Blood Urea Nitrogen Elevation Is a Marker for Pediatric Severe Acute Pancreatitis

Prediction of in-hospital Mortality of Intensive Care Unit Patients with Acute Pancreatitis Based on an Explainable Machine Learning Algorithm

BACKGROUND AND AIM

Acute pancreatitis (AP) is potentially fatal. Therefore, early identification of patients at a high mortality risk and timely intervention are essential. This study aimed to establish an explainable machine-learning model for predicting in-hospital mortality of intensive care unit (ICU) patients with AP.

METHODS

Data on patients with AP, including demographics, vital signs, laboratory tests, comorbidities, treatment, complication, and severity scores, were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) and the eICU collaborative research database (eICU-CRD). Based on the data from MIMIC-IV, we used the least absolute shrinkage and selection operator algorithm to select variables and then established 9 machine-learning models and screened the optimal model. Data from the eICU-CRD were used for external validation. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, accuracy, decision curve, and calibration plots were used to assess the models' efficacy. Shapley's additive explanation values were used to explain the model.

RESULTS

Gaussian naive Bayes (GNB) model had the best performance on the data from MIMIC-IV, with an AUC, accuracy, sensitivity, and specificity of 0.840, 0.787, 0.839, and 0.792, respectively. The GNB model also performed well on the data from the eICU-CRD, with an AUC, accuracy, sensitivity, and specificity of 0.862, 0.833, 0.848, and 0.763, respectively. According to Shapley's additive explanation values, the top 4 predictive factors were maximum red cell distribution width, minimum saturation of blood oxygen, maximum blood urea nitrogen, and the Sequential Organ Failure Assessment score.

CONCLUSION

The GNB model demonstrated excellent performance and generalizability in predicting mortality in ICU patients with AP. Therefore, it can identify patients at a high mortality risk.

The Role of Pancreatitis Risk Genes in Endocrine Insufficiency Development After Acute Pancreatitis in Children

BACKGROUND & AIMS

Acute pancreatitis (AP) is increasingly recognized as a risk factor for diabetes mellitus (DM). We aimed to study the association of pancreatitis genes with pancreatic endocrine insufficiency (pre-DM and DM) development post-AP in children.

METHODS

This was an observational cohort study that enrolled subjects ≤21 years with their first episode of AP and followed them for 12 months for the development of pancreatic endocrine insufficiency. Pancreatitis risk genes (CASR, CEL, CFTR, CLDN2, CPA1, CTRC, PRSS1, SBDS, SPINK1, and UBR1) were sequenced. A genetic risk score was derived from all genes with univariable P < .15.

RESULTS

A total 120 subjects with AP were genotyped. Sixty-three subjects (52.5%) had at least 1 reportable variant identified. For modeling the development of pancreatic endocrine insufficiency at 1 year, 6 were excluded (2 with DM at baseline, 3 with total pancreatectomy, and 1 death). From this group of 114, 95 remained normoglycemic and 19 (17%) developed endocrine insufficiency (4 DM, 15 pre-DM). Severe AP (58% vs 20%; P = .001) and at least 1 gene affected (79% vs 47%; P = .01) were enriched among the endocrine-insufficient group. Those with versus without endocrine insufficiency were similar in age, sex, race, ethnicity, body mass index, and AP recurrence. A model for pre-DM/DM development included AP severity (odds ratio, 5.17 [1.66-16.15]; P = .005) and genetic risk score (odds ratio, 4.89 [1.83-13.08]; P = .002) and had an area under the curve of 0.74.

CONCLUSIONS

In this cohort of children with AP, pancreatitis risk genes and AP disease severity were associated with pre-DM or DM development post-AP.

Computed Tomography Assessment of Severity of Acute Pancreatitis in Bangladeshi Children

Purpose

Acute pancreatitis (AP) is common among children in Bangladesh. Its management depends mainly on risk stratification. This study aimed to assess the severity of pediatric AP using computed tomography (CT).

Methods

This cross-sectional, descriptive study was conducted in pediatric patients with AP at the Department of Pediatric Gastroenterology and Nutrition, BSMMU, Dhaka, Bangladesh.

Results

Altogether, 25 patients with AP were included, of whom 18 (mean age, 10.27±4.0 years) were diagnosed with mild AP, and 7 (mean age, 10.54±4.0 years) with severe AP. Abdominal pain was present in all the patients, and vomiting was present in 88% of the patients. Etiology was not determined. No significant differences in serum lipase, serum amylase, BUN, and CRP levels were observed between the mild and severe AP groups. Total and platelet counts as well as hemoglobin, hematocrit, serum creatinine, random blood sugar, and serum alanine aminotransferase levels (p>0.05) were significantly higher in the mild AP group than in the severe AP group (p=0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of CT severity index (CTSI) were 71.4%, 72.2%, 50%, and 86.7%, respectively. In addition, significant differences in pancreatic appearance and necrosis were observed between the two groups on CT.

Conclusion

CT can be used to assess the severity of AP. In the present study, the CTSI effectively assessed the severity of AP in pediatric patients.

Prediction of prognosis in patients with nontraumatic intracranial hemorrhage using blood urea nitrogen-to-creatinine ratio on admission: a retrospective cohort study based on data from the medical information Mart for intensive care-IV database

Background

The blood urea nitrogen-to-creatinine ratio (BUNCR) has been proposed as a potential biomarker for critical illness-induced catabolism. However, its specific relevance and significance in the context of non-traumatic intracranial hemorrhage (NTIH) remains unclear. As such, the primary objective of this study was to determine the role of BUNCR in the prognosis of patients with NTIH.

Materials and methods

All data were sourced from the Medical Information Mart for Intensive Care-IV 2.0 (MIMIC-IV) database. Study outcomes included 30-day and 1-year mortality rates. Univariate and multivariate logistic regression analyses were used to calculate adjusted odds ratio with corresponding 95% confidence interval, and generalized additive model were used to identify both linear and non-linear relationships between BUNCR and mortality rates. A two-piecewise regression model was performed to calculate the saturation effect. Subgroup analyses were performed to evaluate outcome stability in various groups.

Results

A retrospective study of 3,069 patients with NTIH revealed a U-shaped relationship between BUNCR levels and 30-day/1-year mortality. The two-piecewise regression model showed that the inflection points for 30-day and 1-year mortality were 10.455 and 16.25, respectively. On the left side of the inflection point, the 30-day and 1-year mortality rate decreased by 17.7% (OR = 0.823, 95%CI: 0.705-0.960; p = 0.013) and 5.3% (OR = 0.947, 95%CI: 0.899-0.999; p = 0.046), respectively, per 1 unit increment of BUNCR. On the right side of the inflection point, the 30-day and 1-year mortality rate increased by 1.6% (OR = 1.016, 95%CI: 1.000-1.031; p = 0.046) and 3.6% (OR = 1.036, 95%CI:1.019-1.054; p < 0.001) per 1 unit decrement of BUNCR. Subgroup analyses revealed consistent results across different strata.

Conclusion

This study identified a nonlinear relationship between BUNCR and mortality in patients with NTIH, indicating that BUNCR may be valuable prognostic marker for early identification and proactive management.

A Retrospective Review of Children followed up with the Diagnosis of Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) is an inflammatory disease of the pancreas, the frequency of which increases in childhood.

AIM

To investigate the demographic, etiological, clinical, laboratory, and radiological characteristics of children followed up with the diagnosis of AP. The study also included genetic studies of recurrent cases.

MATERIALS AND METHODS

This retrospective cohort study included pediatric patients <18 years of age with AP who were followed up with recurrent pancreatitis in the Pediatrics Department of a University Hospital between January 2010 and April 2021. Patients who met at least 2 of the 3 criteria defined by the International Pediatric Pancreatitis Study Group (INSPPIRE) were accepted as AP. Demographic, etiological, and clinical data of the patients, developing complications, pathological evaluation of the samples, and genetic analysis results were obtained from the patient files. The obtained data were statistically analyzed using the SPSS version 26.0 program. Descriptive statistics of the data were expressed as mean ± standard deviation, median, minimum and maximum values, number (n), and percentage (%). Kolmogorov-Smirnov test, Mann Whitney U test, Chi-square test and Fischer test were used.

RESULTS

Fifty-four (50%) female and 54 (50%) male patients with a mean age of 9.96 ± 4.8 years who met the study criteria were included in the study. In the follow-up, it was reported that acute recurrent pancreatitis developed in 23 (21%) patients and chronic pancreatitis developed in 8 (7%) patients. The most common complaints were abdominal pain (94.4%), and vomiting (60.2%), followed by malnutrition (36.1%), nausea (17.6%), diarrhea (13%), and fever (13%). Etiology could not be determined in 19.4% of the patients. It was noted that the genetic predisposition of the patients played a role in the development of recurrent and chronic pancreatitis. Amylase, lipase, and CRP values, which are among the laboratory parameters showing the severity and prognosis of AP, were found to be significant.

CONCLUSIONS

Sociocultural and demographic data of the patients should also be taken into account. Gene sequences that cause to genetic predisposition should be determined in recurrent and chronic pancreatitis cases. Acute pancreatitis should be considered in the differential diagnosis of patients with frequent abdominal pain and vomiting.

Elevated BUN Upon Admission as a Predictor of in-Hospital Mortality Among Patients with Acute Exacerbation of COPD: A Secondary Analysis of Multicenter Cohort Study

Background

High blood urea nitrogen (BUN) is observed in a subset of patients with acute exacerbation of COPD (AECOPD) and may be linked to clinical outcome, but findings from previous studies have been inconsistent.

Methods

We performed a retrospective analysis of patients prospectively enrolled in the MAGNET AECOPD Registry study (ChiCTR2100044625). Receiver operating characteristic (ROC) was used to determine the level of BUN that discriminated survivors and non-survivors. Univariate and multivariate Cox proportional hazards regression analyses were performed to assess the impact of BUN on adverse outcomes.

Results

Overall, 13,431 consecutive inpatients with AECOPD were included in this study, of whom 173 died, with the mortality of 1.29%. The non-survivors had higher levels of BUN compared with the survivors [9.5 (6.8-15.3) vs 5.6 (4.3-7.5) mmol/L, P < 0.001]. ROC curve analysis showed that the optimal cutoff of BUN level was 7.30 mmol/L for in-hospital mortality (AUC: 0.782; 95% CI: 0.748-0.816; P < 0.001). After multivariate analysis, BUN level ≥7.3 mmol/L was an independent risk factor for in-hospital mortality (HR = 2.099; 95% CI: 1.378-3.197, P = 0.001), also for invasive mechanical ventilation (HR = 1.540; 95% CI: 1.199-1.977, P = 0.001) and intensive care unit admission (HR = 1.344; 95% CI: 1.117-1.617, P = 0.002). Other independent prognostic factors for in-hospital mortality including age, renal dysfunction, heart failure, diastolic blood pressure, pulse rate, PaCO2 and D-dimer.

Conclusion

BUN is an independent risk factor for in-hospital mortality in inpatients with AECOPD and may be used to identify serious (or severe) patients and guide the management of AECOPD.

Clinical Trial Registration

MAGNET AECOPD; Chinese Clinical Trail Registry NO.: ChiCTR2100044625; Registered March 2021, URL: http://www.chictr.org.cn/showproj.aspx?proj=121626.

Analgesic Patterns and Opioid Administration in Children Hospitalized With Acute Pancreatitis

BACKGROUND

Pain is the most common symptom of acute pancreatitis (AP), and opioids have been utilized as the cornerstone of treatment. Despite the adverse effects of opioids, data on effective analgesia in children with AP is lacking. We aimed to evaluate analgesia prescribing patterns in pediatric AP, identify factors associated with opioid administration, and test the associations between opioid administration and hospital length of stay (LOS).

METHODS

This is a retrospective cohort study of pediatric AP hospitalizations in a single institution from 2010 to 2020. Opioid administration was calculated for the first 48 hours of admission (morphine milligram equivalent; MME48). Data on multimodal analgesia [defined as the administration of acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)] during hospitalization was captured.

RESULTS

The sample included 224 patients, mean age 12.0 years (standard deviation = 4.9) and 58.9% female. Median LOS was 4 days (interquartile range 2-9). Most patients (71.4%) were prescribed opioids, 77.7% acetaminophen, 40.2% NSAIDs, and 37.5% multimodal analgesia. Opioid administration decreased over the study period; in contrast, there was an increase in multimodal analgesia administration. Opioid administration did not differ by sex, age, biliary versus non-biliary etiology, or race/ethnicity. In a multivariate regression model, lower albumin values ( P < 0.01) and younger age ( P < 0.05) were significant predictors of increased LOS, while MME48 was not associated with increased LOS.

CONCLUSIONS

Opioids were commonly administered; only 37.5% of children were administered multimodal analgesia during their hospitalization for AP. Opioid administration was not associated with increased LOS. Prospective studies are needed to determine optimal pain management for pediatric AP.

Prevalence of Gastrointestinal Symptoms and Impact on Quality of Life at 1-Year Follow-Up of Initial Attack of Acute Pancreatitis

OBJECTIVES

This study aims to describe the prevalence of gastrointestinal (GI) symptoms following the first time occurrence of acute pancreatitis (AP) and to measure the impact of the episode on patient health-related quality of life (HRQOL) from the perspectives of patients and parents.

METHODS

Questionnaires regarding GI symptoms 1 year following the initial occurrence of AP were obtained from 74 pediatric patients. Thirty of these patients completed both the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales and the PedsQL Gastrointestinal Symptoms and Worry Scales. These data were compared to legacy-matched healthy controls.

RESULTS

Children with a standalone occurrence of AP experienced a similar rate of GI symptoms compared to those who progressed to acute recurrent pancreatitis (ARP) within 1 year. PedsQL 4.0 Generic Core Scales scores were significantly lower for children self-report and parent proxy-report for patients that experienced AP compared to healthy controls. AP patients also demonstrated significantly more symptoms than healthy controls in the Gastrointestinal Symptoms and Worry Scales across multiple domains.

CONCLUSIONS

Gastrointestinal symptoms affect many children who experience a single AP event even without recurrent attacks. The burden of symptoms is not significantly different from those who develop ARP. This is a novel study that evaluates patient-reported outcomes in children following an AP attack and demonstrates there is a significant impact on HRQOL in children and family experiences post AP. More data are needed to study the progression of disease and the extended impact of AP following an initial AP attack in pediatric patients.

Ultrasound findings of acute pancreatitis in children

BACKGROUND

Studies systematically documenting US findings in children with acute pancreatitis are limited. Pancreas duct dilation is described as the most reliable finding of acute pancreatitis but this has not been rigorously examined in children.

OBJECTIVE

To systematically document US findings in children with acute pancreatitis and to define interobserver agreement on those findings.

MATERIALS AND METHODS

In this cross-sectional study we retrospectively reviewed images for all pediatric patients &lt;18 years of age who had been prospectively enrolled in a registry of patients with index admissions for acute pancreatitis between March 2013 and July 2020. Two blinded observers (R1, R2) reviewed the first transabdominal US examination performed within 2 weeks of the pancreatitis attack for each patient.

RESULTS

In 141 children, US was performed at a median of 1 day (interquartile range [IQR]: 0, 1) following acute attack. Thirty-three (23%, R1) and 38 (27%, R2) children had no abnormal findings on US. Peripancreatic edema was the most frequent finding documented by both reviewers (63% R1, 54% R2). The pancreatic duct was visible in only 35% of the children and was dilated in only 12% (R1) and 14% (R2). There was substantial to almost-perfect agreement between reviewers on findings of acute pancreatitis (κ=0.62-1), including duct visibility.

CONCLUSION

Peripancreatic edema was the most frequently identified finding in children with acute pancreatitis, present in up to 63%, with almost perfect interobserver agreement. Duct dilation, cited in the literature as a reliable finding of acute pancreatitis, was rarely identified in our sample.

Admission risk factors and predictors of moderate or severe pediatric acute pancreatitis: A systematic review and meta-analysis

Introduction

Pediatric acute pancreatitis (PAP) has an increasing incidence and is now estimated to be almost as common as in adults. Up to 30% of patients with PAP will develop moderate or severe disease course (M/SPAP), characterized by organ failure, local or systemic complications. There is still no consensus regarding on-admission severity prediction in these patients. Our aim was to conduct a systematic review and meta-analysis of available predictive score systems and parameters, and differences between on-admission parameters in mild and M/SPAP.

Methods

We conducted a systematic search on the 14th February, 2022 in MEDLINE, Embase and CENTRAL. We performed random-effects meta-analysis of on-admission differences between mild and M/SPAP in laboratory parameters, etiology, demographic factors, etc. calculating risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI) and created forest plots. For the meta-analysis of predictive score systems, we generated hierarchical summary receiver operating characteristic curves using a bivariate model. Chi-squared tests were performed and I2 values calculated to assess statistical heterogeneity.

Results

We included 44 studies - mostly retrospective cohorts - in our review. Among predictive score systems examined by at least 5 studies, the modified Glasgow scale had the highest specificity (91.5% for values ≥3), and the Pediatric Acute Pancreatitis Severity score the highest sensitivity (63.1% for values ≥3). The performance of other proposed score systems and values were summarized. Traumatic (RR: 1.70 95% CI: 1.09-2.67) and drug-induced (RR: 1.33 95% CI: 0.98-1.87) etiologies were associated with a higher rate of M/SPAP, while anatomical (RR: 0.6195% CI: 0.38-0.96) and biliary (RR: 0.72 95% CI: 0.53-0.99) PAP tended to be less severe.

Discussion

Many predictive score systems were proposed to assess the possibility of M/SPAP course. The most commonly used ones exhibit good specificity, but subpar sensitivity. Our systematic review provides a rigorous overview of predictive options assessed thus far, that can serve as a basis for future improvement of scores via the addition of parameters with a better observed sensitivity: e.g., lipase exceeding 7-times the upper threshold, hemoglobin, etc. The addition of etiological factors is another possibility, as they can herald a more severe disease course.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=307271, PROSPERO, identifier: CRD42022307271.

Clinical utility of the pancreatitis activity scoring system in severe acute pancreatitis

Objective: To analyze clinical utility of pancreatitis activity scoring system (PASS) in prediction of persistent organ failure, poor prognosis, and in-hospital mortality in patients with moderately severe acute pancreatitis (MSAP) or severe acute pancreatitis (SAP) admitted to the intensive care unit (ICU).

Methods: The study included a total of 140 patients with MSAP and SAP admitted to the ICU of Shandong Provincial Hospital from 2015 to 2021. The general information, biochemical indexes and PASS scores of patients at ICU admission time were collected. Independent risk factors of persistent organ failure, poor prognosis and in-hospital mortality were analyzed by binary logistic regression. Through receiver operating characteristic curve (ROC), the predictive ability of lactic acid, procalcitonin, urea nitrogen, PASS, and PASS in combination with urea nitrogen for the three outcomes was compared. The best cut-off value was determined.

Results: Binary logistic regression showed that PASS might be an independent risk factor for patients with persistent organ failure (odds ratio [OR]: 1.027, 95% confidence interval [CI]: 1.014–1.039), poor prognosis (OR: 1.008, 95% CI: 1.001–1.014), and in-hospital mortality (OR: 1.009, 95% CI: 1.000–1.019). PASS also had a good predictive ability for persistent organ failure (area under the curve (AUC) = 0.839, 95% CI: 0.769–0.910) and in-hospital mortality (AUC = 0.780, 95% CI: 0.669–0.891), which was significantly superior to lactic acid, procalcitonin, urea nitrogen and Ranson score. PASS (AUC = 0.756, 95% CI: 0.675–0.837) was second only to urea nitrogen (AUC = 0.768, 95% CI: 0.686–0.850) in the prediction of poor prognosis. Furthermore, the predictive power of urea nitrogen in combination with PASS was better than that of each factor for persistent organ failure (AUC = 0.849, 95% CI: 0.779–0.920), poor prognosis (AUC = 0.801, 95% CI: 0.726–0.876), and in-hospital mortality (AUC = 0.796, 95% CI: 0.697–0.894).

Conclusion: PASS was closely correlated with the prognosis of patients with MSAP and SAP. This scoring system may be used as a common clinical index to measure the activity of acute pancreatitis and evaluate disease prognosis.

The course of acute pancreatitis in children and potential simple laboratory markers of severity - a single centre retrospective study

AIM

To evaluate the usefulness of routinely measured biochemical and complete blood count parameters as potential markers of the severity of pediatric acute pancreatitis.

METHODS

The retrospective study included children with acute pancreatitis hospitalised over a 3-year period. Demographic, clinical and laboratory data were collected.

RESULTS

55 patients were enrolled in the study. Mild acute pancreatitis was diagnosed in 45 children (82%), moderately severe in 7 (13%), and severe in 3 patients (5%). Together 10 children (18%) were categorized into a single severe group. Children with severe acute pancreatitis had higher white blood cell and platelet counts on admission as well as a C-reactive protein concentration after 48 hours. The C-reactive protein concentration after 48 hours (cut-off: 127,2 mg/l) and the white blood cell count on admission (cut-off: 13,5x10³ /μl) were found to be statistically significant markers in predicting the severity of the disease. The C-reactive protein concentration after 48 hours was demonstrated as an independent predictor.

CONCLUSION

Severe acute pancreatitis is observed in a quite significant percentage of children. The white blood cell count on admission and the C-reactive protein concentration after 48 hours (as an independent predictor) may be potential simple laboratory markers of the severity of the disease.

Etiology and classification of acute pancreatitis in children admitted to ICU using the Pediatric Sequential Organ Failure Assessment (pSOFA) score

BACKGROUND

Pediatric acute pancreatitis (AP) is rare but increasing. Severe AP is associated with higher morbidity and mortality. However, there are no universally accepted prognostic criteria for AP.

METHODS

This retrospective study included children with AP admitted to an intensive care unit (ICU) of our tertiary pediatric center between January 2009 and December 2018. The severity of organ dysfunction in AP was assessed according to the modified Atlanta criteria using the Pediatric Sequential Organ Failure Assessment (pSOFA) and Computed Tomography Severity Index (CTSI).

RESULTS

Seventy acute episodes of AP were evaluated in 55 children with primary pancreatitis. In addition, secondary AP was diagnosed in 15 patients originally admitted to ICU for different indications. Mild AP [no organ dysfunction, normal computed tomography (CT) finding] was the most prevalent (64/85 episodes in 49 children), followed by moderate AP (15 children; pSOFA 2-9 points, CTSI 3-4 points on admission). Severe AP (pSOFA 4-17 points, CTSI 6-10 points) was diagnosed in 6 children with traumatic or secondary AP. The most frequent etiologies of primary AP episodes were idiopathic (39%) and biliary (31%). Children with idiopathic AP had frequent relapses and comorbidities. Hereditary AP was typically mild, but presented with high pancreatic enzyme levels and recurrence rates. Admission at ICU and an interval without enteral nutrition (EN) were relatively short in drug-induced AP and relatively long in secondary and traumatic AP. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 13 patients with biliary AP and in 4 patients with traumatic AP. No AP-related death was observed.

CONCLUSION

pSOFA score accurately reflects the severity and prognosis of AP in children.

Etiology, case fatality, recurrence, and severity in pediatric acute pancreatitis: a meta-analysis of 48 studies

For children, there are very few published reviews focusing on severe acute pancreatitis (AP). PubMed, EMBASE, Web of Science, Scopus, Chinese National Knowledge Infrastructure (CNKI), Wanfang data, EBSCO, and Cochrane Library were searched from inception until March 2020. Meta-regression analyses were used to estimate the etiology, case fatality, recurrence, and severity of pediatric AP in different regions (North America, Asia, South America, Europe, and Oceania). Pooled data from 47 papers (48 studies) found that main causes of pediatric AP were gallstones in Asia; trauma in Oceania; and idiopathic in Europe, North America, and South America. The case-fatality rate (CFR) of pediatric AP is 4.7% (North America), 6.2% (Europe), 2.4% (Asia), 3.1% (South America), and 7.4% (Oceania). The incidence rates of recurrent acute pancreatitis (RAP) in children who have had an episode of acute pancreatitis in North American, Asia, and Europe were 15.3, 13.1, and 13.8%, respectively. The incidence of severe acute pancreatitis (SAP) in different regions was 30.3% (Oceania), 29.2% (South America), 20.8% (Europe), 15.8% (Asia), and 13.7% (North America). It suggests that physicians should notice the etiology of pediatric AP for the initial assessment, diagnosis, prediction of relapse, and appropriate treatment at a later stage. IMPACT: It indicates the etiology of pediatric acute pancreatitis for the initial assessment, diagnosis, and prediction of relapse. Main causes of pediatric AP were gallstones in Asia; trauma in Oceania; and idiopathic in Europe, North America, and South America. The case-fatality rate of pediatric AP is diverse worldwide. It suggests that physicians noticed the etiology of pediatric AP for the initial assessment, diagnosis, prediction of relapse, and appropriate treatment at a later stage.

Matrix metalloproteinases and their inhibitors in pediatric severe acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is increasing in incidence in adult and pediatric patients. Identification of patients at high risk for progression to severe acute pancreatitis (SAP) is crucial, as it can lead to increased mortality and health system cost. Matrix metalloproteinases (MMPs) are endopeptidases which degrade extracellular matrix proteins and increase activity of pro-inflammatory cytokines. Tissue inhibitors of metalloproteinases (TIMPs) regulate MMP activity. Prior limited studies of MMPs and TIMPs have found some to be associated with development of SAP. The aim of this study was to further investigate the role of MMPs and TIMPs in detecting pediatric patients at risk for developing moderately severe AP or SAP.

METHODS

Plasma samples were prospectively collected for patients <21 years of age presenting with AP between November 2015 and October 2019, along with healthy controls. Bead-based multiplex assays were utilized to test levels of 12 MMPs and TIMPs.

RESULTS

Samples were collected from 7 subjects who developed SAP, 7 with moderately severe AP, 45 with mild AP and 44 healthy controls. MMP-9 (p = 0.04) and TIMP-1 (p = 0.01) levels were significantly higher in SAP patients. A multivariable logistic regression model using MMP-9 and TIMP-1 predicted SAP (AUROC 0.87, 95% CI 0.76-0.98).

CONCLUSION

We have demonstrated that MMP9 and TIMP1 levels are increased at AP presentation in pediatric patients who developed SAP during the course of illness. Further studies are needed to validate the use of MMPs and TIMPs as predictive tools for development of SAP in pediatric pancreatitis.

Prevalence and impact of acute kidney injury in hospitalized pediatric patients with acute pancreatitis

BACKGROUND

The incidence of acute pancreatitis (AP) in pediatric patients is rising with accompanying increased hospitalizations. Acute kidney injury (AKI) is associated with worse clinical outcomes in adults, and similar data in the pediatric age group is limited.

METHODS

We analyzed non-overlapping years of National Inpatient Sample (NIS) and Kids Inpatient Database (KID) to include all patients less than 21 years old with primary diagnosis of AP between 2003 and 2016. Patients with concomitant diagnosis of AKI were compared with patients without AKI for demographics, comorbid/etiologic conditions, procedures, complications, and mortality. Length of stay and inflation-adjusted hospitalization charges were used to compare health care resource utilization.

RESULTS

In total, 123,185 AP-related hospitalizations were analyzed. Overall prevalence of AKI among AP patients was 1.5% during the study period. The prevalence rate of AKI increased almost five-fold from 0.6% (2003) to a peak rate of 2.9% (2016), P < 0.001. Patients with AKI were older, more often male and had either more systemic diseases or chronic comorbid conditions such as malignancies, systemic lupus erythematosus, solid organ transplantation, hypertriglyceridemia, and hypercalcemia. Multivariate analysis demonstrated AP-related hospitalizations with AKI were 1.97 (CI 1.27-3.08, P < 0.001) times more likely to be associated with in-hospital mortality and contributed to 4.3 additional days of hospitalization (CI 4.02-4.6, P < 0.001), also incurring an additional $51,830 (CI 48571-55088, P < 0.001) in hospital charges.

CONCLUSION

The prevalence of AKI is increasing steadily among pediatric patients with AP and is associated with increased risk of mortality and higher health care resource expenditure.

Cytokine Profile Elevations on Admission Can Determine Risks of Severe Acute Pancreatitis in Children

OBJECTIVES

To utilize a Luminex platform to examine multiple cytokines simultaneously as well as clinical laboratory testing to identify markers that predict acute pancreatitis severity in the pediatric population on admission.

STUDY DESIGN

Patients (<19 years of age) prospectively enrolled over a 4-year period in a single institution acute pancreatitis database were included in separate derivation and validation cohorts. Plasma samples were obtained within 48 hours of admission and stored for analysis. Samples from mild acute pancreatitis and severe acute pancreatitis (moderately severe and severe combined) were analyzed using Luminex panels and C-reactive protein (CRP) testing.

RESULTS

The derivation cohort examined 62 cytokines in 66 subject samples (20 control, 36 mild acute pancreatitis, 10 severe acute pancreatitis) and identified interleukin 6 (IL-6) (P = .02) and monocyte chemotactic protein-1 (MCP-1) (P = .02) as cytokines that were differentially expressed between mild and severe acute pancreatitis. Our validation cohort analyzed 76 cytokines between 10 controls, 19 mild acute pancreatitis, and 6 severe acute pancreatitis subjects. IL-6 (P = .02) and MCP-1 (P = .007) were again found to differentiate mild acute pancreatitis from severe acute pancreatitis. CRP values were obtained from 53 of the subjects, revealing a strong association between elevated CRP values and progression to severe disease (P < .0001).

CONCLUSIONS

This study identified and validated IL-6 and MCP-1 as predictors of severe acute pancreatitis using 2 distinct cohorts and showed that CRP elevation is a marker of progression to severe acute pancreatitis. These biomarkers have not been extensively studied in the pediatric acute pancreatitis population. Our data allows for risk-stratification of patients with acute pancreatitis, and represent novel insight into the immunologic response in severe acute pancreatitis.

Urea-Creatinine Ratio (UCR) After Aneurysmal Subarachnoid Hemorrhage: Association of Protein Catabolism with Complication Rate and Outcome

OBJECTIVE

The urea-creatinine ratio (UCR) has been proposed as potential biomarker for critical illness-associated catabolism. Its role in the context of aneurysmal subarachnoid hemorrhage (aSAH) remains to be elucidated, which was the aim of the present study.

METHODS

We enrolled 66 patients with aSAH with normal renal function and 36 patients undergoing elective cardiac surgery as a control group for the effects of surgery. In patients with aSAH, the predictive or diagnostic value of early (day 0-2) and critical (day 5-7) UCRs was assessed with regard to delayed cerebral ischemia (DCI), DCI-related infarction, and clinical outcome after 12 months.

RESULTS

Preoperatively, UCR was similar both groups. Within 2 days postoperatively, UCRs increased significantly in patients in the elective cardiac surgery group (P < 0.001) but decreased back to baseline on day 5-7 (P = 0.245), whereas UCRs in patients with aSAH increased to significantly greater levels on day 5-7 (P = 0.028). Greater early or critical UCRs were associated with poor clinical outcomes (P = 0.015) or DCI (P = 0.011), DCI-related infarction (P = 0.006), and poor clinical outcomes (P < 0.001) respectively. In multivariate analysis, there was an independent association between greater early UCRs and poor clinical outcomes (P = 0.026).

CONCLUSIONS

In this exploratory study of UCR in the context of aSAH, greater early values were predictive for a poor clinical outcome after 12 months, whereas greater critical values were associated with DCI, DCI-related infarctions, and poor clinical outcomes. The clinical implications as well as the pathophysiologic relevance of protein catabolism should be explored further in the context of aSAH.

Early Changes in Blood Urea Nitrogen (BUN) Can Predict Mortality in Acute Pancreatitis: Comparative Study between BISAP Score, APACHE-II, and Other Laboratory Markers-A Prospective Observational Study

BACKGROUND

Changes in BUN have been proposed as a risk factor for complications in acute pancreatitis (AP). Our study aimed to compare changes in BUN versus the Bedside Index for Severity in Acute Pancreatitis (BISAP) score and the Acute Physiology and Chronic Health Evaluation-II score (APACHE-II), as well as other laboratory tests such as haematocrit and its variations over 24 h and C-reactive protein, in order to determine the most accurate test for predicting mortality and severity outcomes in AP.

METHODS

Clinical data of 410 AP patients, prospectively enrolled for study at our institution, were analyzed. We define AP according to Atlanta classification (AC) 2012. The laboratory test's predictive accuracy was measured using area-under-the-curve receiver-operating characteristics (AUC) analysis and sensitivity and specificity tests.

RESULTS

Rise in BUN was the only score related to mortality on the multivariate analysis (p=0.000, OR: 12.7; CI 95%: 4.2-16.6). On the comparative analysis of AUC, the rise in BUN was an accurate test in predicting mortality (AUC: 0.842) and persisting multiorgan failure (AUC: 0.828), similar to the BISAP score (AUC: 0.836 and 0.850) and APACHE-II (AUC: 0.756 and 0.741). The BISAP score outperformed both APACHE-II and rise in BUN at 24 hours in predicting severe AP (AUC: 0.873 vs. 0.761 and 0.756, respectively).

CONCLUSION

Rise in BUN at 24 hours is a quick and reliable test in predicting mortality and persisting multiorgan failure in AP patients.

Who's at Risk? A Prognostic Model for Severity Prediction in Pediatric Acute Pancreatitis

OBJECTIVES

The aim of the study was to validate and optimize a severity prediction model for acute pancreatitis (AP) and to examine blood urea nitrogen (BUN) level changes from admission as a severity predictor.

STUDY DESIGN

Patients from 2 hospitals were included for the validation model (Children's Hospital of the King's Daughters and Children's National Hospital). Children's Hospital of the King's Daughters and Cincinnati Children's Hospital Medical Center data were used for analysis of BUN at 24 to 48 hours.

RESULTS

The validation cohort included 73 patients; 22 (30%) with either severe or moderately severe AP, combined into the all severe AP (SAP) group. Patients with SAP had higher BUN (P = 0.002) and lower albumin (P = 0.005). Admission BUN was confirmed as a significant predictor (P = 0.005) of SAP (area under the receiver operating characteristic [AUROC] 0.73, 95% confidence interval [CI] 0.60-0.86). Combining BUN (P = 0.005) and albumin (P = 0.004) resulted in better prediction for SAP (AUROC 0.83, 95% CI 0.72-0.94). A total of 176 AP patients were analyzed at 24-48 hours; 39 (22%) met criteria for SAP. Patients who developed SAP had a significantly higher BUN (P < 0.001) after 24 hours. Elevated BUN levels within 24 to 48 hours were independently predictive of developing SAP (AUROC: 0.76, 95% CI: 0.66-0.85). Patients who developed SAP had a significantly smaller percentage decrease in BUN from admission to 24 to 48 hours (P = 0.002).

CONCLUSION

We externally validated the prior model with admission BUN levels and further optimized it by incorporating albumin. We also found that persistent elevation of BUN is associated with development of SAP. Our model can be used to risk stratify patients with AP on admission and again at 24 to 48 hours.

Drug induced pancreatitis is the leading known cause of first attack acute pancreatitis in children

BACKGROUND/OBJECTIVES

Drug induced acute pancreatitis (DIAP) as one of the acute pancreatitis (AP) risks factors is a poorly understood entity. The aim of the current study was to compare the characteristics and course of DIAP cases in children presenting with a first attack of AP.

METHODS

Patients presenting with AP were included in a prospective database. We enrolled 165 AP patients that met criteria for inclusion. DIAP patients were included in that group if they were exposed to a drug known to be associated with AP and the rest were included in the non-drug induced-acute pancreatitis (non-DIAP) group.

RESULTS

DIAP was observed in 40/165 (24%) of cases, 24 cases had drug-induced as the sole risk factor, and 16 had DIAP with another risk factor(s). The two groups were similar in intravenous fluid and feeding managements, but ERCP was more commonly performed in the non- DIAP group, 14 (11%), vs 0% in the DIAP group, p = 0.02. Moderately severe [9 (23%) vs 11 (9%)] and severe AP [7 (18%) vs 6 (5%)] were more commonly associated with DIAP than non- DIAP, p = 0.001. DIAP was more commonly associated with ICU stay, 10 (25%), vs 12 (10%), p = 0.01, hospital stay was longer in DIAP median (IQR) of 6 (3.9-11) days vs 3.3 (2-5.7) days in non- DIAP, p = 0.001. The DIAP group had a significantly higher proportion of comorbidities (p < 0.0001).

CONCLUSIONS

DIAP is a leading risk factor for a first attack of AP in children and is associated with increased morbidity and severity of the pancreatitis course. DIAP warrants further investigation in future studies.

Impact of Clinical, Laboratory and Fluid Therapy Variables on Hospital Length of Stay for Children with Acute Pancreatitis

PURPOSE

There have been many efforts to develop generalizable severity markers in children with acute pancreatitis (AP). Expert opinion panels have developed consensus guidelines on management but it is unclear if these are sufficient or valid. Our study aims to assess the effect of clinical and laboratory variables, in addition to treatment modality on hospital length of stay (LOS) as a proxy variable for severity in pediatric patients admitted with AP.

METHODS

We conducted a retrospective chart review of patients between ages of 0-18 years, who were admitted with AP at 2 institutions between 2013-2018, John R. Oishei Children's Hospital (Buffalo, NY, USA) and Medical University of South Carolina Children's Hospital (Charleston, SC, USA). We constructed three linear regression models to analyze the effect of clinical signs of organ dysfunction, laboratory markers and fluid intake on hospital LOS.

RESULTS

Ninety-two patients were included in the study. The mean age was 12 years (range, 7.6-17.4 years), 55% were females, and median LOS was 3 days. The most frequent cause of AP was idiopathic. Our study showed that elevated blood urea nitrogen (BUN) on admission (p<0.005), tachycardia that lasted for ≥48 hours (p<0.001) and need for fluid resuscitation were associated with increase LOS. Total daily fluid intake above maintenance did not have a significant effect on the primary outcome (p=0.49).

CONCLUSION

Elevated serum BUN on admission, persistent tachycardia and need for fluid resuscitation were associated with increase LOS in pediatric AP. Daily total fluid intake above recommended maintenance did not reduce LOS.

Predictive values of neutrophil-lymphocyte ratio as an early indicator for severe acute pancreatitis in the emergency department patients

CONTEXT:

Acute pancreatitis is an acute inflammatory disease presenting with a wide range of severity.

AIMS:

We investigated the predictive values of the neutrophil-lymphocyte ratio (NLR) as an indicator for severe acute pancreatitis in the emergency department patients.

SETTINGS AND DESIGN:

This retrospective study was conducted on patients with acute pancreatitis who were diagnosed in the emergency department, from January 2008 to December 2017.

SUBJECTS AND METHODS:

Patients were classified into either mild-to-moderate severe group or severe group according to the Revised Atlanta Classification for Acute Pancreatitis. Clinical features and laboratory blood test parameters were considered as independent variables.

STATISTICAL ANALYSIS USED:

Independent variables were analyzed using the Chi-square test and Mann–Whitney U-test to determine statistically significant differences between the two groups. Logistic regression analysis and receiver operating characteristic analysis were performed to evaluate the predictive values of significantly different variables.

RESULTS:

Of the 672 patients, 52 (7.7%) were classified into the severe group. Tachycardia, fever, prevalence of liver cirrhosis and chronic alcoholism, white blood cell count, NLR, C-reactive protein (CRP), blood urea nitrogen (BUN), creatinine, aspartate transaminase, and total bilirubin were significantly higher in the severe group. Among them, NLR (adjusted odds ratio [aOR]: 1.13; 95% confidence interval [CI]: 1.081–1.181), CRP (aOR: 1.011; 95% CI: 1.004–1.017), BUN (aOR: 1.036; 95% CI: 1.004–1.069), and creatinine (aOR: 1.703; 95% CI: 1.008–2.877) were significant in the logistic regression analysis. NLR showed relatively high sensitivity (82.7%) and specificity (70%) and showed the highest area under the curve (0.821).

CONCLUSIONS:

The increase in NLR was associated with severe acute pancreatitis. NLR is expected to be useful as a prognostic factor in patients with acute pancreatitis who are visiting the emergency department.

Retrospective study on intercurrent pancreatitis with Babesia gibsoni infection in dogs

Babesia rossi infection has been reported to be associated with the high prevalence of pancreatitis in dogs. In this study, we retrospectively investigated whether pancreatitis occurs in B. gibsoni-infected dogs. The clinical manifestations, and hematological and serum biochemical examination results, including canine pancreatic-specific lipase (cPL), in 20 B. gibsoni-infected dogs were analyzed. The cPL concentration exceeded 400 µg/l in only 2 dogs, and they were suspected of having pancreatitis. Although the cPL concentration did not correlate with the degree of anemia or the level of parasitemia, it correlated with the band neutrophil count, platelet count, and blood urea nitrogen (BUN) level. Our study suggested that the prevalence of pancreatitis is lower among B. gibsoni-infected dogs than B. rossi-infected dogs.