: a retrospective study from a tertiary center

PURPOSE

There is a lack of adequate models specifically designed for elderly patients with severe acute pancreatitis (SAP) to predict the risk of death. This study aimed to develop a nomogram for predicting the overall survival of SAP in elderly patients.

METHODS

Elderly patients diagnosed with SAP between January 1, 2017 and December 31, 2022 were included in the study. Risk factors were identified through least absolute shrinkage and selection operator regression analysis. Subsequently, a novel nomogram model was developed using multivariable logistic regression analysis. The predictive performance of the nomogram was evaluated using metrics such as the receiver operating characteristic curve, calibration curve, and decision curve analysis (DCA).

RESULTS

A total of 326 patients were included in the analysis, with 260 in the survival group and 66 in the deceased group. Multivariate logistic regression indicated that age, respiratory rate, arterial pH, total bilirubin, and calcium were independent prognostic factors for the survival of SAP patients. The nomogram demonstrated a performance comparable to sequential organ failure assessment (P = 0.065). Additionally, the calibration curve showed satisfactory predictive accuracy, and the DCA highlighted the clinical application value of the nomogram.

CONCLUSION

We have identified key demographic and laboratory parameters that are associated with the survival of elderly patients with SAP. These parameters have been utilized to create a precise and user-friendly nomogram, which could be an effective and valuable clinical tool for clinicians.

Comparison of Bedside Index for Severity in Acute Pancreatitis and Emergency Department SpO2, Age and Systemic Inflammatory Response Syndrome Scores in Predicting Severe Acute Pancreatitis in Patients with Acute Pancreatitis in the Emergency Department

BACKGROUND

As the mortality of severe acute pancreatitis (SAP) is significantly higher than those with mild or moderate severity, it is of clinical significance to identify patients most likely to develop SAP at the time of emergency department (ED) presentation.

OBJECTIVES

The aim of this study was to compare the performance of the Bedside Index for Severity in Acute Pancreatitis (BISAP) and the Emergency Department SpO2, Age and SIRS (ED-SAS) scoring systems as early risk assessment tools for identifying patients at high-risk of developing SAP.

METHODS

We retrospectively reviewed adult patients with AP presented to ED between January 2019-September 2022. We calculated the scores of each patient with the parameters of the initial data. The primary outcome was SAP. The secondary outcomes were 30-day mortality, intensive care admission, and identifying low-risk patients without complications.

RESULTS

Of 415 patients, 34 (8.2%) developed SAP and 15 (3.6%) died. With regard to predicting SAP, BISAP and ED-SAS scores had similar discriminative ability with area under the curves (AUCs) of 0.84 (95% confidence interval [CI]:0.80-0.88) and 0.83 (95% CI:0.79-0.86), respectively (p = 0.642). At a cut-off score of ≥2 for SAP, sensitivity/specificity values were 73.5%/82.4% for BISAP, 76.5%/83.2% for ED-SAS. BISAP and ED-SAS scores of ≥3, yielded sensitivity/specificity values of 50%/95.8% and 35.3%/95.5%, respectively. BISAP and ED-SAS were also similar in predicting mortality (AUCs of 0.92 vs. 0.90, respectively) and intensive care unit admission (AUCs 0.91 vs. 0.91).

CONCLUSION

The BISAP and ED-SAS scores performed similarly in predicting SAP, mortality, and intensive care unit admission. As an easily calculated tool early in the ED, ED-SAS may be helpful in disposition decisions for emergency physicians.

Predicting in-hospital mortality in patients with acute pancreatitis in the ED: a direct, retrospective comparison of four clinical and radiological prognostic scores

BACKGROUND

Acute pancreatitis can be a severe disease that significantly impacts patients' quality of life and outcome. The clinical course is variable and predictive scoring systems have a debated role in early prognosis. This study aims to compare the prognostic accuracy of Balthazar, BISAP, HAPS and SOFA scores in the prediction of in-hospital mortality in patients with acute pancreatitis.

METHODS

This is a retrospective, single-center cohort study conducted in the Emergency Department of a third-level university hospital. Patients aged >18 years admitted from 1st January 2018 to 31st December 2021 for the first episode of acute pancreatitis were included.

RESULTS

A total of 385 patients (mean age of 65.4 years and 1.8% in-hospital mortality) were studied. Balthazar, BISAP and SOFA scores were significantly higher in patients with in-hospital mortality and AUROCs were equal to 0.95 (95% CI 0.91-0.99, P<0.001), 0.96 (95% CI 0.89-1, P=0.001), 0.91 (95% CI 0.81-1, P=0.001) with no differences among them and absence of in-hospital mortality in patients with HAPS=0.

CONCLUSIONS

Our data support the concept that clinical prediction scores can be useful for risk stratification in the Emergency Department. However, no single score has shown superiority in predicting acute pancreatitis-related in-hospital mortality among tested tools.

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.

Prediction and evaluation of a nomogram model for recurrent acute pancreatitis

OBJECTIVE

The purpose of this study was to investigate the influencing factors for recurrent acute pancreatitis and construct the nomogram model to predict the risk of recurrent acute pancreatitis.

METHODS

Patients diagnosed with acute pancreatitis in the Affiliated Hospital of Southwest Medical University were enrolled. We collected these patients' basic information, laboratory data, imaging information. Using Logistic regression and least absolute shrinkage and selection operator regression to select risk factor for Cross-Validation Criterion. To create nomogram and validated by receiver operator characteristic curve, calibration curves and decision curve analysis.

RESULTS

A total of 533 patients with acute pancreatitis were included, including 99 recurrent acute pancreatitis patients. The average age of recurrent acute pancreatitis patients was 49.69 years old, and 67.7% of them were male. At the same time, in all recurrent acute pancreatitis patients, hypertriglyceridemic pancreatitis is the most important reason (54.5%). Regression analysis and least absolute shrinkage and selection operator regression showed that smoking history, acute necrotic collection, triglyceride, and alcohol etiology for acute pancreatitis were identified and entered into the nomogram. The area under the receiver operator characteristic curve of the training set was 0.747. The calibration curve showed the consistency between the nomogram model and the actual probability.

CONCLUSION

In conclusion, some high-risk factors like smoking history, acute necrotic collection, triglyceride, and alcohol etiology for acute pancreatitis may predict recurrent pancreatitis and their incorporation into a nomogram has high accuracy in predicting recurrence.

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.

American College of Gastroenterology Guidelines: Management of Acute Pancreatitis

Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.

Early Predictive Value of Different Indicators for Persistent Organ Failure in Acute Pancreatitis: A Systematic Review and Network Meta-Analysis

GOALS

In this study, we conducted this network meta-analysis (based on the ANOVA model) to evaluate the predictive efficacy of each early predictor.

BACKGROUND

Persistent organ failure (POF) is one of the determining factors in patients with acute pancreatitis (AP); however, the diagnosis of POF has a long-time lag (>48 h). It is of great clinical significance for the early noninvasive prediction of POF.

STUDY

We conducted a comprehensive and systematic search in PubMed, Cochrane library, Embase, and Web of Science to identify relevant clinical trials, case-control studies, or cohort studies, extracted the early indicators of POF in studies, and summarized the predictive efficacy of each indicator through network meta-analysis. The diagnostic odds ratio (DOR) was used to rank the prediction efficiency of each indicator.

RESULTS

We identified 23 studies in this network meta-analysis, including 10,393 patients with AP, of which 2014 patients had POF. A total of 10 early prediction indicators were extracted. The mean and 95% CI lower limit of each predictive indicator were greater than 1.0. Albumin had the largest diagnostic odds ratio, followed by high-density lipoprotein-cholesterol (HDL-C), Ranson Score, beside index for severity in acute pancreatitis Score, acute physiology and chronic health evaluation II, C-reactive protein (CRP), Interleukin 6 (IL-6), Interleukin 8 (IL-8), Systemic Inflammatory Response Syndrome (SIRS) and blood urea nitrogen.

CONCLUSIONS

Albumin, high-density lipoprotein-cholesterol, Ranson Score, and beside index for severity in acute pancreatitis Score are effective in the early prediction of POF in patients with AP, which can provide evidence for developing effective prediction systems. However, due to the limitations of the extraction method of predictive indicators in this study, some effective indicators may not be included in this meta-analysis.

The red cell distribution width-to-albumin ratio: A simple index has high predictive accuracy for clinical outcomes in patients with acute pancreatitis

BACKGROUND/OBJECTIVES

Ongoing research is seeking to identify the best prognostic marker for acute pancreatitis (AP). The purpose of this study was to investigate the role of the red blood cell distribution width-to-albumin ratio (RAR) in the prognosis of AP.

METHODS

This 18-month prospective cohort study was conducted between June 2021 and December 2022 with patients diagnosed with AP. The patients were divided into two groups: severe AP (SAP) and non-severe AP. Factors associated with SAP within the first 48 h of admission were determined. In addition, RAR values at admission and at 48 h (RAR-48th) were calculated, and their ability to predict clinical outcomes was assessed. The primary outcomes were severe disease and in-hospital mortality.

RESULTS

Fifty (13.7 %) of 365 patients had SAP. Systemic inflammatory response syndrome, blood urea nitrogen, calcium, and RAR at 48 h after admission were independent predictors of SAP. When RAR-48th was >4.35, the risk of SAP increased approximately 18-fold (OR: 18.59; 95 % CI: 8.58-40.27), whereas no patients with a RAR-48th value of <4.6 died. For in-hospital mortality, the area under the curve (AUC) value of RAR-48th was 0.960 (95 % CI: 0.931-0.989), significantly higher than the AUC values of existing scoring systems. The results of RAR-48th were comparable to those of the other scoring systems with regard to the remaining clinical outcomes.

CONCLUSIONS

RAR-48th successfully predicted clinical outcomes, particularly in-hospital mortality. Being simple and readily calculable, RAR-48th is a promising alternative to burdensome and complex scoring systems for the prediction of clinical outcomes in AP.

Milk fat globule epidermal growth factor 8 alleviates liver injury in severe acute pancreatitis by restoring autophagy flux and inhibiting ferroptosis in hepatocytes

BACKGROUND

Liver injury is common in severe acute pancreatitis (SAP). Excessive autophagy often leads to an imbalance of homeostasis in hepatocytes, which induces lipid peroxidation and mitochondrial iron deposition and ultimately leads to ferroptosis. Our previous study found that milk fat globule epidermal growth factor 8 (MFG-E8) alleviates acinar cell damage during SAP via binding to αvβ3/5 integrins. MFG-E8 also seems to mitigate pancreatic fibrosis via inhibiting chaperone-mediated autophagy.

AIM

To speculate whether MFG-E8 could also alleviate SAP induced liver injury by restoring the abnormal autophagy flux.

METHODS

SAP was induced in mice by 2 hly intraperitoneal injections of 4.0 g/kg L-arginine or 7 hly injections of 50 μg/kg cerulein plus lipopolysaccharide. mfge8-knockout mice were used to study the effect of MFG-E8 deficiency on SAP-induced liver injury. Cilengitide, a specific αvβ3/5 integrin inhibitor, was used to investigate the possible mechanism of MFG-E8.

RESULTS

The results showed that MFG-E8 deficiency aggravated SAP-induced liver injury in mice, enhanced autophagy flux in hepatocyte, and worsened the degree of ferroptosis. Exogenous MFG-E8 reduced SAP-induced liver injury in a dose-dependent manner. Mechanistically, MFG-E8 mitigated excessive autophagy and inhibited ferroptosis in liver cells. Cilengitide abolished MFG-E8’s beneficial effects in SAP-induced liver injury.

CONCLUSION

MFG-E8 acts as an endogenous protective mediator in SAP-induced liver injury. MFG-E8 alleviates the excessive autophagy and inhibits ferroptosis in hepatocytes by binding to integrin αVβ3/5.

Persistently High Procalcitonin and C-Reactive Protein Are Good Predictors of Infection in Acute Necrotizing Pancreatitis: A Systematic Review and Meta-Analysis

Infected necrotizing pancreatitis (INP) is associated with an increased risk of organ failure and mortality. Its early recognition and timely initiation of antibiotic therapy can save patients' lives. We systematically searched three databases on 27 October 2022. In the eligible studies, the presence of infection in necrotizing pancreatitis was confirmed via a reference test, which involved either the identification of gas within the necrotic collection through computed tomography imaging or the examination of collected samples, which yielded positive results in Gram staining or culture. Laboratory biomarkers compared between sterile necrotizing pancreatitis and INP were used as the index test, and our outcome measures included sensitivity, specificity, the receiver operating characteristic (ROC) curve and area under the ROC curve (AUC). Within the first 72 hours (h) after admission, the AUC of C-reactive protein (CRP) was 0.69 (confidence interval (CI): 0.62-0.76), for procalcitonin (PCT), it was 0.69 (CI: 0.60-0.78), and for white blood cell count, it was 0.61 (CI: 0.47-0.75). After the first 72 h, the pooled AUC of CRP showed an elevated level of 0.88 (CI: 0.75-1.00), and for PCT, it was 0.86 (CI: 0.60-1.11). The predictive value of CRP and PCT for infection is poor within 72 h after hospital admission but seems good after the first 72 h. Based on these results, infection is likely in case of persistently high CRP and PCT, and antibiotic initiation may be recommended.

Epidemiology and risk factors for mortality in critically ill patients with pancreatic infection

Background

The AbSeS-classification defines specific phenotypes of patients with intra-abdominal infection based on the (1) setting of infection onset (community-acquired, early onset, or late-onset hospital-acquired), (2) presence or absence of either localized or diffuse peritonitis, and (3) severity of disease expression (infection, sepsis, or septic shock). This classification system demonstrated reliable risk stratification in intensive care unit (ICU) patients with intra-abdominal infection. This study aimed to describe the epidemiology of ICU patients with pancreatic infection and assess the relationship between the components of the AbSeS-classification and mortality.

Methods

This was a secondary analysis of an international observational study ("AbSeS") investigating ICU patients with intra-abdominal infection. Only patients with pancreatic infection were included in this analysis (n=165). Mortality was defined as ICU mortality within 28 days of observation for patients discharged earlier from the ICU. Relationships with mortality were assessed using logistic regression analysis and reported as odds ratio (OR) and 95% confidence interval (CI).

Results

The overall mortality was 35.2% (n=58). The independent risk factors for mortality included older age (OR=1.03, 95% CI: 1.0 to 1.1 P=0.023), localized peritonitis (OR=4.4, 95% CI: 1.4 to 13.9 P=0.011), and persistent signs of inflammation at day 7 (OR=9.5, 95% CI: 3.8 to 23.9, P<0.001) or after the implementation of additional source control interventions within the first week (OR=4.0, 95% CI: 1.3 to 12.2, P=0.013). Gram-negative bacteria were most frequently isolated (n=58, 49.2%) without clinically relevant differences in microbial etiology between survivors and non-survivors.

Conclusions

In pancreatic infection, a challenging source/damage control and ongoing pancreatic inflammation appear to be the strongest contributors to an unfavorable short-term outcome. In this limited series, essentials of the AbSeS-classification, such as the setting of infection onset, diffuse peritonitis, and severity of disease expression, were not associated with an increased mortality risk.ClinicalTrials.gov number: NCT03270345.

Severe Acute Pancreatitis Prediction: A Model Derived From a Prospective Registry Cohort

Background Severe acute pancreatitis (SAP) has a mortality rate as high as 40%. Early identification of SAP is required to appropriately triage and direct initial therapies. The purpose of this study was to develop a prognostic model that identifies patients at risk for developing SAP of patients managed according to a guideline-based standardized early medical management (EMM) protocol. Methods This single-center study included all patients diagnosed with acute pancreatitis (AP) and managed with the EMM protocol Methodist Acute Pancreatitis Protocol (MAPP) between April 2017 and September 2022. Classification and regression tree (CART®; Professional Extended Edition, version 8.0; Salford Systems, San Diego, CA), univariate, and logistic regression analyses were performed to develop a scoring system for AP severity prediction. The accuracy of the scoring system was measured by the area under the receiver operating characteristic curve. Results A total of 516 patients with mild (n=436) or moderately severe and severe (n=80) AP were analyzed. CART analysis identified the cutoff values: creatinine (CR) (1.15 mg/dL), white blood cells (WBC) (10.5 × 109/L), procalcitonin (PCT) (0.155 ng/mL), and systemic inflammatory response system (SIRS). The prediction model was built with a multivariable logistic regression analysis, which identified CR, WBC, PCT, and SIRS as the main predictors of severity. When CR and only one other predictor value (WBC, PCT, or SIRS) met thresholds, then the probability of predicting SAP was >30%. The probability of predicting SAP was 72% (95%CI: 0.59-0.82) if all four of the main predictors were greater than the cutoff values. Conclusions Baseline laboratory cutoff values were identified and a logistic regression-based prognostic model was developed to identify patients treated with a standardized EMM who were at risk for SAP.

Management of Intra-Abdominal Infections: The Role of Procalcitonin

Patients with intra-abdominal sepsis suffer from significant mortality and morbidity. The main pillars of treatment for intra-abdominal infections are (1) source control and (2) early delivery of antibiotics. Antibiotic therapy should be started as soon as possible. However, the duration of antibiotics remains a matter of debate. Prolonged antibiotic delivery can lead to increased microbial resistance and the development of nosocomial infections. There has been much research on biomarkers and their ability to aid the decision on when to stop antibiotics. Some of these biomarkers include interleukins, C-reactive protein (CRP) and procalcitonin (PCT). PCT's value as a biomarker has been a focus area of research in recent years. Most studies use either a cut-off value of 0.50 ng/mL or an >80% reduction in PCT levels to determine when to stop antibiotics. This paper performs a literature review and provides a synthesized up-to-date global overview on the value of PCT in managing intra-abdominal infections.

Glucocorticoid Treatment in Acute Respiratory Distress Syndrome: An Overview on Mechanistic Insights and Clinical Benefit

Acute lung injury/acute respiratory distress syndrome (ALI/ARDS), triggered by various pathogenic factors inside and outside the lungs, leads to diffuse lung injury and can result in respiratory failure and death, which are typical clinical critical emergencies. Severe acute pancreatitis (SAP), which has a poor clinical prognosis, is one of the most common diseases that induces ARDS. When SAP causes the body to produce a storm of inflammatory factors and even causes sepsis, clinicians will face a two-way choice between anti-inflammatory and anti-infection objectives while considering the damaged intestinal barrier and respiratory failure, which undoubtedly increases the difficulty of the diagnosis and treatment of SAP-ALI/ARDS. For a long time, many studies have been devoted to applying glucocorticoids (GCs) to control the inflammatory response and prevent and treat sepsis and ALI/ARDS. However, the specific mechanism is not precise, the clinical efficacy is uneven, and the corresponding side effects are endless. This review discusses the mechanism of action, current clinical application status, effectiveness assessment, and side effects of GCs in the treatment of ALI/ARDS (especially the subtype caused by SAP).

A modified Ranson score to predict disease severity, organ failure, pancreatic necrosis, and pancreatic infection in patients with acute pancreatitis

Background

Although there are several scoring systems currently used to predict the severity of acute pancreatitis, each of them has limitations. Determine the accuracy of a modified Ranson score in predicting disease severity and prognosis in patients with acute pancreatitis (AP).

Methods

AP patients admitted or transferred to our institution were allocated to a modeling group (n = 304) or a validation group (n = 192). A modified Ranson score was determined by excluding the fluid sequestration parameter and including the modified computed tomography severity index (CTSI). The diagnostic performance of the modified Ranson score was compared with the Ranson score, modified CTSI, and bedside index of severity in acute pancreatitis (BISAP) score in predicting disease severity, organ failure, pancreatic necrosis and pancreatic infection.

Results

The modified Ranson score had significantly better accuracy that the Ranson score in predicting all four outcome measures in the modeling group and in the validation group (all p < 0.05). For the modeling group the modified Ranson score had the best accuracy for predicting disease severity and organ failure, and second-best accuracy for predicting pancreatic necrosis and pancreatic infection. For the verification group, it had the best accuracy for predicting organ failure, second-best accuracy for predicting disease severity and pancreatic necrosis, and third-best accuracy for predicting pancreatic infection.

Conclusion

The modified Ranson score provided better accuracy than the Ranson score in predicting disease severity, organ failure, pancreatic necrosis and pancreatic infection. Relative to the other scoring systems, the modified Ranson system was superior in predicting organ failure.

Comparing Prognostic Scores and Inflammatory Markers in Predicting the Severity and Mortality of Acute Pancreatitis

BACKGROUND

Acute pancreatitis is an emergency gastrointestinal condition for which severity prediction is crucial during hospitalization. This study aimed to compare the diagnostic accuracy of inflammatory markers with gold standard scoring systems in predicting pancreatitis severity.

MATERIALS AND METHODS

A prospective, hospital-based, cohort study was conducted, including 249 patients diagnosed with acute pancreatitis via clinical examination. Laboratory investigations and radiological investigations were conducted. The diagnostic accuracy of the inflammatory markers neutrophil/lymphocyte ratio (NLR), lymphocyte/monocyte ratio (LMR), red cell distribution width (RDW), and prognostic nutritional index (PNI) was compared with gold standard prognostic scores, namely, the Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), Bedside Index of Severity in Acute Pancreatitis (BISAP), and Systemic Inflammatory Response Syndrome (SIRS), in predicting primary and secondary outcomes. All values were analyzed using mean and standard deviation (SD). Sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve for mortality prediction were calculated for NLR, LMR, RDW, and PNI.

RESULTS

Of 249 patients with acute pancreatitis (mean age: 39-43 years), 94 were classified as mild acute, 74 as moderately severe acute, and 81 as severe acute. The most common etiology was alcohol use (40.2%), followed by gallstones (29.7%), hypertriglyceridemia (6.4%), steroid use (4%), diabetic ketoacidosis (2.8%), hypercalcemia (2.8%), and complication of endoscopic retrograde cholangiopancreatography (2%). On day 1, mean values of NLR, LMR, RDW, and PNI were 8.23±5.11, 2.63±1.76, 15.93±3.64, and 32.84±8.13, respectively. Compared to APACHE II, SAPS II, BISAP, and SIRS on day 1, day 3, day 7, and day 14, the cutoff values for NLR were 4.06, 10.75, 8.75, and 13.75, respectively. Similarly, on day 1, the cutoff value of LMR was 1.95, and on day 1 and day 3, the cutoff values of RDW were 14.75% and 15%, respectively.

CONCLUSION

The results indicate that inflammatory biomarkers NLR, LMR, RDW, and PNI are comparable with gold standard scoring systems for predicting the severity and mortality of acute pancreatitis. NLR on day 7 was significantly associated with higher severity of illness. NLR on days 3, 7, and 14, LMR on day 1, and RDW on days 1 and 3 were significantly associated with mortality.

Predictive Value of Antithrombin III and d -Dimer in the Development of Moderate-To-Severe Acute Pancreatitis : A Prospective, Observational Study (AT-PROPANC)

OBJECTIVES

To analyze if antithrombin III (AT-III) and d -dimer levels at admission and at 24 hours can predict acute pancreatitis (AP) progression to moderately severe AP (MSAP) to severe AP (SAP) and to determine their predictive value on the development of necrosis, infected necrosis, organ failure, and mortality.

METHODS

Prospective observational study conducted in patients with mild AP in 2 tertiary hospitals (2015-2017).

RESULTS

Three hundred forty-six patients with mild AP were included. Forty-four patients (12.7%) evolved to MSAP/SAP. Necrosis was detected in 36 patients (10.4%); in 10 (2.9%), infection was confirmed. Organ failure was recorded in 9 patients (2.6%), all of whom died. Those who progressed to MSAP/SAP showed lower AT-III levels; d -dimer and C-reactive protein (CRP) levels increased. The best individual marker for MSAP/SAP at 24 hours is CRP (area under the curve [AUC], 0.839). Antithrombin III (AUC, 0.641), d -dimer (AUC, 0.783), and creatinine added no benefit compared with CRP alone. Similar results were observed for patients who progressed to necrosis, infected necrosis, and organ failure/death.

CONCLUSION

Low AT-III and high d -dimer plasma levels at 24 hours after admission were significantly associated with MSAP/SAP, although their predictive ability was low. C-reactive protein was the best marker tested.

CLINICAL STUDY IDENTIFIER

ClinicalTrials.gov NCT02373293.

Plasma renalase levels are associated with the development of acute pancreatitis

BACKGROUND/OBJECTIVES

Severe acute pancreatitis is associated with significant morbidity and mortality. Identifying factors that affect the risk of developing severe disease could influence management. Plasma levels of renalase, an anti-inflammatory secretory protein, dramatically decrease in a murine acute pancreatitis model. We assessed this response in hospitalized acute pancreatitis patients to determine if reduced plasma renalase levels occur in humans.

METHODS

Plasma samples were prospectively and sequentially collected from patients hospitalized for acute pancreatitis. Two forms of plasma renalase, native (no acid) and acidified, were measured by ELISA and RNLS levels were compared between healthy controls and patients with mild and severe disease (defined as APACHE-II score ≥7) using nonparametric statistical analysis.

RESULTS

Control (33) and acute pancreatitis (mild, 230 (76.7%) and severe, 70 (23.3%) patients were studied. Acidified RNLS levels were lower in pancreatitis patients: Control: 10.1 μg/ml, Mild 5.1 μg/ml, Severe 6.0 μg/ml; p < 0.001. Native RNLS levels were increased in AP: Control: 0.4 μg/ml, Mild 0.9 μg g/ml, Severe 1.2 μg/ml p < 0.001; those with severe AP trended to have higher native RNLS levels than those with mild disease (p = 0.056). In patients with severe AP, higher APACHE-II scores at 24 h after admission correlated with lower acid-sensitive RNLS levels on admission (r = -0.31, p = 0.023).

CONCLUSION

Low plasma acidified RNLS levels, and increased native RNLS levels are associated with AP. Additional studies should assess the clinical correlation between plasma RNLS levels and AP severity and outcomes.

Prediction of Surgical Treatment in Acute Pancreatitis Using Biochemical and Clinical Parameters

Background

Deep Acute pancreatitis (AP) is an urging cause of hospitalization in the gastroenterology due to different causes and an unpredictable outcome. Known causes are grouped into four main groups: metabolic, mechanical, vascular and infectious.

Objective

To determine the role of certain biochemical or radiological parameters as predictors of an involvement of other organs in AP different pathological staging and the surgical outcome in the treatment of AP.

Methods

Ninety-seven AP patients hospitalized in General Hospital "Prim.dr Abdulah Nakaš" Sarajevo, in a period between 2016 and 2021 for both sexes, were divided according to the etiological factors of AP into four groups: nutritional factors, biliary concernments, alcohol and morphological changes of the pancreas. Beside laboratory tests, the imaging methods of abdomen (transabdominal ultrasound, abdominal computed tomography) used in determining morphological changes in the pancreas and other organs were analyzed in relation to parameters that predict the need for surgical outcomes.

Results

AP etiological factors of patients differ significantly by gender and showed the dominance of dietary factors in female subjects (51%), followed by the presence of concernments in the biliary tract in 36% of cases, and alcohol consumption in male subjects in 28% of cases. The only variable correlated with the indicator of necessity for surgery is the existence of pleural effusion (coefficient of correlation was 0.38; risk ratio was 5.5) resulting that patients with pleural effusion have a 5.5 times higher chance of surgery indication than other patients.

Conclusion

The application of simple parameters such as creatinine value with the values of amylases in serum and urine and the presence of pleural effusion confirmed by radiological imaging of the lungs opens the possibility of a simple and effective selection of patients for surgical treatment with a more severe form of AP.

Deep Learning Models for Severity Prediction of Acute Pancreatitis in the Early Phase From Abdominal Nonenhanced Computed Tomography Images

OBJECTIVES

To develop and validate deep learning (DL) models for predicting the severity of acute pancreatitis (AP) by using abdominal nonenhanced computed tomography (CT) images.

METHODS

The study included 978 AP patients admitted within 72 hours after onset and performed abdominal CT on admission. The image DL model was built by the convolutional neural networks. The combined model was developed by integrating CT images and clinical markers. The performance of the models was evaluated by using the area under the receiver operating characteristic curve.

RESULTS

The clinical, Image DL, and the combined DL models were developed in 783 AP patients and validated in 195 AP patients. The combined models possessed the predictive accuracy of 90.0%, 32.4%, and 74.2% for mild, moderately severe, and severe AP. The combined DL model outperformed clinical and image DL models with 0.820 (95% confidence interval, 0.759-0.871), the sensitivity of 84.76% and the specificity of 66.67% for predicting mild AP and the area under the receiver operating characteristic curve of 0.920 (95% confidence interval, 0.873-0.954), the sensitivity of 90.32%, and the specificity of 82.93% for predicting severe AP.

CONCLUSIONS

The DL technology allows nonenhanced CT images as a novel tool for predicting the severity of AP.

The Evaluation of Inflammatory Biomarkers in Predicting Progression of Acute Pancreatitis to Pancreatic Necrosis: A Diagnostic Test Accuracy Review

Acute pancreatitis is the acute inflammation of the pancreas; 30% of cases may progress to pancreatic necrosis. The aim of this study was to assess the diagnostic accuracy of inflammatory biomarkers (C-reactive protein (CRP), procalcitonin (PCT), and lactate dehydrogenase (LDH)) in detecting pancreatic necrosis in adults with confirmed acute pancreatitis within 14 days of symptom onset and without organ failure. A systematic search was conducted across the Cumulative Index of Nursing and Allied Health (CINAHL), Cochrane, Embase, PubMed, and Web of Science until May 30, 2022, with the following keywords: acute disease, biomarkers, C-reactive protein, calcitonin, differential, diagnosis, lactate dehydrogenase, pancreatitis, acute necrotizing, necrosis, sensitivity, specificity. Statistical analysis was conducted in RevMan 5.4.1 (Cochrane). Five studies pooling 645 participants were included of which 59.8% were males, with a mean age of 49 years. CRP was the best cutoff at 279 mg/L (χ2 = 47.43, p < 0.001), followed by 200 mg/L (χ2 = 36.54, p < 0.001). LDH was cut off at 290 units/L (χ2 = 51.6, p < 0.001), whereas PCT did not display the most reliable results at 0.05 ng/mL. Inflammatory biomarkers are scalable diagnostic tools that may confer clinical value by decreasing the mortality of acute pancreatitis sequelae.

Diagnosis, severity stratification and management of adult acute pancreatitis–current evidence and controversies

Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe with an unpredictable natural course. Majority of cases (80%) are mild and self-limiting. However, severe AP (SAP) has a mortality risk of up to 30%. Establishing aetiology and risk stratification are essential pillars of clinical care. Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause. Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence. In SAP, patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit. Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP. Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition. If unable to tolerate per-orally, nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit. Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis. Delayed step-up strategy including percutaneous retroperitoneal drainage, endoscopic debridement, or minimal-access necrosectomy are sufficient in most SAP patients. Patients should be monitored for diabetes mellitus and pseudocyst.

Evidence-Based Approach to the Surgical Management of Acute Pancreatitis

Background  Acute pancreatitis is a significant challenge to health services. Remarkable progress has been made in the last decade in optimizing its management.

Methods  This review is a comprehensive assessment of 7 guidelines employed in current clinical practice with an appraisal of the underlying evidence, including 15 meta-analyses/systematic reviews, 16 randomized controlled trials, and 31 cohort studies.

Results  Key tenets of early management of acute pancreatitis include severity stratification based on the degree of organ failure and early goal-directed fluid resuscitation. Rigorous determination of etiology reduces the risk of recurrence. Early enteral nutrition and consideration of epidural analgesia have been pioneered in recent years with promising results. Indications for invasive intervention are becoming increasingly refined. The definitive indications for endoscopic retrograde cholangiopancreatography in acute pancreatitis are associated with cholangitis and common bile duct obstruction. The role of open surgical necrosectomy has diminished with the development of a minimally invasive step-up necrosectomy protocol. Increasing use of endoscopic ultrasound–guided intervention in the management of pancreatic necrosis has helped reduce pancreatic fistula rates and hospital stay.

Conclusion  The optimal approach to surgical management of complicated pancreatitis depends on patient physiology and disease anatomy, in addition to the available resources and expertise. This is best achieved with a multidisciplinary approach. This review provides a distillation of the recommendations of clinical guidelines and critical discussion of the evidence that informs them and presents an algorithmic approach to key areas of patient management.

Predicting persistent organ failure on admission in patients with acute pancreatitis: development and validation of a mobile nomogram

BACKGROUND

Early prediction of persistent organ failure (POF) is important for triage and timely treatment of patients with acute pancreatitis (AP).

METHODS

All AP patients were consecutively admitted within 48 h of symptom onset. A nomogram was developed to predict POF on admission using data from a retrospective training cohort, validated by two prospective cohorts. The clinical utility of the nomogram was defined by concordance index (C-index), decision curve analysis (DCA), and clinical impact curve (CIC), while the performance by post-test probability.

RESULTS

There were 816, 398, and 880 patients in the training, internal and external validation cohorts, respectively. Six independent predictors determined by logistic regression analysis were age, respiratory rate, albumin, lactate dehydrogenase, oxygen support, and pleural effusion and were included in the nomogram (web-based calculator: https://shina.shinyapps.io/DynNomapp/). This nomogram had reasonable predictive ability (C-indexes 0.88/0.91/0.81 for each cohort) and promising clinical utility (DCA and CIC). The nomogram had a positive likelihood ratio and post-test probability of developing POF in the training, internal and external validation cohorts of 4.26/31.7%, 7.89/39.1%, and 2.75/41%, respectively, superior or equal to other prognostic scores.

CONCLUSIONS

This nomogram can predict POF of AP patients and should be considered for clinical practice and trial allocation.

Diagnosis and Treatment of Acute Pancreatitis

The pancreas is a glandular organ that is responsible for the proper functioning of the digestive and endocrine systems, and therefore, it affects the condition of the entire body. Consequently, it is important to effectively diagnose and treat diseases of this organ. According to clinicians, pancreatitis—a common disease affecting the pancreas—is one of the most complicated and demanding diseases of the abdomen. The classification of pancreatitis is based on clinical, morphologic, and histologic criteria. Medical doctors distinguish, inter alia, acute pancreatitis (AP), the most common causes of which are gallstone migration and alcohol abuse. Effective diagnostic methods and the correct assessment of the severity of acute pancreatitis determine the selection of an appropriate treatment strategy and the prediction of the clinical course of the disease, thus preventing life-threatening complications and organ dysfunction or failure. This review collects and organizes recommendations and guidelines for the management of patients suffering from acute pancreatitis.

Lactated Ringers Does Not Reduce SIRS in Acute Pancreatitis Compared to Normal Saline: An Updated Meta-Analysis

BACKGROUND

We aimed to compare outcomes according to a Lactated Ringers (LR) versus Normal Saline (NS)-based strategy for acute pancreatitis.

METHODS

A database search through November 2020 was done to identify studies comparing LR to NS for fluid rehydration in AP. The primary endpoint was systemic inflammatory response syndrome (SIRS) at 24 h. Mantel-Haenszel pooled odds ratios (OR) and 95% confidence intervals were constructed using a random effects model. Heterogeneity was assessed using the I² statistic. Publication bias was assessed using funnel plots.

RESULTS

Six studies were included totaling 549 patients. No difference in the odds of developing SIRS was noted at 24 h (pooled OR 0.59, 95% CI 0.22-1.62, P = 0.31) between LR and NS. I² indices showed low heterogeneity between the groups, and a funnel plot showed no obvious publication bias. There was no difference between LR and NS found for SIRS at 48 and 72 h, mortality, and other secondary outcomes. LR was associated with a decreased need for ICU admission.

CONCLUSIONS

This updated meta-analysis does not support the previously published finding that the use of LR (rather than NS) leads to a statistically significant decreased odds of SIRS in acute pancreatitis.

Dynamic nomogram for persistent organ failure in acute biliary pancreatitis: Development and validation in a retrospective study

BACKGROUND

Persistent organ failure (POF) increases the risk of death in patients with acute biliary pancreatitis (ABP). Currently, there is no early risk assessment tool for POF in patients with ABP.

AIMS

To establish and validate a dynamic nomogram for predicting the risk of POF in ABP.

METHODS

This was a retrospective study of 792 patients with ABP, with 595 cases in the development group and 197 cases in the validation group. Least absolute shrinkage and selection operator regression screened the predictors of POF, and logistic regression established the model (P < 0.05). A dynamic nomogram showed the model. We evaluated the model's discrimination, calibration, and clinical effectiveness; used the bootstrap method for internal validation; and conducted external validation in the validation group.

RESULTS

Neutrophils, haematocrit, serum calcium, and blood urea nitrogen were predictors of POF in ABP. In the development group and validation group, the areas under the receiver operating characteristic curves (AUROCs) were 0.875 and 0.854, respectively, and the Hosmer-Lemeshow test (P > 0.05) and calibration curve showed good consistency between the actual and prediction probability. Decision curve analysis showed that the dynamic nomogram has excellent clinical value.

CONCLUSION

This dynamic nomogram helps with the early identification and screening of high-risk patients with POF in ABP.

Blood Urea Nitrogen/Albumin Ratio and Mortality Risk in Patients with COVID-19

Introduction

We researched blood urea nitrogen (BUN), albumin and their ratio (BAR), and compared them with C-reactive protein (CRP), D-dimer, and computed tomography severity scores (CT-SS), to predict in-hospital mortality.

Methods

One-hundred and thirty-one coronavirus disease-2019 (COVID-19) confirmed patients brought to the emergency department (ED) were dispensed to the survivor or non-survivor group, in light of in-hospital mortality. Information on age, gender, complaints, comorbidities, laboratory parameters, and outcome were gathered from the patient's record files.

Results

The median BUN, mean total protein, mean albumin, median BAR, median creatinine, median CRP, and median D-dimer were recorded. CT-SS were utilized in categorizing the patient as mild, moderate, and severe. In-hospital mortality occurred in 42 (32.06%) patients (non-survivor group) and did not occur in 89 (67.94%) patients (survivor group). The median BUN (mg/dL) and BAR (mg/gm) values were significantly raised in the non-survivor group than in the survivor group [BUN: 23.48 (7.51–62.75) and 20.66 (4.07–74.67), respectively (p = 0.009); BAR: 8.33 mg/g (2.07–21.86) and 6.11 mg/g (1.26–23.33); (p = 0.0003)]. The mean albumin levels (gm/dL) in the non-survivor group were significantly lower than in the survivor group [2.96 ± 0.35 and 3.27 ± 0.35, respectively (p <0.0001)]. Albumin with an odd's ratio of 6.14 performed the best in predicting in-hospital mortality, followed by D-dimer (4.98). BAR and CRP had similar outcome of 3.75; BUN showed an OR of 3.13 at the selected cutoff value.

Conclusion

The BUN, albumin, and BAR were found to be dependable predictors of in-hospital mortality in COVID-19 patients, with albumin (hypoalbuminemia) performing even better.

How to cite this article

Singh S, Singh K. Blood Urea Nitrogen/Albumin Ratio and Mortality Risk in Patients with COVID-19. Indian J Crit Care Med 2022;26(5):626–631.

Growth differentiation factor 15 is an early predictor for persistent organ failure and mortality in acute pancreatitis

OBJECTIVES

Early prediction of persistent organ failure (POF) is crucial for patients with acute pancreatitis (AP). Growth differentiation factor 15 (GDF15), also known as macrophage inhibitory cytokine 1 (MIC-1), is associated with inflammatory responses. We investigated changes in plasma GDF15 and assessed its predictive value in AP.

METHODS

The study included 290 consecutive patients with AP admitted within 36 h after symptoms onset. Clinical data obtained during hospitalization were collected. Plasma GDF15 levels were determined using enzyme-linked immunosorbent assays. The predictive value of GDF15 for POF was analyzed.

RESULTS

There were 105 mild, 111 moderately severe, and 74 severe AP patients. Plasma GDF15 peak level were measured on admission, and significantly declined on the 3rd and 7th day. Admission GDF15 predicted POF and mortality with areas under the curve (AUC) of 0.847 (95% confidence interval [CI] 0.798-0.895) and 0.934 (95% CI 0.887-0.980), respectively. Admission GDF15, Bedside Index of Severity in Acute Pancreatitis, and hematocrit were independent factors for POF by univariate and multivariate logistic regression, and the nomogram built on these variables showed good performance (optimism-corrected c-statistic = 0.921). The combined predictive model increased the POF accuracy with an AUC 0.925 (95% CI 0.894-0.956), a net reclassification improvement of 0.3024 (95% CI: 0.1482-0.4565, P < 0.001), and an integrated discrimination index of 0.11 (95% CI 0.0497-0.1703; P < 0.001).

CONCLUSIONS

Plasma GDF15 measured within 48 h of symptom onset could help predict POF and mortality in AP patients.

Risk Factors Associated with In-Hospital Mortality in Iranian Patients with COVID-19: Application of Machine Learning

Introduction: Predicting the mortality risk of COVID-19 patients based on patient’s physiological conditions and demographic characteristics can help optimize resource consumption along with the provision of effective medical services for patients. In the current study, we aimed to develop several machine learning models to forecast the mortality risk in COVID-19 patients, evaluate their performance, and select the model with the highest predictive power.

Material and methods: We conducted a retrospective analysis of the records belonging to COVID-19 patients admitted to one of the main hospitals of Qazvin located in the northwest of Iran over 12 months period. We selected 29 variables for developing machine learning models incorporating demographic factors, physical symptoms, comorbidities, and laboratory test results. The outcome variable was mortality as a binary variable. Logistic regression analysis was conducted to identify risk factors of in-hospital death.

Results: In prediction of mortality, Ensemble demonstrated the maximum values of accuracy (0.8071, 95%CI: 0.7787, 0.8356), F1-score (0.8121 95%CI: 0.7900, 0.8341), and AUROC (0.8079, 95%CI: 0.7800, 0.8358). Including fourteen top-scored features identified by maximum relevance minimum redundancy algorithm into the subset of predictors of ensemble classifier such as BUN level, shortness of breath, seizure, disease history, fever, gender, body pain, WBC, diarrhea, sore throat, blood oxygen level, muscular pain, lack of taste and history of drug (medication) use are sufficient for this classifier to reach to its best predictive power for prediction of mortality risk of COVID-19 patients.

Conclusions: Study findings revealed that old age, lower oxygen saturation level, underlying medical conditions, shortness of breath, seizure, fever, sore throat, and body pain, besides serum BUN, WBC, and CRP levels, were significantly associated with increased mortality risk of COVID-19 patients. Machine learning algorithms can help healthcare systems by predicting and reduction of the mortality risk of COVID-19 patients.

Early prediction of severe acute pancreatitis using machine learning

BACKGROUND

Acute pancreatitis (AP) is one of the most common causes of gastrointestinal-related hospitalizations in the United States. Severe AP (SAP) is associated with a mortality rate of nearly 30% and is distinguished from milder forms of AP. Risk stratification to identify SAP cases needing inpatient treatment is an important aspect of AP diagnosis.

METHODS

We developed machine learning algorithms to predict which patients presenting with AP would require treatment for SAP. Three models were developed using logistic regression, neural networks, and XGBoost. Models were assessed in terms of area under the receiver operating characteristic (AUROC) and compared to the Harmless Acute Pancreatitis Score (HAPS) and Bedside Index for Severity in Acute Pancreatitis (BISAP) scores for AP risk stratification.

RESULTS

61,894 patients were used to train and test the machine learning models. With an AUROC value of 0.921, the model developed using XGBoost outperformed the logistic regression and neural network-based models. The XGBoost model also achieved a higher AUROC than both HAPS and BISAP for identifying patients who would be diagnosed with SAP.

CONCLUSIONS

Machine learning may be able to improve the accuracy of AP risk stratification methods and allow for more timely treatment and initiation of interventions.

Sequential organ failure assessment score is superior to other prognostic indices in acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a common surgical condition, with severe AP (SAP) potentially lethal. Many prognostic indices, including; acute physiology and chronic health evaluation II score (APACHE II), bedside index of severity in acute pancreatitis (BISAP), Glasgow score, harmless acute pancreatitis score (HAPS), Ranson’s score, and sequential organ failure assessment (SOFA) evaluate AP severity and predict mortality.

AIM

To evaluate these indices' utility in predicting severity, intensive care unit (ICU) admission, and mortality.

METHODS

A retrospective analysis of 653 patients with AP from July 2009 to September 2016 was performed. The demographic, clinical profile, and patient outcomes were collected. SAP was defined as per the revised Atlanta classification. Values for APACHE II score, BISAP, HAPS, and SOFA within 24 h of admission were retrospectively obtained based on laboratory results and patient evaluation recorded on a secure hospital-based online electronic platform. Data with < 10% missing data was imputed via mean substitution. Other patient information such as demographics, disease etiology, and patient outcomes were also derived from electronic medical records.

RESULTS

The mean age was 58.7 ± 17.5 years, with 58.7% males. Gallstones (n = 404, 61.9%), alcohol (n = 38, 5.8%), and hypertriglyceridemia (n = 19, 2.9%) were more common aetiologies. 81 (12.4%) patients developed SAP, 20 (3.1%) required ICU admission, and 12 (1.8%) deaths were attributed to SAP. Ranson’s score and APACHE-II demonstrated the highest sensitivity in predicting SAP (92.6%, 80.2% respectively), ICU admission (100%), and mortality (100%). While SOFA and BISAP demonstrated lowest sensitivity in predicting SAP (13.6%, 24.7% respectively), ICU admission (40.0%, 25.0% respectively) and mortality (50.0%, 25.5% respectively). However, SOFA demonstrated the highest specificity in predicting SAP (99.7%), ICU admission (99.2%), and mortality (98.9%). SOFA demonstrated the highest positive predictive value, positive likelihood ratio, diagnostic odds ratio, and overall accuracy in predicting SAP, ICU admission, and mortality. SOFA and Ranson’s score demonstrated the highest area under receiver-operator curves at 48 h in predicting SAP (0.966, 0.857 respectively), ICU admission (0.943, 0.946 respectively), and mortality (0.968, 0.917 respectively).

CONCLUSION

The SOFA and 48-h Ranson’s scores accurately predict severity, ICU admission, and mortality in AP, with more favorable statistics for the SOFA score.

A Novel Nomogram for Predicting Survival in Patients with Severe Acute Pancreatitis: An Analysis Based on the Large MIMIC-III Clinical Database

BACKGROUND

Severe acute pancreatitis (SAP) can cause various complications. Septic shock is a relatively common and serious complication that causes uncontrolled systemic inflammatory response syndrome, which is one of the main causes of death. This study aimed to develop a nomogram for predicting the overall survival of SAP patients during the initial 24 hours following admission.

MATERIALS AND METHODS

All the data utilized in this study were obtained from the MIMIC-III (Medical Information Mart for Intensive Care III) database. The data were analyzed using multivariate Cox regression, and the performance of the proposed nomogram was evaluated based on Harrell's concordance index (C-index) and the area under the receiver operating characteristic curve (AUC). The clinical value of the prediction model was tested using decision-curve analysis (DCA). The primary outcomes were 28-day, 60-day, and 90-day mortality rates.

RESULTS

The 850 patients included in the analysis comprised 595 in the training cohort and 255 in the validation cohort. The training cohort consisted of 353 (59.3%) males and 242 (40.7%) females with SAP. Multivariate Cox regression showed that weight, sex, insurance status, explicit sepsis, SAPSII score, Elixhauser score, bilirubin, anion gap, creatinine, hematocrit, hemoglobin, RDW, SPO2, and respiratory rate were independent prognostic factors for the survival of SAP patients admitted to an intensive care unit. The predicted values were compared using C-indexes, calibration plots, integrated discrimination improvement, net reclassification improvement, and DCA.

CONCLUSIONS

We have identified some important demographic and laboratory parameters related to the prognosis of patients with SAP and have used them to establish a more accurate and convenient nomogram for evaluating their 28-day, 60-day, and 90-day mortality rates.

Ranson score to stratify severity in Acute Pancreatitis remains valid - Old is gold

Introduction: Acute pancreatitis (AP) is a common gastrointestinal disease with a wide spectrum of severity and morbidity. Developed in 1974, the Ranson score was the first scoring system to prognosticate AP. Over the past decades, while the Ranson score remains widely used, it was identified to have certain limitations, such as having low predictive power. It has also been criticized for its 48-hour requirement for computation of the final score, which has been argued to potentially delay management. With advancements in our understanding of AP, is the Ranson score still relevant as an effective prognostication system for AP?Areas covered: This review summarizes the available evidence comparing Ranson score with other conventional and novel scoring systems, in terms of prognostic accuracy, benefits, limitations and clinical applicability. It also evaluates the effectiveness of Ranson score with regard to the Revised Atlanta Classification.Expert opinion: The Ranson score consistently exhibits comparable prognostic accuracy to other newer scoring systems, and the 48-hour timeframe for computing the full Ranson score is an inherent strength, not a weakness. These aspects, coupled with relative ease of use, practicality and universality of the score, advocate for the continued relevance of the Ranson score in modern clinical practice.

C-reactive protein predicts the development of walled-off necrosis in patients with severe acute pancreatitis

Background and Aim

Walled‐off necrosis (WON) is reported to occur in 1–9% of patients with acute pancreatitis. However, the factors associated with the onset of this condition have not been elucidated. This study aimed to investigate the potential predictive factors for WON in patients diagnosed with severe acute pancreatitis at our hospital.

Methods

This study included 26 patients with severe acute pancreatitis identified among the 211 patients with acute pancreatitis admitted to our hospital between January 2014 and December 2018. Patients with and without WON (WON and non‐WON groups, respectively) were compared to identify potential factors involved in the onset of this condition.

Results

The 26 patients had a median age of 67 years, and 65% were male. WON occurred in 15 patients (57.7%). In a univariate analysis, the WON and non‐WON groups differed significantly in terms of maximum C‐reactive protein (CRP) levels (median) (322.7 mg/L vs 163.8 mg/L [P = 0.001]). In a multivariate analysis, a significant association was identified between the maximum CRP level and the onset of WON (odds ratio: 1.20, 95% confidence interval: 1.05–1.37). The CRP level peaked within 3 days in 88%.

Conclusion

The maximum CRP level was identified as a predictive factor for the onset of WON, and a high proportion of patients with WON exhibited elevated CRP levels within 3 days after diagnosis. This work suggests the clinical importance of continuous monitoring at an early stage after diagnosis to identify the maximum CRP level.

Role of endoscopic ultrasonography in the management of peripancreatic collections. Diagnostic and therapeutic approach

Pancreatic fluid collections are surrounded by a wall of granulation tissue and may contain necrotic debris. They occur following a severe acute pancreatitis and most of the cases resolve spontaneously after several weeks. However, their management may lead to a very hardto-treat condition, requiring a multidisciplinary approach. During the last decades we assisted to a change of paradigm involving Endoscopic Ultrasonography, from a pure diagnostic technique to an interventional-therapeutic one, allowing an effective, safe and less invasive approach than other existing treatment standards, historically consisting of surgical and percutaneous drainage. Treatment of pancreatic fluid collections is indicated if they become infected or symptomatic. Over the past years, exponential developments were done in interventional endoscopic approach, making it the first line suggested modality. The use of endoscopic ultrasound allows assessment of the collection, even when it is not directly bulging on gastrointestinal wall, creation of an internal fistulous tract, checking for surrounding vessels with the use of Doppler, and deployment of a stent avoiding the discomfort of external tubes. Several types of stent have been used for endoscopic drainage: plastic double pigtail stents, fully covered self-expanding metal stents and, more recently, lumen apposing metal stents, which are considered revolutionary because of their two-side flanges and wide and short internal channel, a new design that made easier direct endoscopic necrosectomy. This review aims to go through currently available literature on the diagnostic and therapeutic role of Endoscopic Ultrasonography to handle pancreatic fluid collections.

THE ACCEPTANCE OF CHANGES IN THE MANAGEMENT OF PATIENTS WITH ACUTE PANCREATITIS AFTER THE REVISED ATLANTA CLASSIFICATION

BACKGROUND

New recommendations for the management of patients with acute pancreatitis were set after the Atlanta Classification was revised in 2012.

OBJECTIVE

The aim of the present systematic review is to assess whether these recommendations have already been accepted and implemented in daily medical practices.

METHODS

A systematic literature review was carried out in studies conducted with humans and published in English and Portuguese language from 10/25/2012 to 11/30/2018. The search was conducted in databases such as PubMed/Medline, Cochrane and SciELO, based on the following descriptors/Boolean operator: "Acute pancreatitis" AND "Atlanta". Only Randomized Clinical Trials comprising some recommendations released after the revised Atlanta Classification in 2012 were included in the study.

RESULTS

Eighty-nine studies were selected and considered valid after inclusion, exclusion and qualitative evaluation criteria application. These studies were stratified as to whether, or not, they applied the recommendations suggested after the Atlanta Classification revision. Based on the results, 68.5% of the studies applied the recommendations, with emphasis on the application of severity classification (mild, moderately severe, severe); 16.4% of them were North-American and 14.7% were Chinese. The remaining 31.5% just focused on comparing or validating the severity classification.

CONCLUSION

Few studies have disclosed any form of acceptance or practice of these recommendations, despite the US and Chinese efforts. The lack of incorporation of these recommendations didn't enable harnessing the benefits of their application in the clinical practice (particularly the improvement of the communication among health professionals and directly association with the worst prognoses); thus, it is necessary mobilizing the international medical community in order to change this scenario.

Metabolomic-based clinical studies and murine models for acute pancreatitis disease: A review

Acute pancreatitis (AP) is one of the most common gastroenterological disorders requiring hospitalization and is associated with substantial morbidity and mortality. Metabolomics nowadays not only help us to understand cellular metabolism to a degree that was not previously obtainable, but also to reveal the importance of the metabolites in physiological control, disease onset and development. An in-depth understanding of metabolic phenotyping would be therefore crucial for accurate diagnosis, prognosis and precise treatment of AP. In this review, we summarized and addressed the metabolomics design and workflow in AP studies, as well as the results and analysis of the in-depth of research. Based on the metabolic profiling work in both clinical populations and experimental AP models, we described the metabolites with potential utility as biomarkers and the correlation between the altered metabolites and AP status. Moreover, the disturbed metabolic pathways correlated with biological function were discussed in the end. A practical understanding of current and emerging metabolomic approaches applicable to AP and use of the metabolite information presented will aid in designing robust metabolomics and biological experiments that result in identification of unique biomarkers and mechanisms, and ultimately enhanced clinical decision-making.

Clinical Significance of Inflammation Markers in Predicting the Severity of Acute Pancreatitis

OBJECTIVES

Acute pancreatitis (AP) is an inflammatory disease of the pancreas. We analyzed changes in inflammation markers to explore the clinical significance of using these markers to predict the severity of AP.

METHODS

The study included 169 patients (severe AP = 50 and nonsevere AP = 119) admitted to Yanbian University Hospital between January 2015 and July 2017. The neutrophil-to-lymphocyte ratio (NLR), prognostic nutrition index (PNI), lymphocyte-to-monocyte ratio, red blood cell distribution width coefficient of variation, mean platelet volume, platelet-to-lymphocyte ratio, and red blood cell distribution width-to-platelet ratio of the patients were detected after admission. Correlations between AP severity and various inflammatory markers were statistically analyzed.

RESULTS

The results indicated that the NLR on the first day after admission (area under the curve, 0.824; 95% confidence interval, 0.753-0.896) and the PNI on the third day after admission (area under the curve, 0.814; 95% confidence interval, 0.753-0.896) had more significance than other inflammation markers in predicting the severity of AP. In AP patients, the NLR showed a gradual decline, and the PNI initially decreased and then increased.

CONCLUSIONS

The NLR and PNI can provide new reference values for predicting the severity of AP.

Macrophage migration inhibitory factor is an early marker of severe acute pancreatitis based on the revised Atlanta classification

BACKGROUND

Various serum markers for early identification of severe acute pancreatitis (SAP) have been studied. Serum macrophage migration inhibitory factor (MIF) was reported to be correlated with severity of acute pancreatitis (AP) based on the 1992 Atlanta classification. However, MIF has never been proven to be predictive of disease severity based on the revised Atlanta classification (RAC). The potential predictive value of MIF needs to be further validated.

METHODS

Consecutive patients with AP within 48 h after symptom onset and 10 healthy control volunteers were enrolled prospectively. Serum MIF levels were measured by enzyme-linked immunosorbent assay (ELISA). The predictive value of MIF, clinical scores and other serum markers were determined.

RESULTS

Among 143 patients with AP, there were 52 (36.4%), 65 (45.5%) and 26 (18.1%) with mild, moderate and severe disease based on the RAC respectively. Compared with healthy volunteers, serum levels of MIF were significantly higher in AP patients, especially those with SAP (P < 0.001). Multivariate regression analysis indicated that increased serum MIF (cut-off 2.30 ng/ml, OR = 3.16, P = 0.008), IL-6 (cut-off 46.8 pg/ml, OR = 1.21, P = 0.043), APACHE II score (cut-off 7.5, OR = 2.57, P = 0.011) and BISAP score (cut-off 1.5, OR = 1.01, P = 0.038) were independent risk factors for predicting SAP (P < 0.05). By using the area under the receiver operating characteristic (ROC) curve (AUC), MIF (AUC 0.950) demonstrated more excellent discriminative power for predicting SAP than APACHE II (AUC 0.899), BISAP (AUC 0.886), and IL-6 (AUC 0.826).

CONCLUSIONS

Serum MIF is a valuable early marker for predicting the severity of AP based on the RAC.

Diagnostic Performance of a Blood Urea Nitrogen to Creatinine Ratio-based Nomogram for Predicting In-hospital Mortality in COVID-19 Patients

Background

The novel coronavirus disease (COVID-19) is leading to high morbidity and mortality. This aim of this study was to test whether blood urea nitrogen-to-creatinine ratio (BCR) is a predictor for mortality in patients with COVID-19.

Methods

Ranges of "normal" BCR values were calculated from 9165 healthy subjects, and 337 and 79 COVID-19 patients were randomly assigned to the training cohort and the validation cohort, respectively. Prognostic factor of death incidence was selected by LASSO regression analyses. The prognostic ability of BCR range was assessed by logistic regression analysis. A nomogram for predicting in-hospital mortality based on BCR was developed. The performance of the nomogram was evaluated with respect to its calibration, discrimination, and clinical usefulness.

Results

Among 337 COVID-19 patients, 13.4% and 11.3% were classified into higher and lower than normal range group, respectively. Kaplan-Meier curves for all-cause mortality showed that patients with higher BCR group had worse prognosis (P<0.0001). BCR above the normal range was independently associated with death in COVID-19 patients (OR: 7.54; 95%CI: 1.55-36.66; P=0.012). The nomogram had good discrimination in the training cohort (C-index 0.838; 0.795-0.880) and the validation cohort (C-index 0.929; 0.869-0.989), and good calibration. Using maximum Youden index, the cutoff values of 59.8 points, the sensitivity and specificity were 75.4% and 81%. Decision curve and clinical impact curve analysis demonstrated that the nomogram was clinically useful.

Conclusion

BCR was a useful prognostic factor for COVID-19 patients. Development of an individualized BCR-based prediction nomogram can effectively predict the risk of mortality and help clinicians to make individual treatment early.

Appraisal of the diagnostic procedures of acute pancreatitis in the guidelines

OBJECTIVES

The purpose of this study was to comprehensively assess the heterogeneity of procedures in the diagnostic guidelines for acute pancreatitis and to identify gaps limiting knowledge in diagnosing this disease.

METHODS

A systematic search of a number of databases was performed to determine the guidelines for the diagnosis of acute pancreatitis in patients with severe pancreatitis. The guidelines for the diagnosis of severe pancreatitis were evaluated by AGREE II. The Measurement Scale of Rate of Agreement (MSRA) was used to assess the guidelines (2015-2020) and extract evidence supporting these recommendations for analysis.

RESULTS

Seven diagnostic guidelines for acute pancreatitis were included. Only the 2019 WSES Guidelines for the Management of Severe Acute Pancreatitis and the Japanese Guidelines for the Management of Acute Pancreatitis: Japanese Guidelines 2015 had a total score of more than 60%, which is worthy of clinical recommendation. The average scores of the Scope and Purpose domain and the Clarity and Expression domain were the highest at 71.62% and 75.59%, respectively, while the average score of the Applicability area was the lowest at 16.67%. The included guidelines were further analyzed to determine the heterogeneity of the diagnosis of acute pancreatitis. The main reasons for the heterogeneity were the citation of low-quality evidence, the presence of far too many indicators for the classification of acute pancreatitis, unclear depictions of the standard, and poorly comprehensive recommendations for the diagnosis of the aetiology in the primary diagnosis of acute pancreatitis, the severity classification, the aetiological diagnosis, and the diagnosis of comorbidities.

CONCLUSIONS

The quality of different diagnostic guidelines for severe pancreatitis is uneven. The recommendations are largely based on low-quality evidence, and the guidelines still have much room for improvement to reach a high level of quality. The diagnostic procedures for acute pancreatitis vary widely in different guidelines. There are large differences between them, and resolving the abovementioned reasons would be a very wise choice for guideline developers to revise and upgrade the guidelines in the future.

Early prediction of in-hospital mortality in acute pancreatitis: a retrospective observational cohort study based on a large multicentre critical care database

OBJECTIVE

To develop and validate a prediction model for predicting in-hospital mortality in patients with acute pancreatitis (AP).

DESIGN

A retrospective observational cohort study based on a large multicentre critical care database.

SETTING

All subject data were collected from the eICU Collaborative Research Database (eICU-CRD), which covers 200 859 intensive care unit admissions of 139 367 patients in 208 US hospitals between 2014 and 2015.

PARTICIPANTS

A total of 746 patients with AP were drawn from eICU-CRD. Due to loss to follow-up (four patients) or incomplete data (364 patients), 378 patients were enrolled in the primary cohort to establish a nomogram model and to conduct internal validation.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome of the prediction model was in-hospital mortality. All risk factors found significant in the univariate analysis were considered for multivariate analysis to adjust for confounding factors. Then a nomogram model was established. The performance of the nomogram model was evaluated by the concordance index (C-index) and the calibration plot. The nomogram model was internally validated using the bootstrap resampling method. The predictive accuracy of the nomogram model was compared with that of Acute Physiology, Age, and Chronic Health Evaluation (APACHE) IV. Decision curve analysis (DCA) was performed to evaluate and compare the potential net benefit using of different predictive models.

RESULTS

The overall in-hospital mortality rate is 4.447%. Age, BUN (blood urea nitrogen) and lactate (ABL) were the independent risk factors determined by multivariate analysis. The C-index of nomogram model ABL (0.896 (95% CI 0.825 to 0.967)) was similar to that of APACHE IV (p=0.086), showing a comparable discriminating power. Calibration plot demonstrated good agreement between the predicted and the actual in-hospital mortality. DCA showed that the nomogram model ABL was clinically useful.

CONCLUSIONS

Nomogram model ABL, which used readily available data, exhibited high predictive value for predicting in-hospital mortality in AP.

Assessment of acute pancreatitis severity via determination of serum levels of hsa-miR-126-5p and IL-6

Early assessment of acute pancreatitis (AP) severity is key to its treatment. The present study aimed to explore the role of microRNAs (miRNAs/miRs) combined with inflammatory factors in determining AP severity. For this, serum pro-inflammatory cytokines [tumor necrosis factor (TNF)-α, interleukin (IL)-1, IL-6, IL-8 and IL-10)] and miRNAs [Homo sapiens (hsa)-miR-548d-5p, hsa-miR-126-5p and hsa-miR-130b-5p] were detected in patients with mild AP (MAP), severe AP (SAP) and recurrent AP (RAP). High expression of IL-10, TNF-α, hsa-miR-126-5p, hsa-miR-548d-5p and hsa-miR-130b-5p was able to distinguish SAP from MAP and RAP (P<0.05). Multifactorial binary logistic regression analysis indicated that IL-1/IL-6 combined with hsa-miR-126-5p/hsa-miR-548d-5p had a significant influence on AP and AP severity (P<0.05). Receiver operating characteristic analysis revealed that IL-1 combined with hsa-miR-126-5p [area under the curve (AUC), 0.926; sensitivity, 90.0%; specificity, 86.7%, P<0.001] and IL-6 combined with hsa-miR-126-5p (AUC, 0.952; sensitivity, 93.3%; specificity, 90.0%; P<0.001) were able to better distinguish MAP from SAP than IL-1/IL-6 combined with hsa-miR-548d-5p, lipase, and amylase. IL-1 or IL-6 combined with hsa-miR-548d-5p (AUC, 0.924; sensitivity, 83.3%; specificity, 93.3%; P<0.001) were able to better distinguish SAP from RAP than IL-1/IL-6 combined with hsa-miR-126-5p, lipase, and amylase. IL-1 combined with hsa-miR-126-5p (AUC, 0.926; sensitivity, 90.0%; specificity, 86.7%; P<0.001) and IL-6 combined with hsa-miR-126-5p (AUC, 0.952; sensitivity, 93.3%; specificity, 90.0%; P<0.001) were able to better differentiate between MAP and RAP than IL-1/IL-6 combined with hsa-miR-548d-5p, lipase, and amylase. These results demonstrated that the combined detection of serum IL-6 and hsa-miR-126-5p may be useful for the early prediction of AP classification.

Early laboratory biomarkers for severity in acute pancreatitis; A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Acute pancreatitis is complicated by local and systemic complications in 20-30% of the patients. Accurate prediction of severity may be important for clinical decision making. Our aim is to identify and compare the accuracy of laboratory biomarkers that predict severity and complications in adult patients.

METHODS

Medline, EMBASE, Web of Science and Cochrane Library (1993 to August 2020) were searched for studies with an unselected population of patients with acute pancreatitis, that contains accuracy data for ≥1 laboratory biomarker(s) and/or APACHE-II score for the prediction of a patient outcomes of interest during the first 48 h of admission. The primary outcome is moderate severe or severe acute pancreatitis (MSAP/SAP). Secondary outcomes are severe acute pancreatitis, pancreatic necrosis and organ failure. Risk of bias was assed using QUADAS-2. Biomarkers extracted from ≥3 unique sources, were analyzed using hierarchical summary receiver operating characteristic (HSROC) and bivariate model analysis.

RESULTS

In total, 181 studies were included in the qualitative analysis reporting on 29 biomarkers. For the primary outcome at admission, summary sensitivities and specificities were, respectively, 87% (95% CI 69-95%) and 88% (95% CI 80-93%) for IL-6 at a threshold of >50 pg/ml, 72% (95% CI 64-79%) and 76% (95% CI 67-84%) for an APACHE-II score of ≥8, and 53% (95% CI 35-71%) and 82% (95% CI 74-88%) for CRP >150 mg/l. HSROC curve analysis confirmed these results.

CONCLUSION

This study indicates superiority of IL-6 for the early prediction of MSAP/SAP and may be used for to guide clinical decision making.

Impact of the etiology and Vitamin D receptor TaqI rs731236 gene polymorphism on the severity of acute pancreatitis

BACKGROUND/PURPOSE

This work aimed to assess the impact of different etiologies of acute pancreatitis (AP) and vitamin D receptor (VDR) TaqI rs731236 gene polymorphism on the severity of AP.

METHODS

This case-control study included 70 patients with AP and 40 healthy controls. Etiologies of AP were identified by imaging, ANA, cytomegalovirus (CMV) IgM, coxsackie B virus IgM, and IgG4. Genotyping of VDR TaqI rs731236 polymorphism, Laboratory tests and severity scores using Ranson, BISAP, Atlanta and APACHE II scores were determined.

RESULTS

The age in AP patients was 36.03 ± 10.76, and females were 85.7%. The etiologies of AP were as follows: biliary (51.4%), coxsackievirus (22.9%), autoimmune (14.3%), post-ERCP (8.6%) and 2.9% were idiopathic. The TT genotype of VDR polymorphism was significantly more common in AP than control (P = .001) and allele T dominated in AP group (OR = 2; 95% CI: 0.665-5.64). Most cases showed low severity scores with significant differences among etiologies and VDR genotypes. Biliary pancreatitis showed highest percentages of severe AP. However, etiologies and VDR polymorphism were not predictors of severity.

CONCLUSION

Etiology of AP could have impact on the disease severity. VDR gene polymorphism increases the risk of AP. Neither the etiology nor VDR gene polymorphism could predict AP severity.

Diagnostic performance of initial blood urea nitrogen combined with D-dimer levels for predicting in-hospital mortality in COVID-19 patients

The crude mortality rate in critical pneumonia cases with coronavirus disease 2019 (COVID-19) reaches 49%. This study aimed to test whether levels of blood urea nitrogen (BUN) in combination with D-dimer were predictors of in-hospital mortality in COVID-19 patients. The clinical characteristics of 305 COVID-19 patients were analysed and were compared between the survivor and non-survivor groups. Of the 305 patients, 85 (27.9%) died and 220 (72.1%) were discharged from hospital. Compared with discharged cases, non-survivor cases were older and their BUN and D-dimer levels were significantly higher (P < 0.0001). Least absolute shrinkage and selection operator (LASSO) and multivariable Cox regression analyses identified BUN and D-dimer levels as independent risk factors for poor prognosis. Kaplan-Meier analysis showed that elevated levels of BUN and D-dimer were associated with increased mortality (log-rank, P < 0.0001). The area under the curve for BUN combined with D-dimer was 0.94 (95% CI 0.90-0.97), with a sensitivity of 85% and specificity of 91%. Based on BUN and D-dimer levels on admission, a nomogram model was developed that showed good discrimination, with a concordance index of 0.94. Together, initial BUN and D-dimer levels were associated with mortality in COVID-19 patients. The combination of BUN ≥ 4.6 mmol/L and D-dimer ≥ 0.845 μg/mL appears to identify patients at high risk of in-hospital mortality, therefore it may prove to be a powerful risk assessment tool for severe COVID-19 patients.

The Effect of an Invasive Strategy for Treating Pancreatic Necrosis on Mortality: a Retrospective Multicenter Cohort Study

BACKGROUND

Infected acute necrotic collections (ANC) and walled-off necrosis (WON) of the pancreas are associated with high mortality. The difference in mortality between open necrosectomy and minimally invasive therapies in these patients remains unclear.

METHODS

This retrospective multicenter cohort study was conducted among 44 institutions in Japan from 2009 to 2013. Patients who had undergone invasive treatment for suspected infected ANC/WON were enrolled and classified into open necrosectomy and minimally invasive treatment (laparoscopic, percutaneous, and endoscopic) groups. The association of each treatment with mortality was evaluated and compared.

RESULTS

Of 1159 patients with severe acute pancreatitis, 122 with suspected infected ANC or WON underwent the following treatments: open necrosectomy (33) and minimally invasive treatment (89), (laparoscopic three, percutaneous 49, endoscopic 37). Although the open necrosectomy group had a significantly higher mortality on univariate analysis (p = 0.047), multivariate analysis showed no significant associations between open necrosectomy or Charlson index and mortality (p = 0.29, p = 0.19, respectively). However, age (for each additional 10 years, p = 0.012, odds ratio [OR] 1.50, 95% confidence interval [CI] 1.09-2.06) and revised Atlanta criteria-severe (p = 0.001, OR 7.84, 95% CI 2.40-25.6) were significantly associated with mortality.

CONCLUSIONS

In patients with acute pancreatitis and infected ANC/WON, age and revised Atlanta criteria-severe classification are significantly associated with mortality whereas open necrosectomy is not. The mortality risk for patients undergoing open necrosectomy and minimally invasive treatment does not differ significantly. Although minimally invasive surgery is generally preferred for patients with infected ANC/WON, open necrosectomy may be considered if clinically indicated.

Does pendimethalin develop in pancreatic cancer induced inflammation?

Pendimethalin, one of the dinitroaniline group herbicides, is applied for controlling weeds in cereals, legumes and vegetable crops, and has been classified as possible human carcinogen. It is indicated that pendimethalin should arise risks of developing some cancer types; however, there is no data on the effects of pendimethalin on pancreatic cancer-induced inflammation. Injuries resulting from by acute pancreatitis attacks and inflammation are significant factors in the development of pancreatic cancer. Therefore, we investigated whether pendimethalin triggers inflammation as a mechanism of pancreatic cancer development. Parameters related to pancreatic activation, oxidative stress, and inflammation were measured in the human pancreatic (PANC-1) cell line. In the range of 0-100 μM, the levels of chymotrypsin decreased. It should be indicated that the reason for the decrease in chymotrypsin may be the high rates of cell death (20%) observed in the high concentration levels. We observed that pendimethalin significantly induced oxidative damage, while levels of interleukin-6 (IL-6) and interleukin-8 (IL-8) did not change. The obtained results may draw attention to the usage and possible toxic effect of pendimethalin due to oxidative damage induction; however, detailed inflammation mechanisms and other cancer pathways should be investigated.