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Ke L, Mao W, Shao F, Zhou J, Xu M, Chen T, Liu Y, Tong Z, Windsor J, Ma P, Li W. Association between pretreatment lymphocyte count and efficacy of immune-enhancing therapy in acute necrotising pancreatitis: a post-hoc analysis of the multicentre, randomised, placebo-controlled TRACE trial. EClinicalMedicine 2023; 58:101915. [PMID: 37007743 PMCID: PMC10050769 DOI: 10.1016/j.eclinm.2023.101915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 04/04/2023] Open
Abstract
Background Immune-enhancing thymosin alpha 1 (Tα1) therapy may reduce infected pancreatic necrosis (IPN) in acute necrotising pancreatitis (ANP). However, the efficacy might be impacted by lymphocyte count due to the pharmacological action of Tα1. In this post-hoc analysis, we tested the hypothesis that pre-treatment absolute lymphocyte count (ALC) determines whether patients with ANP benefit from Tα1 therapy. Methods A post-hoc analysis of data from a multicentre, double-blind, randomised, placebo-controlled trial testing the efficacy of Tα1 therapy in patients with predicted severe ANP was performed. Patients from 16 hospitals of China were randomised to receive a subcutaneous injection of Tα1 1.6 mg every 12 h for the frst 7 days and 1.6 mg once a day for the following 7 days or a matching placebo during the same period. Patients who discontinued the Tα1 regimen prematurely were excluded. Three subgroup analyses were conducted using the baseline ALC (at randomisation), and the group allocation was maintained as intention-to-treat. The primary outcome was the incidence of IPN 90 days after randomisation. The fitted logistic regression model was applied to identify the range of baseline ALC where Tα1 therapy could exert a maximum effect. The original trial is registered with ClinicalTrials.gov, NCT02473406. Findings Between March 18, 2017, and December 10, 2020, a total of 508 patients were randomised in the original trial, and 502 were involved in this analysis, with 248 in the Tα1 group and 254 in the placebo group. Across the three subgroups, there was a uniform trend toward more significant treatment effects in patients with higher baseline ALC. Within the subgroup of patients with baseline ALC≥0.8 × 10ˆ9/L (n = 290), the Tα1 therapy significantly reduced the risk of IPN (covariate adjusted risk difference, -0.12; 95% CI, -0.21,-0.02; p = 0.015). Patients with baseline ALC between 0.79 and 2.00 × 10ˆ9/L benefited most from the Tα1 therapy in reducing IPN (n = 263). Interpretation This post-hoc analysis found that the efficacy of immune-enhancing Tα1 therapy on the incidence of IPN may be associated with pretreatment lymphocyte count in patients with acute necrotising pancreatitis. Funding National Natural Science Foundation of China.
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Affiliation(s)
- Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, 210010, Jiangsu, China
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, 210010, Jiangsu, China
| | - Wenjian Mao
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, 210010, Jiangsu, China
| | - Fang Shao
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China
| | - Jing Zhou
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, 210010, Jiangsu, China
| | - Minyi Xu
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China
| | - Tao Chen
- Department of Public Health, Policy and Systems, Institute of Population Health, The University of Liverpool, Liverpool, UK
| | - Yuxiu Liu
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, 210010, Jiangsu, China
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, 210010, Jiangsu, China
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China
| | - Zhihui Tong
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, 210010, Jiangsu, China
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, 210010, Jiangsu, China
- Corresponding author. Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, Jiangsu Province, 210002, China.
| | - John Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Penglin Ma
- Department of Critical Care Medicine, Guiqian International General Hospital, Guiyang, 550004, Guizhou, China
- Corresponding author. Department of Critical Care Medicine, Guiqian International General Hospital, Guiyang, Guizhou Province, 550004, China.
| | - Weiqin Li
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, 210010, Jiangsu, China
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, 210010, Jiangsu, China
- Corresponding author. Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, Jiangsu Province, 210002, China.
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Venkatesh K, Glenn H, Delaney A, Andersen CR, Sasson SC. Fire in the belly: A scoping review of the immunopathological mechanisms of acute pancreatitis. Front Immunol 2023; 13:1077414. [PMID: 36713404 PMCID: PMC9874226 DOI: 10.3389/fimmu.2022.1077414] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/21/2022] [Indexed: 01/13/2023] Open
Abstract
Introduction Acute pancreatitis (AP) is characterised by an inflammatory response that in its most severe form can cause a systemic dysregulated immune response and progression to acute multi-organ dysfunction. The pathobiology of the disease is unclear and as a result no targeted, disease-modifying therapies exist. We performed a scoping review of data pertaining to the human immunology of AP to summarise the current field and to identify future research opportunities. Methods A scoping review of all clinical studies of AP immunology was performed across multiple databases. Studies were included if they were human studies of AP with an immunological outcome or intervention. Results 205 studies met the inclusion criteria for the review. Severe AP is characterised by significant immune dysregulation compared to the milder form of the disease. Broadly, this immune dysfunction was categorised into: innate immune responses (including profound release of damage-associated molecular patterns and heightened activity of pattern recognition receptors), cytokine profile dysregulation (particularly IL-1, 6, 10 and TNF-α), lymphocyte abnormalities, paradoxical immunosuppression (including HLA-DR suppression and increased co-inhibitory molecule expression), and failure of the intestinal barrier function. Studies including interventions were also included. Several limitations in the existing literature have been identified; consolidation and consistency across studies is required if progress is to be made in our understanding of this disease. Conclusions AP, particularly the more severe spectrum of the disease, is characterised by a multifaceted immune response that drives tissue injury and contributes to the associated morbidity and mortality. Significant work is required to develop our understanding of the immunopathology of this disease if disease-modifying therapies are to be established.
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Affiliation(s)
- Karthik Venkatesh
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW, Australia,The Kirby Institute, The University of New South Wales, Kensington, NSW, Australia,*Correspondence: Karthik Venkatesh,
| | - Hannah Glenn
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW, Australia,Division of Critical Care, The George Institute for Global Health, Newtown, NSW, Australia
| | - Christopher R. Andersen
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW, Australia,The Kirby Institute, The University of New South Wales, Kensington, NSW, Australia,Division of Critical Care, The George Institute for Global Health, Newtown, NSW, Australia
| | - Sarah C. Sasson
- The Kirby Institute, The University of New South Wales, Kensington, NSW, Australia,Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
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Ke L, Zhou J, Mao W, Chen T, Zhu Y, Pan X, Mei H, Singh V, Buxbaum J, Doig G, He C, Gu W, Lu W, Tu S, Ni H, Zhang G, Zhao X, Sun J, Chen W, Song J, Shao M, Tu J, Xia L, He W, Zhu Q, Li K, Yao H, Wu J, Fu L, Jiang W, Zhang H, Lin J, Li B, Tong Z, Windsor J, Liu Y, Li W. Immune enhancement in patients with predicted severe acute necrotising pancreatitis: a multicentre double-blind randomised controlled trial. Intensive Care Med 2022; 48:899-909. [PMID: 35713670 PMCID: PMC9205279 DOI: 10.1007/s00134-022-06745-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/16/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Infected pancreatic necrosis (IPN) is a highly morbid complication of acute necrotising pancreatitis (ANP). Since there is evidence of early-onset immunosuppression in acute pancreatitis, immune enhancement may be a therapeutic option. This trial aimed to evaluate whether early immune-enhancing Thymosin alpha 1 (Tα1) treatment reduces the incidence of IPN in patients with predicted severe ANP. METHODS We conducted a multicentre, double-blind, randomised, placebo-controlled trial involving ANP patients with an Acute Physiology and Chronic Health Evaluation II (APACHE II) score ≥ 8 and a computed tomography (CT) severity score ≥ 5 admitted within 7 days of the advent of symptoms. Enrolled patients were assigned to receive a subcutaneous injection of Tα1 1.6 mg every 12 h for the first 7 days and 1.6 mg once a day for the subsequent 7 days or matching placebos (normal saline). The primary outcome was the development of IPN during the index admission. RESULTS A total of 508 patients were randomised, of whom 254 were assigned to receive Tα1 and 254 placebo. The vast majority of the participants required admission to the intensive care unit (ICU) (479/508, 94.3%). During the index admission, 40/254(15.7%) patients in the Tα1 group developed IPN compared with 46/254 patients (18.1%) in the placebo group (difference -2.4% [95% CI - 7.4 to 5.1%]; p = 0.48). The results were similar across four predefined subgroups. There was no difference in other major complications, including new-onset organ failure (10.6% vs. 15%), bleeding (6.3% vs. 3.5%), and gastrointestinal fistula (2% vs. 2.4%). CONCLUSION The immune-enhancing Tα1 treatment of patients with predicted severe ANP did not reduce the incidence of IPN during the index admission.
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Affiliation(s)
- Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210000 Jiangsu China ,National Institute of Healthcare Data Science, Nanjing University, Nanjing, 210010 Jiangsu China
| | - Jing Zhou
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210000 Jiangsu China ,Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, 210010 Jiangsu China
| | - Wenjian Mao
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, 210010 Jiangsu China
| | - Tao Chen
- Department of Public Health, Policy and Systems, Institute of Population Health, Whelan Building, Quadrangle, The University of Liverpool, Liverpool, L69 3GB UK
| | - Yin Zhu
- Pancreatic Disease Centre, Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006 Jiangxi China
| | - Xinting Pan
- Department of Emergency Intensive Care Unit, The Affiliated Hospital of Qingdao University, Qingdao, 266000 Shandong China
| | - Hong Mei
- Department of Critical Care Medicine, The Affiliated Hospital of Zunyi Medical University, Zunyi, 536000 Guizhou China
| | - Vikesh Singh
- Pancreatitis Centre, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD USA
| | - James Buxbaum
- Division of Gastroenterology, Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Gordon Doig
- Northern Clinical School, Royal, North Shore Hospital, University of Sydney, Sydney, Australia
| | - Chengjian He
- Department of Critical Care Medicine, the Affiliated Nanhua Hospital, University of South China, Hengyang, 421002 Hunan China
| | - Weili Gu
- Department of Critical Care Medicine, Affiliated Hospital 2 of Nantong University, Nantong, 226000 Jiangsu China
| | - Weihua Lu
- Department of Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, 241001 Anhui China
| | - Shumin Tu
- Department of Emergency Medicine, Shangqiu First People’s Hospital, Shangqiu, 476000 Henan China
| | - Haibin Ni
- Department of Emergency Medicine, Jiangsu Provincial Hospital of Integrated Chinese and Western Medicine, Nanjing, 210010 Jiangsu China
| | - Guoxiu Zhang
- Department of Emergency Medicine, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, 471003 Henan China
| | - Xiangyang Zhao
- Department of Intensive Care Unit, Qilu Hospital of Shandong University, Qingdao, 266000 Shandong China
| | - Junli Sun
- Department of Intensive Care Unit, Luoyang Central Hospital, Zhengzhou University, Luoyang, 471100 Henan China
| | - Weiwei Chen
- Department of Gastroenterology, Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu China
| | - Jingchun Song
- Department of Critical Care Medicine, 94Th Hospital of PLA, Nanchang, 330006 Jiangxi China
| | - Min Shao
- Department of Intensive Care Unit, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022 Anhui China
| | - Jianfeng Tu
- Department of Emergency Medicine, Zhejiang Provincial People’s Hospital, Hangzhou, 310014 Zhejiang China
| | - Liang Xia
- Pancreatic Disease Centre, Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006 Jiangxi China
| | - Wenhua He
- Pancreatic Disease Centre, Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006 Jiangxi China
| | - Qingyun Zhu
- Department of Emergency Intensive Care Unit, The Affiliated Hospital of Qingdao University, Qingdao, 266000 Shandong China
| | - Kang Li
- Department of Critical Care Medicine, The Affiliated Hospital of Zunyi Medical University, Zunyi, 536000 Guizhou China
| | - Hongyi Yao
- Department of Critical Care Medicine, the Affiliated Nanhua Hospital, University of South China, Hengyang, 421002 Hunan China
| | - Jingyi Wu
- Department of Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, 241001 Anhui China
| | - Long Fu
- Department of Emergency Medicine, Shangqiu First People’s Hospital, Shangqiu, 476000 Henan China
| | - Wendi Jiang
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210000 Jiangsu China
| | - He Zhang
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Southeast University, Nanjing, 210002 Jiangsu China
| | - Jiajia Lin
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210000 Jiangsu China
| | - Baiqiang Li
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210000 Jiangsu China
| | - Zhihui Tong
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210000 Jiangsu China
| | - John Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, 1142 New Zealand
| | - Yuxiu Liu
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210000 Jiangsu China ,Department of Medical Statistics, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002 Jiangsu China
| | - Weiqin Li
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210000 Jiangsu China ,Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, 210010 Jiangsu China ,National Institute of Healthcare Data Science, Nanjing University, Nanjing, 210010 Jiangsu China
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The challenge of prognostic markers in acute pancreatitis: internist's point of view. J Genet Eng Biotechnol 2021; 19:77. [PMID: 34036463 PMCID: PMC8149536 DOI: 10.1186/s43141-021-00178-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 05/10/2021] [Indexed: 12/12/2022]
Abstract
Acute pancreatitis, the most frequent hospitalization reason in internal medicine ward among gastrointestinal diseases, is burdened by high mortality rate. The disease manifests mainly in a mild form, but about 20-30% patients have a severe progress that requires intensive care. Patients presenting with acute pancreatitis should be clinically evaluated for organ failure signs and symptoms. Stratifying patients in the first days from symptoms onset is essential to determine therapy and care setting. The aim of our study is to evaluate prognostic factors for acute pancreatitis patients, hospitalized in internal medicine wards, and moreover, understanding the role of various prognostic scores validated in intensive care setting in predicting in-hospital mortality and/or admission to intensive care unit. We conducted a retrospective study enrolling all patients with diagnosis of acute pancreatitis admitted took an internal medicine ward between January 2013 and May 2019. Adverse outcome was considered in-hospital mortality and/or admission to intensive care unit. In total, 146 patients (137 with positive outcome and 9 with adverse outcome) were enrolled. The median age was (67.89 ± 16.44), with a slight prevalence of male (55.1%) compared to female (44.9%). C protein reactive (p = 0.02), creatinine (p = 0.01), sodium (p = 0.05), and troponin I (p = 0.013) after 48 h were significantly increased in patients with adverse outcome. In our study, progression in SOFA score independently increases the probability of adverse outcome in patients hospitalized with acute pancreatitis. SOFA score > 5 is highly predictive of in-hospital mortality (O.R. 32.00; C.I. 6.73-152.5; p = 0.001) compared to other scores. The use of an easy tool, validated in intensive care setting such as SOFA score, might help to better stratify the risk of in-hospital mortality and/or clinical worsening in patients hospitalized with acute pancreatitis in internal medicine ward.
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Jabłońska B, Mrowiec S. Nutritional Support in Patients with Severe Acute Pancreatitis-Current Standards. Nutrients 2021; 13:nu13051498. [PMID: 33925138 PMCID: PMC8145288 DOI: 10.3390/nu13051498] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/20/2021] [Accepted: 04/25/2021] [Indexed: 12/14/2022] Open
Abstract
Severe acute pancreatitis (SAP) leads to numerous inflammatory and nutritional disturbances. All SAP patients are at a high nutritional risk. It has been proven that proper nutrition significantly reduces mortality rate and the incidence of the infectious complications in SAP patients. According to the literature, early (started within 24–48 h) enteral nutrition (EN) is optimal in most patients. EN protects gut barrier function because it decreases gastrointestinal dysmotility secondary to pancreatic inflammation. Currently, the role of parenteral nutrition (PN) in SAP patients is limited to patients in whom EN is not possible or contraindicated. Early versus delayed EN, nasogastric versus nasojejunal tube for EN, EN versus PN in SAP patients and the role of immunonutrition (IN) in SAP patients are discussed in this review.
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Mallick B, Tomer S, Arora SK, Lal A, Dhaka N, Samanta J, Sinha SK, Gupta V, Yadav TD, Kochhar R. Change in serum levels of inflammatory markers reflects response of percutaneous catheter drainage in symptomatic fluid collections in patients with acute pancreatitis. JGH OPEN 2019; 3:295-301. [PMID: 31406922 PMCID: PMC6684513 DOI: 10.1002/jgh3.12158] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 01/18/2019] [Indexed: 02/06/2023]
Abstract
Background Percutaneous catheter drainage (PCD) is used as the first step in the management of symptomatic fluid collections in patients with acute pancreatitis (AP). There are limited data on the effect of PCD on inflammatory markers. Aim To study the effects of PCD on serum levels of C‐reactive protein (CRP), IL‐6, and IL‐10 and its correlation with the outcome. Methods Consecutive patients of AP with symptomatic fluid collections undergoing PCD were evaluated for serum levels of CRP, IL‐6, and IL‐10 before PCD and at 3 and 7 days after PCD. Resolution of organ failure (OF), sepsis, and pressure symptoms was considered to demonstrate the success of PCD. Changes in levels following PCD were correlated with outcome. Results Indications of PCD in 59 patients (age 38.9 ± 13.17 years, 49 male) were suspected/documented infected pancreatic necrosis (n = 45), persistent OF (n = 40), and pressure symptoms (n = 7). A total of 49 (83.1%) patients improved with PCD, five patients required surgery, and six died. A significant difference was noted between baseline levels of CRP (P = 0.026) and IL‐6 (P = 0.013) among patients who improved compared to those who worsened following PCD. Significant decrease (P < 0.01) of all three markers on day 3 of PCD insertion, with further decrease (P < 0.01) on day 7, was noted. The percentage of the decrease of IL‐6 levels on day 3 and of CRP on day 7 correlated with the outcome. Conclusion PCD is associated with a significant decrease in CRP, IL‐6, and IL‐10 levels. Percentage decrease in IL‐6 on day 3 and CRP on day 7 correlated with the outcome of patients managed with PCD.
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Affiliation(s)
- Bipadabhanjan Mallick
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Shallu Tomer
- Department of Immunopathology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Sunil K Arora
- Department of Immunopathology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Anupam Lal
- Department of Radiodiagnosis Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Narendra Dhaka
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Jayanta Samanta
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Saroj K Sinha
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Vikas Gupta
- Department of General Surgery Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Thakur Deen Yadav
- Department of General Surgery Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Rakesh Kochhar
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
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The diffuse reduction in spleen density: an indicator of severe acute pancreatitis? Biosci Rep 2017; 37:BSR20160418. [PMID: 27920277 PMCID: PMC5322749 DOI: 10.1042/bsr20160418] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 11/30/2016] [Accepted: 12/05/2016] [Indexed: 02/07/2023] Open
Abstract
We observed that acute pancreatitis (AP) was associated with diffuse reduction in spleen density (DROSD) in some patients. Furthermore, the condition of these patients was more serious, and the potential relationship between DROSD and structural and functional injury of the spleen remained unclear. Therefore, we performed a preliminary exploration of these factors. We analysed pertinent clinical data for AP patients with normal spleen density (control group) and for those with DROSD (reduction group) at the First Affiliated Hospital of Harbin Medical University (June 2013–June 2015). We measured the immunoglobulin M (IgM) B-cells of the AP patients and examined pancreatic and splenic tissues from AP rats with optical microscopy and TEM. The reduction group had a higher acute physiology and chronic health evaluation II (APACHE II) score, a longer length of stay (LOS) and lower serum calcium than the control group. The levels of triglycerides (TG) and total cholesterol (TC) did not differ significantly between the two groups. The percentage of IgM memory B-cells was significantly lower in the DROSD group than in the control group. TEM revealed that the spleen T-lymphocytes were normal in AP rats, but pyroptotic and necrotic spleen B-cells were observed in the severe AP rats. In AP, DROSD was an independent indicator of more severe conditions. Furthermore, spleen B-lymphocytes showed obvious damage at the cellular level, and the immunological function of the spleen was down-regulated when AP was associated with DROSD.
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Pathophysiological mechanisms in acute pancreatitis: Current understanding. Indian J Gastroenterol 2016; 35:153-66. [PMID: 27206712 DOI: 10.1007/s12664-016-0647-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 03/16/2016] [Indexed: 02/04/2023]
Abstract
The precise mechanisms involved in the pathophysiology of acute pancreatitis (AP) are still far from clear. Several earlier studies have focused mainly on pancreatic enzyme activation as the key intracellular perturbation in the pancreatic acinar cells. For decades, the trypsin-centered hypothesis has remained the focus of the intra-acinar events in acute pancreatitis. Recent advances in basic science research have lead to the better understanding of various other mechanisms such as oxidative and endoplasmic stress, impaired autophagy, mitochondrial dysfunction, etc. in causing acinar cell injury. Despite all efforts, the clinical outcome of patients with AP has not changed significantly over the years. This suggests that the knowledge of the critical molecular pathways in the pathophysiology of AP is still limited. The mechanisms through which the acinar cell injury leads to local and systemic inflammation are not well understood. The role of inflammatory markers and immune system activation is an area of much relevance from the point of view of finding a target for therapeutic intervention. Some data are available from experimental animal models but not much is known in human pancreatitis. This review intends to highlight the current understanding in this area.
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Xiao Z, Wilson C, Robertson HL, Roberts DJ, Ball CG, Jenne CN, Kirkpatrick AW. Inflammatory mediators in intra-abdominal sepsis or injury - a scoping review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:373. [PMID: 26502877 PMCID: PMC4623902 DOI: 10.1186/s13054-015-1093-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 10/07/2015] [Indexed: 12/16/2022]
Abstract
Introduction Inflammatory and protein mediators (cytokine, chemokine, acute phase proteins) play an important, but still not completely understood, role in the morbidity and mortality of intra-abdominal sepsis/injury. We therefore systematically reviewed preclinical and clinical studies of mediators in intra-abdominal sepsis/injury in order to evaluate their ability to: (1) function as diagnostic/prognostic biomarkers; (2) serve as therapeutic targets; and (3) illuminate the pathogenesis mechanisms of sepsis or injury-related organ dysfunction. Methods We searched MEDLINE, PubMed, EMBASE and the Cochrane Library. Two investigators independently reviewed all identified abstracts and selected articles for full-text review. We included original studies assessing mediators in intra-abdominal sepsis/injury. Results Among 2437 citations, we selected 182 studies in the scoping review, including 79 preclinical and 103 clinical studies. Serum procalcitonin and C-reactive protein appear to be useful to rule out infection or monitor therapy; however, the diagnostic and prognostic value of mediators for complications/outcomes of sepsis or injury remains to be established. Peritoneal mediator levels are substantially higher than systemic levels after intra-abdominal infection/trauma. Common limitations of current studies included small sample sizes and lack of uniformity in study design and outcome measures. To date, targeted therapies against mediators remain experimental. Conclusions Whereas preclinical data suggests mediators play a critical role in intra-abdominal sepsis or injury, there is no consensus on the clinical use of mediators in diagnosing or managing intra-abdominal sepsis or injury. Measurement of peritoneal mediators should be further investigated as a more sensitive determinant of intra-abdominal inflammatory response. High-quality clinical trials are needed to better understand the role of inflammatory mediators. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1093-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zhengwen Xiao
- Regional Trauma Services, Foothills Medical Centre, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada.
| | - Crystal Wilson
- Regional Trauma Services, Foothills Medical Centre, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada.
| | - Helen Lee Robertson
- Health Sciences Library, Health Sciences Centre, University of Calgary, 3330 Hospital Drive NW, T2N 4N1, Calgary, AB, Canada.
| | - Derek J Roberts
- Department of Surgery, Foothills Medical Centre, University of Calgary, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada. .,Department of Community Health Sciences (Division of Epidemiology), University of Calgary, 3280 Hospital Drive Northwest, T2N 4Z6, Calgary, AB, Canada.
| | - Chad G Ball
- Regional Trauma Services, Foothills Medical Centre, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada. .,Department of Surgery, Foothills Medical Centre, University of Calgary, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada.
| | - Craig N Jenne
- Department of Critical Care Medicine, Foothills Medical Centre, University of Calgary, 3134 Hospital Drive NW, T2N 5A1, Calgary, AB, Canada. .,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3280 Hospital Drive NW, T2N 4N1, Calgary, AB, Canada.
| | - Andrew W Kirkpatrick
- Regional Trauma Services, Foothills Medical Centre, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada. .,Department of Surgery, Foothills Medical Centre, University of Calgary, 1403 - 29 Street NW, T2N 2T9, Calgary, AB, Canada. .,Department of Critical Care Medicine, Foothills Medical Centre, University of Calgary, 3134 Hospital Drive NW, T2N 5A1, Calgary, AB, Canada.
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Akinosoglou K, Gogos C. Immune-modulating therapy in acute pancreatitis: Fact or fiction. World J Gastroenterol 2014; 20:15200-15215. [PMID: 25386069 PMCID: PMC4223254 DOI: 10.3748/wjg.v20.i41.15200] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 05/21/2014] [Accepted: 06/17/2014] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP) is one of the most common diseases of the gastrointestinal tract, bearing significant morbidity and mortality worldwide. Current treatment of AP remains unspecific and supportive and is mainly targeted to aggressively prevent systemic complications and organ failure by intensive care. As acute pancreatitis shares an indistinguishable profile of inflammation with sepsis, therapeutic approaches have turned towards modulating the systemic inflammatory response. Targets, among others, have included pro- and anti-inflammatory modulators, cytokines, chemokines, immune cells, adhesive molecules and platelets. Even though, initial results in experimental models have been encouraging, clinical implementation of immune-regulating therapies in acute pancreatitis has had a slow progress. Main reasons include difficulty in clinical translation of experimental data, poor understanding of inflammatory response time-course, flaws in experimental designs, need for multimodal approaches and commercial drawbacks. Whether immune-modulation in acute pancreatitis remains a fact or just fiction remains to be seen in the future.
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Premkumar R, Phillips ARJ, Petrov MS, Windsor JA. The clinical relevance of obesity in acute pancreatitis: targeted systematic reviews. Pancreatology 2014; 15:25-33. [PMID: 25464938 DOI: 10.1016/j.pan.2014.10.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 09/26/2014] [Accepted: 10/15/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND With the rising prevalence of obesity, its impact on the severity and outcome of acute pancreatitis remains an important consideration when managing obese patients with acute pancreatitis. OBJECTIVE To determine the clinical relevance of obesity in acute pancreatitis. METHODS A series of clinically relevant questions were framed which formed the basis of our literature search using PubMed and EMBASE databases. These related to acute pancreatitis severity, systemic inflammatory response, mortality, local and systemic complications. The search was restricted to human studies. Studies were classified according to the Oxford Centre for Evidence Based Medicine levels of evidence 1 for prognostic studies. Obesity was defined according to the guidelines of the World Health Organization. In keeping with studies included the binary classification (mild and severe) of acute pancreatitis was used. RESULTS Obesity is associated with an amplified systemic inflammatory response in acute pancreatitis and is a prognostic factor for mortality, local, systemic complications and severity in acute pancreatitis. Obesity was not found to be an independent prognostic factor for mortality and organ failure in patients with acute pancreatitis. It was evident that further studies are required to determine whether incorporating obesity into existing scoring systems improves severity prediction. Emerging evidence suggests that an obesity paradox is present in patients with acute pancreatitis. CONCLUSION This review demonstrates that obesity has a clinically relevant impact on the course and outcome of acute pancreatitis.
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Affiliation(s)
- Rakesh Premkumar
- Surgical Center for Outcomes Research and Evaluation, Department of Surgery & Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand.
| | - Anthony R J Phillips
- Surgical Center for Outcomes Research and Evaluation, Department of Surgery & Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Maxim S Petrov
- Surgical Center for Outcomes Research and Evaluation, Department of Surgery & Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - John A Windsor
- Surgical Center for Outcomes Research and Evaluation, Department of Surgery & Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand.
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The Role of IL-6, 8, and 10, sTNFr, CRP, and Pancreatic Elastase in the Prediction of Systemic Complications in Patients with Acute Pancreatitis. Gastroenterol Res Pract 2013; 2013:282645. [PMID: 23476635 PMCID: PMC3583135 DOI: 10.1155/2013/282645] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Accepted: 11/26/2012] [Indexed: 12/16/2022] Open
Abstract
Background and Aim. Early assessment of severity in acute pancreatitis (AP) is a key measure to provide rational and effective management. The aim of our study is to determine the prognostic value of interleukins (IL) 6, 8, and 10, soluble receptor for tumor necrosis factor (sTNFr), pancreatic elastase (E1), and C-reactive protein (CRP) as predictors of systemic complications in AP. Patients and Methods. A hundred and fifty patients with confirmed AP were enrolled in the study. The severity of AP was defined according to Atlanta criteria. Measurements of interleukins and sTNFr were performed on the first day of admission. CRP and E1 levels were assessed on admission and after 48 hours. ROC analysis was performed for all parameters. Results. Interleukins and sTNFr significantly differentiated patients with systemic complications from those without. Elevation of IL-6 showed the highest significance as a predictor (P = 0.001). CRP and elastase levels did not differ between mild and severe cases on admission, but reached statistical significance when measured on the third day (P = 0.002 and P = 0.001, resp.). Conclusion. Our study confirmed that IL-6, IL-8, IL-10, and sTNFr measured on admission, and CRP and pancreatic elastase measured on third day of admission represent valuable prognostic factors of severity and systemic complications of AP.
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The clinical course of acute pancreatitis and the inflammatory mediators that drive it. Int J Inflam 2012; 2012:360685. [PMID: 23304633 PMCID: PMC3530799 DOI: 10.1155/2012/360685] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 11/09/2012] [Accepted: 11/15/2012] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP) is a common emergency condition. In the majority of cases, it presents in a mild and self-limited form. However, about 20% of patients develop severe disease with local pancreatic complications (including necrosis, abscess, or pseudocysts), systemic organ dysfunction, or both. A modern classification of AP severity has recently been proposed based on the factors that are causally associated with severity of AP. These factors are both local (peripancreatic necrosis) and systemic (organ failure). In AP, inflammation is initiated by intracellular activation of pancreatic proenzymes and/or nuclear factor-κB. Activated leukocytes infiltrate into and around the pancreas and play a central role in determining AP severity. Inflammatory reaction is first local, but may amplify leading to systemic overwhelming production of inflammatory mediators and early organ failure. Concomitantly, anti-inflammatory cytokines and specific cytokine inhibitors are produced. This anti-inflammatory reaction may overcompensate and inhibit the immune response, rendering the host at risk for systemic infection. Currently, there is no specific treatment for AP. However, there are several early supportive treatments and interventions which are beneficial. Also, increasing the understanding of the pathogenesis of systemic inflammation and the development of organ dysfunction may provide us with future treatment modalities.
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Abstract
OBJECTIVES This study aimed at T-cell inhibition by immunosuppressants to reduce cell damage and improve the course of severe acute pancreatitis (SAP). METHODS A taurocholate-induced SAP was used and 5 groups were compared: (1) rapamycin + FTY720, (2) rapamycin, (3) FTY720, (4) cortisol, and (5) control: sodium chloride. Drugs were applied intravenously at SAP induction; 6 hours later, rats were killed. Interleukin (IL)-1, IL-6, IL-10, tumor necrosis factor α, platelet-activating factor, amylase, and lipase were measured in serum and myeloperoxidase tissue activity in pancreas, kidney, lung, liver, and spleen. Edema, inflammation, and necrosis were histologically determined in pancreas. CD4/CD8 immunohistochemistry was performed. RESULTS Inflammation was ameliorated in all 4 treated groups. Necrosis development was suppressed by FTY720, FTY720 + rapamycin, and cortisol. IL-6 and IL-10 were significantly lower in these groups. Amylase was higher in all treatment groups compared to the controls except for the cortisol group. Tumor necrosis factor α, lipase, and myeloperoxidase activity were not affected by therapy. CD4+/CD8+ cells were significantly less in FTY720-treated pancreata. CONCLUSION Rapamycin and FTY720 ameliorated the severity of SAP, which may be due to early suppression of helper T cells. FTY720 reduced the development of pancreatic necrosis. The combination of both immunosuppressants did not show advantage to treatment with FTY720 alone.
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Aoun E, Chen J, Reighard D, Gleeson FC, Whitcomb DC, Papachristou GI. Diagnostic accuracy of interleukin-6 and interleukin-8 in predicting severe acute pancreatitis: a meta-analysis. Pancreatology 2010; 9:777-85. [PMID: 20110745 DOI: 10.1159/000214191] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Accepted: 04/09/2009] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The early identification of patients at risk for severe acute pancreatitis (SAP) is crucial. Serum markers of disease severity have been assessed including interleukin (IL)-6 and IL-8; however, their predictive accuracy has varied significantly across studies. We conducted a meta-analysis to assess the accuracy of IL-6 and IL-8 at predicting SAP. METHODS We identified relevant published articles and calculated pooled sensitivities, specificities and likelihood ratios using the random-effect model. We included values for days 1, 2 and 3 of presentation for IL-6 and for days 1 and 2 for IL-8. We also constructed summary receiver-operating curves and assessed the area under the curve (AUC) and the diagnostic odds ratios (DORs) as measures of diagnostic accuracy. RESULTS For IL-6, we included 7 reports for day 1 and 4 reports for days 2 and 3. For IL-8, we analyzed 5 studies for day 1 and 4 for day 2. The pooled IL-6 sensitivities ranged between 81.0 and 83.6% and specificities between 75.6 and 85.3% with positive likelihood ratios of 3.43, 4.90 and 4.40 for days 1, 2 and 3, respectively. The IL-8 pooled sensitivities were 65.8 and 70.9% with specificities of 66.5 and 91.3% for days 1 and 2 with positive likelihood ratios of 1.96 and 8.15. The IL-6 AUCs were 0.75, 0.88 and 0.85 for days 1, 2 and 3. The IL-8 AUCs were 0.73 and 0.91 for days 1 and 2. The DOR for IL-6 was higher than that of IL-8 on day 1. CONCLUSION IL-6 and IL-8 seem to perform at an acceptable level in predicting SAP. Larger confirmatory studies formally comparing this performance with that of more commonly used markers are needed.
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Affiliation(s)
- Elie Aoun
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pa., USA
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Chen XL, Ciren SZ, Zhang H, Duan LG, Wesley AJ. Effect of 5-FU on modulation of disarrangement of immune-associated cytokines in experimental acute pancreatitis. World J Gastroenterol 2009; 15:2032-7. [PMID: 19399939 PMCID: PMC2675097 DOI: 10.3748/wjg.15.2032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effects of 5-Fluorouracil (5-FU) on modulation of pro-inflammatory and anti-inflammatory cytokines in acute pancreatitis and the mechanism of it in the treatment of acute pancreatitis.
METHODS: Male Sprague Dawley rats were assigned to 3 Groups: Group A, sham operated rats as controls (n = 7); Group B, acute pancreatitis induced by ductal injection with 5% sodium cholate at a volume of 1.0 mL/kg without any other treatment; Group C, after the pancreatitis was induced as in Group B, the rats were injected intravenously with 5-FU 40 mg/kg. The animals in Groups B and C were killed at 2, 6 and 24 h after operation (n = 7), and blood samples were taken for measurement of tumor necrosis factor-α (TNF-α), interleukin-1 (IL-1), interleukin-6 (IL-6) (by bioassay), and interleukin-10 (IL-10), transforming growth factor-β (TGF-β) (by ELISA). The wet weight of pancreatic tissue, serum amylase levels and white blood cells were also measured.
RESULTS: Four rats in Group B and one in Group C died after pancreatitis was induced. Both pro-inflammatory cytokines (TNF-α, IL-1, IL-6) at the 2 and 6 h period and the anti-inflammatory cytokines (IL-10, TGF-β) at 24 h increased significantly (P < 0.05) in rats of Group B. After treatment with 5-FU, TNF-α, IL-1, and IL-6 in serum of rats of Group C were inhibited at 2 and 6 h after operation (P < 0.05), and IL-10, TGF-β were inhibited at 24 h compared to Group B (P < 0.05). Obvious improvements in the severity of the acute pancreatitis, including the amylase levels, wet weight of pancreatic tissue and neutrophil counts, were also observed after treatment with 5-FU.
CONCLUSION: 5-FU is an anti-metabolic and immunosuppressive agent which can minimize the abnormal immune cytokine response and relieve the pathophysiological disorders associated with experimental acute pancreatitis.
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Early induction of moderate hypothermia suppresses systemic inflammatory cytokines and intracellular adhesion molecule-1 in rats with caerulein-induced pancreatitis and endotoxemia. Pancreas 2008; 37:176-81. [PMID: 18665080 DOI: 10.1097/mpa.0b013e318162cb26] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To evaluate the systemic effects of moderate hypothermia (MH) and the timing of induction on acute pancreatitis (AP) and endotoxemia in rats. METHODS The effects of MH were compared in 4 groups, that is, sham group (38 degrees C), control group (38 degrees C), early MH group (32 degrees C on administration of lipopolysaccharide [LPS]), and delayed MH group (32 degrees C 1 hour after LPS). AP and endotoxemia were induced by intramuscular injection of caerulein and intraperitoneal injection of LPS. RESULTS Serum interleukin 6 (IL-6) in both MH groups was significantly lower than that in the control group at 3 hours. Serum interleukin 10 (IL-10) in the early MH group was significantly higher than those in the other 3 groups at 1 hour. IL-10/IL-6 ratios in both MH groups were significantly higher than that in the control group at 3 hours. Serum soluble intercellular adhesion molecule (sICAM-1) in both MH groups was significantly lower than that in the control group at 3 hours. Serum sICAM-1 in the early MH group was significantly lower than that in the delayed MH group. The tendency of pancreatic ICAM-1 was similar to that of serum sICAM-1. CONCLUSIONS Early induction of MH might be protective against pancreatic injury and systemic inflammation in AP and endotoxemia.
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Sempere L, Martinez J, de Madaria E, Lozano B, Sanchez-Paya J, Jover R, Perez-Mateo M. Obesity and fat distribution imply a greater systemic inflammatory response and a worse prognosis in acute pancreatitis. Pancreatology 2008; 8:257-64. [PMID: 18497538 DOI: 10.1159/000134273] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Accepted: 12/12/2007] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Acute pancreatitis (AP) is a systemic inflammatory disease. It is already known that obesity and central fat distribution are related to the severity of AP, but the intimate mechanism of this relationship remains unknown. Obesity and central fat distribution are associated with an inflammatory state that could amplify the systemic inflammatory response (SIR) in AP. The aim of this study was to investigate how obesity and body fat distribution correlate with the SIR and severity of AP. METHODS 85 consecutive patients with AP were studied. Body mass index, body fat distribution and previous comorbidity were obtained at admission. The SIR was assessed by the serum levels of interleukin (IL)-1beta, IL-1ra, IL-6, IL-8, IL-10, IL-12p70, tumor necrosis factor-alpha (TNF-alpha) and C-reactive protein. Serum concentrations of the previously mentioned cytokines were also determined in a control group of 40 healthy volunteers. RESULTS 63 patients (74%) had mild AP and 22 patients (26%) had severe AP. All the cytokines except IL-12p70 and TNF-alpha were increased in the AP group in comparison with the control group. The SIR was significantly increased in patients with severe AP. Obese patients and patients with central fat distribution had significantly more comorbidity, a higher proportion of severe AP and more intense SIR. Patients with comorbidity had a significantly higher proportion of severe AP and more SIR. CONCLUSION The severity of AP in obese patients and in patients with central fat distribution seems to be related to the comorbidity and the amplification of SIR. and IAP.
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Affiliation(s)
- Laura Sempere
- Department of Gastroenterology, Hospital General Universitario de Alicante, Alicante, Spain
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Abo-Zenah HA, Shoeb SA, Sabry AA, Ismail HA. Relating circulating thyroid hormone concentrations to serum interleukins-6 and -10 in association with non-thyroidal illnesses including chronic renal insufficiency. BMC Endocr Disord 2008; 8:1. [PMID: 18211669 PMCID: PMC2254394 DOI: 10.1186/1472-6823-8-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2007] [Accepted: 01/22/2008] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Because of the possible role of cytokines including interleukins (IL) in systemic non-thyroidal illnesses' (NTI) pathogenesis and consequently the frequently associated alterations in thyroid hormone (TH) concentrations constituting the euthyroid sick syndrome (ESS), we aimed in this research to elucidate the possible relation between IL-6 & IL-10 and any documented ESS in a cohort of patients with NTI. METHODS Sixty patients and twenty healthy volunteers were recruited. The patients were subdivided into three subgroups depending on their underlying NTI and included 20 patients with chronic renal insufficiency (CRI), congestive heart failure (CHF), and ICU patients with myocardial infarction (MI). Determination of the circulating serum levels of IL-6 and IL-10, thyroid stimulating hormone (TSH), as well as total T4 and T3 was carried out. RESULTS In the whole group of patients, we detected a significantly lower T3 and T4 levels compared to control subjects (0.938 +/- 0.477 vs 1.345 +/- 0.44 nmol/L, p = 0.001 and 47.9 +/- 28.41 vs 108 +/- 19.49 nmol/L, p < 0.0001 respectively) while the TSH level was normal (1.08+0.518 muIU/L). Further, IL-6 was substantially higher above controls' levels (105.18 +/- 72.01 vs 3.35 +/- 1.18 ng/L, p < 0.00001) and correlated negatively with both T3 and T4 (r = -0.620, p < 0.0001 & -0.267, p < 0.001, respectively). Similarly was IL-10 level (74.13 +/- 52.99 vs 2.64 +/- 0.92 ng/ml, p < 0.00001) that correlated negatively with T3 (r = -0.512, p < 0.0001) but not T4. Interestingly, both interleukins correlated positively (r = 0.770, p = <0.001). Moreover, IL-6 (R2 = 0.338, p = 0.001) and not IL-10 was a predictor of low T3 levels with only a borderline significance for T4 (R2 = 0.082, p = 0.071).By subgroup analysis, the proportion of patients with subnormal T3, T4, and TSH levels was highest in the MI patients (70%, 70%, and 72%, respectively) who displayed the greatest IL-6 and IL-10 concentrations (192.5 +/- 45.1 ng/L & 122.95 +/- 46.1 ng/L, respectively) compared with CHF (82.95 +/- 28.9 ng/L & 69.05 +/- 44.0 ng/L, respectively) and CRI patients (40.05 +/- 28.9 ng/L & 30.4 +/- 10.6 ng/L, respectively). Surprisingly, CRI patients showed the least disturbance in IL-6 and IL-10 despite the lower levels of T3, T4, and TSH in a higher proportion of them compared to CHF patients (40%, 45%, & 26% vs 35%, 25%, & 18%, respectively). CONCLUSION the high prevalence of ESS we detected in NTI including CRI may be linked to IL-6 and IL-10 alterations. Further, perturbation of IL-6 and not IL-10 might be involved in ESS pathogenesis although it is not the only key player as suggested by our findings in CRI.
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Affiliation(s)
- Hamdy A Abo-Zenah
- Departments Of Internal Medicine, Faculty Of Medicine, Menufiya University, Egypt
| | - Sabry A Shoeb
- Departments Of Internal Medicine, Faculty Of Medicine, Menufiya University, Egypt
| | - Alaa A Sabry
- Mansura Urology and Nephrology Institute, Mansura University, Egypt
| | - Hesham A Ismail
- Molecular Diagnostic Department, Genetic Engineering and Biotechnology Research Institute, Menufiya University, Egypt
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Mentula P, Kylänpää ML, Kemppainen E, Repo H, Puolakkainen P. Early inflammatory response in acute pancreatitis is little affected by body mass index. Scand J Gastroenterol 2007; 42:1362-8. [PMID: 17852885 DOI: 10.1080/00365520701427086] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Obesity is a known risk factor for severe acute pancreatitis (AP), but the mechanism by which it affects the severity of AP is not fully understood. The main objective of this study was to investigate the relationship between obesity and inflammatory markers in AP. MATERIAL AND METHODS Thirty patients with AP who developed organ failure (Group I) and 87 patients with AP who survived without organ failure (Group II) were studied. Patients' height and weight were measured at admission for calculation of body mass index (BMI). Blood samples were taken at admission for measurement of plasma interleukin (IL)-1beta, IL-6, IL-10, IL-1 receptor antagonist, procalcitonin, C-reactive protein (CRP) and monocyte human leucocyte antigen (HLA)-DR expression. RESULTS Group I patients had higher BMI values (median 26.2 kg/m2) than Group II patients (25.2 kg/m2), p =0.033. Both CRP values and monocyte HLA-DR expression showed a significant correlation with BMI (Spearman's rank correlation r=0.32, p =0.003 and r= -0.33, p = 0.002, respectively). The correlation between BMI and monocyte HLA-DR expression was significant in Group II patients (r = -0.34, p =0.002) but not in Group I patients (r = -0.02, p >0.05). There was no correlation between BMI and IL-1beta, IL-6, IL-10, IL-1 receptor antagonist or procalcitonin. CONCLUSIONS BMI did not affect either proinflammatory or anti-inflammatory cytokine levels in early AP. However, in patients with mild AP, BMI correlated positively with CRP levels and inversely with monocyte HLA-DR expression, which might reflect an amplified inflammatory response in these patients. Taken together, acute inflammatory response in AP, which ultimately determines the severity of AP, was little affected by BMI.
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Affiliation(s)
- Panu Mentula
- Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland.
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21
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Sullivan DH, Roberson PK, Johnson LE, Mendiratta P, Bopp MM, Bishara O. Association between Inflammation-Associated Cytokines, Serum Albumins, and Mortality in the Elderly. J Am Med Dir Assoc 2007; 8:458-63. [PMID: 17845949 DOI: 10.1016/j.jamda.2007.04.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate the association between serum albumin, prealbumin, various serum inflammation associated-cytokines, and mortality in older geriatric recuperative care patients. DESIGN A prospective cohort study. SETTING A geriatric rehabilitation unit of a university-affiliated Department of Veterans Affairs hospital. PARTICIPANTS Participants were 53 geriatric patients (mean age 78 +/- 7.3, 96% male) admitted to a Geriatric Evaluation and Management (GEM) unit. Patients with documented near-terminal medical disorder, overt infections, and any systemic or localized inflammatory disorders were excluded. MEASUREMENTS Inflammation-associated cytokines (IL-8, IL-1beta, IL-6, IL-10, TNF-alpha), albumin, prealbumin, and C-reactive protein were measured at hospital discharge and each subject was then tracked for 1 year. MAIN RESULTS By Cox Proportional-Hazards Regression analysis, the strongest predictor of mortality within 6 months of study entry was the serum IL-6. For each log increase in IL-6, there was nearly a 9-fold greater 6-month mortality risk (RR 8.99, 95% CI 1.65 to 49.03). The association between albumin and mortality was no longer significant after controlling for IL-6. There was a strong inverse correlation between IL-6 and both albumin (R2 0.39, P < .001) and prealbumin (R2 0.41, P < .001). CONCLUSION Subclinical inflammation appears to be an important factor contributing to low serum albumins in older recuperative care patients and may confound the association between albumin and mortality in this population. More in-depth studies of these associations are warranted.
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Affiliation(s)
- Dennis H Sullivan
- Geriatric Research Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, AR 72205, USA.
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Sathyanarayan G, Garg PK, Prasad H, Tandon RK. Elevated level of interleukin-6 predicts organ failure and severe disease in patients with acute pancreatitis. J Gastroenterol Hepatol 2007; 22:550-4. [PMID: 17376050 DOI: 10.1111/j.1440-1746.2006.04752.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIM Cytokines play an important role in the pathogenesis of acute pancreatitis (AP). The aim of the present paper was to study the profile of anti- and proinflammatory cytokines in AP and to determine their predictive value for severity of AP, organ failure and mortality. METHODS Consecutive patients with AP were included in the study. Cytokines were measured in those patients who presented within the first 72 h of the onset of AP. Plasma levels of proinflammatory cytokines tumor necrosis factor (TNF)-alpha, interleukin (IL)-Ibeta, IL-6 and anti-inflammatory cytokine IL-10 were measured on days 1, 3, 7 and 14 of AP. RESULTS Of 108 patients, 30 presented within 72 h of the onset (mean age 40.27 +/- 13.89 years; 22 males). Of the 30 patients, 13 (43.3%) had severe and 17 (56.7%) had mild pancreatitis. Eleven (36.7%) patients developed organ failure and three died. The level of IL-6 on day 3 was significantly higher in severe pancreatitis than in mild pancreatitis (146.29 +/- 57.53 pg/mL vs 91.42 +/- 71.65 pg/mL; P = 0.04) and was significantly higher in patients who developed organ failure compared with those who did not (161.59 +/- 53.46 pg/mL vs 88.16 +/- 65.50 pg/mL; P = 0.004). At a cut-off value of 122 pg/mL on day 3, IL-6 predicted organ failure and severe pancreatitis with a sensitivity and specificity of 81.8% and 77.7%, respectively. TNF-alpha and IL-10 were detectable only in one-third of patients and were not related to the severity of pancreatitis, while Il-1beta was not detectable. CONCLUSION Elevated levels of IL-6 predicted organ failure and severe pancreatitis and suggested its pathophysiological significance in AP.
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Affiliation(s)
- Garipati Sathyanarayan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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Jordan WJ, Eskdale J, Boniotto M, Rodia M, Kellner D, Gallagher G. Modulation of the human cytokine response by interferon lambda-1 (IFN-lambda1/IL-29). Genes Immun 2007; 8:13-20. [PMID: 17082759 DOI: 10.1038/sj.gene.6364348] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Accepted: 09/12/2006] [Indexed: 12/15/2022]
Abstract
The interferon lambda family (IFN-lambda1/2/3) is a newly described group of cytokines that are related to both the type-1 interferons and IL-10 family members. These novel cytokines are induced during viral infection and, like type-1 interferons, display significant anti-viral activity. In order to understand their function in more depth, we have examined the ability of IFN-lambda1/IL-29 to regulate cytokine production by human immune cells. Whole peripheral blood mononuclear cells (PBMC) exposed to IFN-lambda1 specifically upregulated IL-6, -8 and -10 but there were no visible effects on TNF or IL-1. This response was produced in a dose-dependant fashion and was inhibited by IL-10. Examination of purified cell populations isolated from PBMC demonstrated that monocytes, rather than lymphocytes, were the major IFN-lambda1-responsive cellular subset, producing IL-6, -8 and -10 in response to IFN-lambda1. Monocyte responses induced by low-level LPS stimulation were also synergistically enhanced by the presence of IFN-lambda1. Human macrophages were also shown to react to IFN-lambda1 similarly to monocytes, by producing the cytokines IL-6, -8 and -10. In conclusion, we have shown that IFN-lambda1, a cytokine produced in response to viral infection, activates both monocytes and macrophages producing a restricted panel of cytokines and may therefore be important in activating innate immune responses at the site of viral infection.
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Affiliation(s)
- W J Jordan
- Department of Oral Biology, New Jersey Dental School, Newark, NJ, USA
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Simovic MO, Ballard BR, Gray KD, Stain SC. The STAT4 and STAT6 Pathways in Pancreatitis-Associated Lung Injury. J Surg Res 2007; 137:10-5. [PMID: 17109890 DOI: 10.1016/j.jss.2006.07.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2006] [Revised: 07/18/2006] [Accepted: 07/19/2006] [Indexed: 01/13/2023]
Abstract
BACKGROUND The STAT pathways are integral to the inflammatory response and these proteins provide a direct link between the cytokine receptors and cytokine-induced gene transcription. We examined the roles of STAT4 and STAT6 in lung injury after caerulein-induced severe acute pancreatitis. We hypothesized that a modified organ expression of cytokines and chemokines that occurs in transgenic mice may affect the systemic response to severe acute pancreatitis. METHODS Acute pancreatitis [13-hourly intraperitoneal injections of caerulein (50 microg/kg body weight, 0.2 mL) or the same volume of saline] was induced in wild-type (BALB/c) and transgenic (STAT4 or STAT6) mice of the same background, 7 to 8 weeks old. The pancreatic and lung tissues were collected at 1, 6, 12, and 24 h after the completion of caerulein administration. Tissue leukocyte sequestration was assessed by myeloperoxidase (MPO) activity. Standard histological staining hematoxylin and eosin was performed and blindly scored by a pathologist for evidence of lung injury (pulmonary edema, accumulations of neutrophils and mononuclear cells, thickness of alveolar-capillary membrane, perivascular infiltrate, and hemorrhage). RESULTS Caerulein-treated wild-type mice exhibited increased lung injury score at 1 through 12 h, as compared to saline controls. As compared to wild-type, STAT6-deficient mice had increased lung injury from 1 to 6 h, with full recovery by 12 h. An opposite pattern was observed in STAT4-deficient mice with mild injury seen at 1 and 6 h, and maximal injury at 12 h. MPO activity was significantly increased at 6 h in caerulein-treated wild-type mice compared to saline-treated controls. Caerulein-treated STAT6 and STAT4 mice had markedly increased MPO activity as compared with their saline controls during the first 6 h. Both caerulein-treated STAT4- and STAT6-deficient mice had significantly increased MPO activity in comparison with wild-type mice with pancreatitis at 6 h. CONCLUSION We found the maximal lung injury after caerulein-induced pancreatitis occurred at different time-points in STAT4 and STAT6-deficient mice. These temporal differences may suggest alternative roles in the systemic inflammatory response associated with pancreatitis.
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Affiliation(s)
- Misho O Simovic
- Department of Surgery, Meharry Medical College, Nashville, Tennessee, USA.
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Abstract
Acute pancreatitis has an incidence of approximately 40 cases per year per 100,000 adults. Although usually self-limiting, 10% to 20% of afflicted patients will progress to severe pancreatitis. The mortality rate among patients with severe pancreatitis may approach 30% when they progress to multisystem organ failure. The development of acute pancreatitis illustrates the requirement for understanding the basic mechanisms of disease progression to drive the exploration of therapeutic options. The pathogenesis of acute pancreatitis involves the interplay of local and systemic immune responses that are often difficult to characterize, particularly when results from animal models are used as a foundation for human trials. Experimental studies suggest that the prognosis for acute pancreatitis depends upon the degree of pancreatic necrosis and the intensity of multisystem organ failure generated by the systemic inflammatory response. This suggests an intricate balance between localized tissue damage with proinflammatory cytokine production and a systemic, anti-inflammatory response that restricts the inappropriate movement of proinflammatory agents into the circulation. The critical players of this interaction include the proinflammatory cytokines IL-1beta, TNF-alpha, IL-6, IL-8, and platelet activating factor (PAF). The anti-inflammatory cytokines IL-10, as well as TNF-soluble receptors and IL-1 receptor antagonist, have also been shown to be intimately involved in the inflammatory response to acute pancreatitis. Other compounds implicated in disease pathogenesis in experimental models include complement, bradykinin, nitric oxide, reactive oxygen intermediates, substance P, and higher polyamines. Several of these mediators have been documented to be present at increased concentrations in the plasma of patients with severe, acute pancreatitis. Preclinical work has shown that some of these mediators are markers for disease activity, whereas other inflammatory components may actually drive the disease process as important mediators. Implication of such mediators suggests that interruption or blunting of an inappropriate immune response has the potential to improve outcome. Although the manipulations of specific mediators in animal models may be promising, they may not transition well to the human clinical setting. However, continued reliance on experimental animal models of acute pancreatitis may be necessary to determine the underlying causes of disease. Full understanding of these basic mechanisms involves determining not only which mediators are present, but also closely documenting the kinetics of their appearance. Measurement of the inflammatory response may also serve to identify diagnostic markers for the presence of acute pancreatitis and provide insight into prognosis. Understanding the models, documenting the markers, and deciphering the mediators have the potential to improve treatment of acute pancreatitis.
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Affiliation(s)
- Jill Granger
- Department of Pathology, University of Michigan, Ann Arbor, MI 48109-0602, USA
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Schetz MR, Van den Berghe G. Do we have reliable biochemical markers to predict the outcome of critical illness? Int J Artif Organs 2006; 28:1197-210. [PMID: 16404695 DOI: 10.1177/039139880502801202] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Current outcome prediction in critically ill patients relies on the art of clinical judgement and/or the science of prognostication using illness severity scores. The biochemical processes underlying critical illness have increasingly been unravelled. Several biochemical markers reflecting the process of inflammation, immune dysfunction, impaired tissue oxygenation and endocrine alterations have been evaluated for their predictive power in small subpopulations of critically ill patients. However, none of these parameters has been validated in large populations of unselected ICU patients as has been done for the illness severity and organ failure scores. A simple biochemical predictor of ICU mortality will probably remain elusive because the processes underlying critical illness are very complex and heterogeneous. Future prognostic models will need to be far more sophisticated.
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Affiliation(s)
- M R Schetz
- Department of Intensive Care Medicine, Catholic University of Leuven, Leuven, Belgium
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Stimac D, Fisić E, Milić S, Bilić-Zulle L, Perić R. Prognostic values of IL-6, IL-8, and IL-10 in acute pancreatitis. J Clin Gastroenterol 2006; 40:209-12. [PMID: 16633121 DOI: 10.1097/00004836-200603000-00007] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
GOALS The prognostic importance of interleukin-6 (IL-6), IL-8, and IL-10 in the prediction of acute pancreatitis severity. BACKGROUND Early assessment of severity in acute pancreatitis could help the patients who are at risk of developing complications. Unfortunately, the used prognostic scoring systems generally are only moderately accurate in assessing disease severity. STUDY We studied 117 consecutive patients with a diagnosis of acute pancreatitis admitted to our hospital during the past 2 years. Laboratory parameters and cytokines were analyzed from serum taken routinely on admission. Severity criteria were noted for each patient using Ranson, Glasgow, and APACHE II scoring systems. Local and systemic complications, developed during a follow-up period, were classified by Atlanta criteria. RESULTS IL-6 was the only parameter that statistically significantly predicted complicated acute pancreatitis (P<0.05). IL-8 and IL-10 and the 3 prognostic scoring systems used did not properly assess complicated versus noncomplicated acute pancreatitis. CONCLUSIONS Our prospective study supported the potential importance of IL-6 in the early assessment of complicated acute pancreatitis, but also suggested that pancreatitis classified as complicated in a large number of patients could not be correctly predicted with the Ranson, Glasgow, and APACHE II scoring systems.
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Affiliation(s)
- Davor Stimac
- Division of Gastroenterology, Department of Internal Medicine, Clinical Hospital Center Rijeka, Rijeka, Croatia.
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Laveda R, Martinez J, Munoz C, Penalva JC, Saez J, Belda G, Navarro S, Feu F, Mas A, Palazon JM, Sanchez-Paya J, Such J, Perez-Mateo M. Different profile of cytokine synthesis according to the severity of acute pancreatitis. World J Gastroenterol 2005; 11:5309-13. [PMID: 16149137 PMCID: PMC4622800 DOI: 10.3748/wjg.v11.i34.5309] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the cellular synthetic ability of cytokines involved in pro- and anti-inflammatory reactions in patients with AP.
METHODS: Sixty-seven patients with AP (16 severe, 51 mild) and 10 controls were included in the study. Cultures of whole blood were performed in samples obtained within the first 72 h from the onset of pain. Serum levels of interleukins (IL) 6, 8, 10, and TNF-α were measured at baseline and in the supernatant of cultures with (functional reserve) or without stimulation with phytohemaglutinin.
RESULTS: Basal levels of cytokines were significantly higher in patients with severe AP. A significant increase of all pro-inflammatory cytokines vs basal levels was observed in the supernatant after 24 h of whole blood cultures in patients, but not in controls. In contrast, IL-10 increased significantly in the supernatant of cultures only in patients with mild AP. Cells showed a statistically significant functional reserve for all IL in patients with mild, but only for pro-inflammatory cytokines in patients with severe AP.
CONCLUSION: A marked activation of immune system may be observed in patients with AP, being balanced between pro- and anti-inflammatory cytokines in patients with mild but not severe AP. A reduced functional reserve for the synthesis of IL-10 may be observed in patients with severe AP, which might lead to a worst prognosis.
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Affiliation(s)
- Raquel Laveda
- Department of Gastroenterology, Hospital General Universitario de Alicante, Pintor Baeza s/n, Alicante 03010, Spain
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Mentula P, Kylänpää ML, Kemppainen E, Jansson SE, Sarna S, Puolakkainen P, Haapiainen R, Repo H. Early prediction of organ failure by combined markers in patients with acute pancreatitis. Br J Surg 2005; 92:68-75. [PMID: 15521080 DOI: 10.1002/bjs.4786] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Several biological markers and clinical scoring systems have been used to predict the course of acute pancreatitis. Because organ failure is the most severe complication of the disease, prognostic markers and their combinations that would predict organ failure on hospital admission were sought. METHODS Some 351 consecutive patients with acute pancreatitis were studied. Blood samples were taken within 12 h of admission. This case-control study included all 33 patients with organ failure and 99 matched controls without organ failure. Measurements included 19 prognostic markers and Acute Physiology And Chronic Health Evaluation (APACHE) II score. RESULTS Plasma interleukin 10, serum glucose and serum calcium were identified as independent predictors of organ failure by logistic regression analysis. Calcium level correlated with clinical onset of organ failure. The combination of interleukin 10 (more than 50 pg/ml) or calcium (less than 1.65 mmol/l) was a significantly better predictor than any single marker or APACHE II score, with a sensitivity of 88 per cent, specificity 93 per cent and diagnostic odds ratio 94. CONCLUSION Organ failure in acute pancreatitis can be predicted with high accuracy at hospital admission using a combination of plasma interleukin 10 and serum calcium measurements.
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Affiliation(s)
- P Mentula
- Department of Bacteriology and Immunology, Haartman Institute, University of Helsinki, Finland
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Predictive value of pro- and anti-inflammatory cytokines in assessing severity and outcome of acute pancreatitis. ACTA ACUST UNITED AC 2005. [DOI: 10.2298/jmb0504253m] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Abstract
PURPOSE OF REVIEW A major health care trend in the last decade has been the increased use of complementary and alternative medicine and nutritional supplements. Indeed, we now have Physician's Desk References for both herbal therapies and dietary supplements. A large amount of out-of-pocket dollars are spent on complementary and alternative medicine each year in the United States, and complementary and alternative medicine users believe strongly in the efficacy of their treatments. RECENT FINDINGS In the area of inflammatory bowel disease, probiotics appear to be a highly promising form of therapy. In acute pancreatitis, enteral nutrition has been shown to be safe and effective. Peppermint oil is one of the most widely used complementary and alternative medicine therapies for irritable bowel syndrome. Antioxidants are increasingly used in liver disease, especially agents involved in methionine metabolism. Both S-adenosylmethionine and betaine have shown efficacy in animal models of alcoholic liver disease, and "knockout" mice that develop S-adenosylmethionine deficiency also develop steatohepatitis. Thus, there is great interest in these complementary and alternative medicine agents in both alcoholic liver disease and nonalcoholic steatohepatitis. There are also important safety issues related to complementary and alternative medicine. Deaths of well-known athletes have highlighted the risks of ephedra, and some research suggests that complementary and alternative medicine agents are a major cause of fulminant liver failure necessitating liver transplantation. SUMMARY Thus, physicians must be aware not only of the potential therapeutic benefits of complementary and alternative medicine agents and nutritional supplements, but also their potential risks, including toxicity and drug interactions.
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Affiliation(s)
- Kristine J Krueger
- Department of Internal Medicine, University of Louisville Medical Center, Kentucky 40292, USA
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Kusnierz-Cabala B, Kedra B, Sierzega M. Current concepts on diagnosis and treatment of acute pancreatitis. Adv Clin Chem 2003; 37:47-81. [PMID: 12619705 DOI: 10.1016/s0065-2423(03)37006-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- B Kusnierz-Cabala
- Department of Clinical Biochemistry, Collegium, Medicum Jagiellonian University, Krakow, Poland
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Wereszczynska-Siemiatkowska U, Dabrowski A, Siemiatkowski A, Mroczko B, Laszewicz W, Gabryelewicz A. Serum profiles of E-selectin, interleukin-10, and interleukin-6 and oxidative stress parameters in patients with acute pancreatitis and nonpancreatic acute abdominal pain. Pancreas 2003; 26:144-52. [PMID: 12604912 DOI: 10.1097/00006676-200303000-00010] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Excessive inflammatory response is one of the major causes of early mortality in acute pancreatitis (AP). AIM To evaluate the serum profiles of E-selectin, interleukin (IL)-6, and IL-10 along with their correlation to the markers of oxidative stress and neutrophil activation in patients with AP and patients with nonpancreatic acute abdominal pain (NPAAP). METHODOLOGY This prospective clinical study included 56 patients with AP (28 with mild AP and 28 with severe AP) as well as 15 patients with NPAAP. RESULTS Serum concentrations of E-selectin, IL-10, and IL-6 and plasma concentrations of polymorphonuclear leukocyte elastase (determined on days 1-3, 5, and 10 after admission) were the highest in severe AP during the first 3 days and then declined. At day 10, the E-selectin level in severe AP was still higher than that in mild AP, and the IL-10 concentration increased again. There was no elevation in the E-selectin concentration in NPAAP patients, and IL-10 levels remained unchanged in mild AP. Oxidative stress, measured by serum malondialdehyde and 4-hydroxyalkenals levels, was the most pronounced in severe AP. CONCLUSIONS The serum E-selectin concentration is markedly elevated in severe AP and is less in mild AP but not in NPAAP. It may result from stimulation with different inflammatory mediators or indicate vascular endothelium injury mediated by oxidative stress, especially in the severe form of AP.
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Loisa P, Rinne T, Laine S, Hurme M, Kaukinen S. Anti-inflammatory cytokine response and the development of multiple organ failure in severe sepsis. Acta Anaesthesiol Scand 2003; 47:319-25. [PMID: 12648199 DOI: 10.1034/j.1399-6576.2003.00004.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The production of proinflammatory cytokines activates the systemic inflammatory response in sepsis. Patients also develop a compensatory anti-inflammatory reaction, which may have an important down-regulatory effect on the overactive inflammation. However, the role of this anti-inflammatory response in sepsis is not completely clarified. In this prospective study, we investigated the relationship between the pro- and anti-inflammatory cytokine profiles in severe sepsis and their role in the development of multiple organ failure (MOF). METHODS Thirty-eight patients meeting the criteria for severe sepsis were studied. MOF was defined as a maximum SOFA score of 10 or higher. Serial measurements of the proinflammatory IL-6 and IL-1beta and the anti-inflammatory IL-10 and IL-1ra were used. The cytokine samples were taken at the onset of sepsis and on the third and fifth day during the ICU period. RESULTS The initial IL-10 and IL-1ra responses were identical in patients with or without MOF. The anti-inflammatory cytokine levels remained elevated in the MOF patients, whereas in patients without MOF the levels declined. The IL-6/IL-10 ratio was significantly higher in the MOF patients on days 1 and 3 compared with patients without MOF. CONCLUSIONS We could not demonstrate overproduction of anti-inflammatory IL-10 in MOF patients. On the contrary, the high IL-6/IL-10 ratio indicates that IL-10 deficiency may contribute to the development of MOF in severe sepsis.
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Affiliation(s)
- P Loisa
- Departments of Anaesthesia and Intensive Care, Tampere University Hospital, Tampere, Finland.
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Rivera-Chavez FA, Wheeler H, Lindberg G, Munford RS, O'Keefe GE. Regional and systemic cytokine responses to acute inflammation of the vermiform appendix. Ann Surg 2003; 237:408-16. [PMID: 12616126 PMCID: PMC1514319 DOI: 10.1097/01.sla.0000055274.56407.71] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To measure local (peritoneal fluid) and systemic (plasma) cytokine profiles in patients with infection-inflammation of the vermiform appendix, a relatively mild, localized inflammatory process. SUMMARY BACKGROUND DATA The systemic host response to invading microorganisms, often termed the systemic inflammatory response syndrome (SIRS), includes changes in heart rate, respiratory rate, body temperature, and circulating white blood cell numbers. Although these changes can be induced experimentally by administering proinflammatory cytokines, the mediators that appear in the bloodstream during early, localized infection in humans have not been defined. METHODS The authors studied 56 patients with pathologically proven appendicitis. Blood was obtained before the induction of anesthesia, when 82% of the patients met the criteria for SIRS. Peritoneal fluid (PF) was obtained by intraoperative lavage. Cytokines were measured by immunoassay. To assess the net impact of the mediators within plasma, the authors studied the ability of patient plasma to augment or suppress bacterial lipopolysaccharide (LPS) stimulation of monocytes in vitro. RESULTS Of the proinflammatory cytokines, tumor necrosis factor-alpha was present in PF but not in plasma, interleukin (IL)-1beta and interferon-gamma were found in low concentrations in both PF and plasma, and IL-12 (p70) was detectable in plasma but not PF. In contrast, IL-6 and IL-1 receptor antagonist (IL-1ra) were the most abundant cytokines in the PF and plasma, and the concentrations of IL-4 and IL-10 were also elevated in both compartments. Patients with more severe appendicitis had higher plasma levels of IL-6 and IL-10 and lower plasma levels of IL-12 and interferon-gamma than did those with uncomplicated disease. Patient plasma inhibited LPS-induced stimulation of a monocyte cell line, and this inhibition was accentuated by complicated disease. CONCLUSIONS As judged from the pattern of soluble cytokines in plasma and the effect of the plasma on monocyte activation by LPS, mild, localized infection can induce a systemic response that is predominantly anti-inflammatory.
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Bumbasirević V, Milićević M, Bukumirović V, Ranković V, Pavlović A, Djukić V, Radenković D, Lausević Z, Sijacki A. Prevention and treatment of progressive multiple organ disfunction in acute pancreatitis. ACTA ACUST UNITED AC 2003; 50:115-25. [PMID: 14994578 DOI: 10.2298/aci0302114b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Acute pancreatitis is illness with unpredictable outcome. In some patients course of illness is progressive and leading to multiple organ dysfunction syndrome often resulting with lethal outcome. During last decade the treatment protocols have changed. Basic patophysiologic mechanisms leading to progression of the illness, as well as, contemporary diagnostic and treatment possibilities that can prevent occurrence of severe consequences and improve outcome are presented.
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Affiliation(s)
- V Bumbasirević
- Institut za anesteziologiju i reanimatologiju, Urgentni centar KCS, Beograd
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Flint RS, Windsor JA. The role of the intestine in the pathophysiology and management of severe acute pancreatitis. HPB (Oxford) 2003; 5:69-85. [PMID: 18332961 PMCID: PMC2020573 DOI: 10.1080/13651820310001108] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The outcome of severe acute pancreatitis has scarcely improved in 10 years. Further impact will require new paradigms in pathophysiology and treatment. There is accumulating evidence to support the concept that the intestine has a key role in the pathophysiology of severe acute pancreatitis which goes beyond the notion of secondary pancreatic infection. Intestinal ischaemia and reperfusion and barrier failure are implicated in the development of multiple organ failure. DISCUSSION Conventional management of severe acute pancreatitis has tended to ignore the intestine. More recent attempts to rectify this problem have included 1) resuscitation aimed at restoring intestinal blood flow through the use of appropriate fluids and splanchnic-sparing vasoconstrictors or inotropes; 2) enteral nutrition to help maintain the integrity of the intestinal barrier; 3) selective gut decontamination and prophylactic antibiotics to reduce bacterial translocation and secondary infection. Novel therapies are being developed to limit intestinal injury, and these include antioxidants and anti-cytokine agents. This paper focuses on the role of the intestine in the pathogenesis of severe acute pancreatitis and reviews the implications for management.
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Affiliation(s)
- RS Flint
- Pancreatitis Research Group, Department of Surgery, Faculty of Medical and Health Sciences, University of AucklandAucklandNew Zealand
| | - JA Windsor
- Pancreatitis Research Group, Department of Surgery, Faculty of Medical and Health Sciences, University of AucklandAucklandNew Zealand
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Jeschke MG, Barrow RE, Suzuki F, Rai J, Benjamin D, Herndon DN. IGF-I/IGFBP-3 Equilibrates Ratios of Pro- to Anti-inflammatory Cytokines, Which Are Predictors for Organ Function in Severely Burned Pediatric Patients. Mol Med 2002. [DOI: 10.1007/bf03402149] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
Acute pancreatitis (AP) is a common disease with wide variation of severity. The diagnosis of AP is usually based on high serum amylase or lipase values but the accuracy of these methods is considered unsatisfactory. One in five of the patients develops a severe disease and carries a considerable risk of development of organ failure and high mortality. Early detection of patients with severe AP and especially those with increased risk of organ failure is importance since such patients seem to benefit from treatment in an intensive care unit started as soon as possible after presentation. In addition to enzymological methods, increasing interest has been focused on laboratory markers reflecting the level of inflammatory response in AP. At present, in routine clinical work the most commonly used severity marker is serum C-reactive protein, the concentration of which rises too slowly to be used for early prediction of severity. New therapies aiming at modifying the course of systemic inflammation in AP are being developed and therefore monitoring the patient's immune inflammatory status is needed. In this review article we present the current knowledge of laboratory tests, which has been evaluated for diagnostic and prognostic purposes in AP.
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Abstract
Pathophysiology of sepsis is characterised by a whole body inflammatory reaction and concurrent activation of the host's anti-inflammatory mechanisms. The balance between pro- and anti-inflammatory reactions is critical for the outcome of the patient. Strongly activated phagocytes and high levels of proinflammatory cytokines occur in patients who are at risk of developing circulatory shock and multiple organ dysfunction. Extensive anti-inflammatory reaction, which is characterised by the presence of high levels of circulating anti-inflammatory cytokines and impaired innate and adaptive immune functions, renders critically ill patients prone to secondary infections. Evaluation of the immune-inflammatory status on admission to the hospital may be helpful in the early identification of patients who are bound to develop organ dysfunction. Such patients could possibly benefit from a mode of therapy aimed at modifying the course of inflammatory response. The use of inflammatory markers may also improve diagnosis of severe infection. The present review summarises the studies on markers of inflammation and immune suppression used, first, as predictors of organ dysfunction in patients with systemic inflammation, and, second, as indicators of infection in adults and neonates.
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Affiliation(s)
- Annika Takala
- Department of Anesthesia and Intensive Care Medicine, Helsinki University Central Hospital, P.O. Box 340, FI-00029 Hus, Finland.
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Abstract
AIMS To assess the implications of detection of interleukin 8 (IL-8) in urine. METHODS IL-8 was measured by immunoassay in all 305 urine samples from children aged 0-18.4 years received by our microbiology laboratory during four weeks, with a retrospective structured case note audit for all those in whom IL-8, white cells, or bacteria were detected. Patients were divided into three groups: urinary tract infection (UTI), at least one sample with >/=5 leucocytes x 10(9)/l and >/=10(5) cultured bacteria/ml; possible UTI, at least one sample with >/=5 leucocytes x 10(9)/l or >/=10(5) cultured bacteria/ml but not both; UTI unlikely, sample(s) with <5 leucocytes x 10(9)/l and <10(5) cultured bacteria/ml. Medical records were sought for all in groups 1 (14/14 found) and 2 (18/21 found) and those in group 3 (41/59 found) in whose urine any leucocytes, cultured bacteria, or IL-8 were detected. RESULTS IL-8 was detected in 58/305 samples from 48/264 patients. IL-8 was detected in at least one urine sample from 13/14 patients with confirmed UTI (group 1); in 11/21 patients with possible UTI (group 2), of whom two were treated as UTI; and in 23/228 patients without UTI. Using a cut off of 200 pg/ml, urine IL-8 had a sensitivity of 93% and a specificity of 90% for diagnosing UTI. CONCLUSIONS Urine IL-8 is a sensitive test for UTI, but is poorly specific as it is also present in a variety of other infectious and inflammatory disorders.
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Affiliation(s)
- W H Rao
- Child Health, University of Sheffield, Children's Hospital, Sheffield, UK
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Affiliation(s)
- J A Windsor
- Department of Surgery, Auckland Hospital, New Zealand
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Angood PB. Pancreatitis inflammatory response syndrome (PIRS)? Can there be another inflammatory response syndrome? Crit Care Med 1999; 27:2832-3. [PMID: 10628638 DOI: 10.1097/00003246-199912000-00041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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