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Levytskyi H, Sheiko V. Predicting the dynamics of organ failure in patients with acute pancreatitis depending on the mean platelet volume. Surg Open Sci 2024; 19:166-171. [PMID: 38770184 PMCID: PMC11103941 DOI: 10.1016/j.sopen.2024.04.011] [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: 12/28/2023] [Revised: 04/02/2024] [Accepted: 04/28/2024] [Indexed: 05/22/2024] Open
Abstract
Background The aim of this study is to determine the correlation between the blood serum mean platelet volume (MPV) and the dynamics of the OF course during the early phase in patients with moderately severe and severe acute pancreatitis (AP). Methods The predetermined criterion was the presence of the OF according to the revised Atlanta criteria 2012 for moderately severe and severe AP. A prospective sample of patients was stratified by severity, and two groups were defined based on MPV. Demographic indicators, comorbidities and clinical outcomes were compared between these groups. Multifactorial analysis determined whether an elevated MPV is independently associated with early OF and other unfavorable outcomes. Results Out of 108 patients, 20 had moderately severe AP and 88 had severe AP. The blood serum MPV, measured within 72 h of the onset of AP symptoms was lower 11.8 fL in 32 patients and equal to or greater 11.8 fL in 76 patients. Patients with elevated MPV were older (63 vs. 48 years), had obesity (59.2 % vs. 25 %), diabetes mellitus (DM) (51.3 % vs. 12.5 %), ischemic heart disease (70.8 % vs. 28.1 %) and more frequently experienced persistent OF (93.4 % vs. 53.1 %) compared to those with MPV lower 11.8 fL. The incidence of early OF increased proportionally with the severity of MPV (81.6 % vs. 34.4 % in the group with MPV lower 11.8 fL, Ptrend < 0.0001). In multifactorial analysis, adjusted for body mass index and DM, MPV equal to or greater 11.8 fL was independently associated with early OF. Conclusions Elevated blood serum MPV of patients with AP are independently and proportionally correlated with early organ failure in patients with alcoholic and idiopathic etiology of AP. Key message The study provides an evaluation of MPV as a prognostic marker for organ failure within the initial 7 days following the onset of acute pancreatitis symptoms. Additionally, alterations in MPV were identified in patients with acute pancreatitis who had diabetes or ischemic heart disease within the first 24 h of hospitalization.
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Affiliation(s)
- Heorhii Levytskyi
- Department of Surgery No. 2, Poltava State Medical University, Poltava, Ukraine
| | - Volodymyr Sheiko
- Department of Surgery No. 2, Poltava State Medical University, Poltava, Ukraine
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2
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Antoniak D, Twohig P, Olson K, Samson K, Mitchell C, Eichele D. Lactated Ringer's or Normal Saline for Initial Resuscitation in Patients Hospitalized With Acute Pancreatitis: A Retrospective Database Analysis. Pancreas 2023; 52:e203-e209. [PMID: 37716004 DOI: 10.1097/mpa.0000000000002237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
OBJECTIVES Fluid resuscitation is required in acute pancreatitis (AP) to prevent hypovolemia and organ hypoperfusion. Lactated Ringer's (LR) is a buffered crystalloid with possible advantages in AP versus normal saline (NS). We aim to assess outcomes in patients hospitalized with AP based on fluid used for resuscitation. METHODS In this retrospective analysis, we identified hospital admissions to Veterans Affairs facilities for AP from 2011 to 2017 and grouped by initial resuscitation fluid: LR versus NS. Outcomes included major complications and mortality at 30 and 365 days. Multivariable models were used to adjust for confounding variables. RESULTS A total of 20,049 admissions were included in the study, of which 10% received LR as initial fluid. After adjustment for all available confounders, resuscitation with LR was associated with lower 1-year mortality compared with NS (adjusted odds ratio, 0.61 [95% confidence interval, 0.50-0.76]). Major complication and early mortality were similar between groups. CONCLUSIONS In this study, we demonstrate an association between use of LR as initial resuscitation fluid and reduced 1-year mortality in a large retrospective sample of veterans hospitalized with AP. These results support the use of LR for resuscitation for most patients hospitalized with AP.
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Affiliation(s)
| | | | | | - Kaeli Samson
- Department of Biostatistics, University of Nebraska College of Public Health, Omaha, NE
| | - Christine Mitchell
- Department of Veterans Affairs, Nebraska-Western Iowa Healthcare System, Omaha, NE
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3
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Walker A, O'Kelly J, Graham C, Nowell S, Kidd D, Mole DJ. Increased risk of type 3c diabetes mellitus after acute pancreatitis warrants a personalized approach including diabetes screening. BJS Open 2022; 6:6901345. [PMID: 36515672 PMCID: PMC9749482 DOI: 10.1093/bjsopen/zrac148] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/07/2022] [Accepted: 10/16/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Acute pancreatitis (AP) is a frequent cause of hospitalization with long-term health consequences, including type 3c diabetes mellitus (DM). The incidence and risk factors for new-onset morbidities after AP need to be clarified to inform a personalized medicine approach. METHODS Using a longitudinal electronic healthcare record-linkage analysis, all patients admitted to hospital in Scotland with a first episode of AP between 1 April 2009 and 31 March 2012 and followed for a minimum of 5 years after their index AP admission were identified. All new-onset morbidity with specific focus on type 3c DM were analysed and, using time-split multiple regression. RESULTS A total of 2047 patients were included. AP requiring critical care was followed by 2 years of heightened risk (HR 5.24) of developing type 3c DM, increased risk of new-onset cardiac disease (HR 1.61), and renal disease (HR 2.96). The additional risk conferred by critical care AP had a negative interaction with time, whereas additional risk associated with male sex and a non-gallstone aetiology was long lasting. CONCLUSION Based on these findings, a personalized approach to include type 3c DM screening for a minimum of 2 years for individuals who required critical care when hospitalized with AP is recommended.
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Affiliation(s)
- Alexander Walker
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - James O'Kelly
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Catriona Graham
- Edinburgh Clinical Research Facility, University of Edinburgh, Edinburgh, UK
| | - Sian Nowell
- eData Research & Innovation Service (eDRIS), formerly Information Services Division, NHS National Services Scotland now part of Public Health Scotland, Edinburgh, Scotland, UK
| | - Doug Kidd
- eData Research & Innovation Service (eDRIS), formerly Information Services Division, NHS National Services Scotland now part of Public Health Scotland, Edinburgh, Scotland, UK
| | - Damian J Mole
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK.,Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
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4
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Chen S, Zhu J, Sun LQ, Liu S, Zhang T, Jin Y, Huang C, Li D, Yao H, Huang J, Qin Y, Zhou M, Chen G, Zhang Q, Ma F. LincRNA-EPS alleviates severe acute pancreatitis by suppressing HMGB1-triggered inflammation in pancreatic macrophages. Immunology 2021; 163:201-219. [PMID: 33512718 DOI: 10.1111/imm.13313] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/30/2020] [Accepted: 01/14/2021] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP), an inflammatory disorder of the pancreas with a high hospitalization rate, frequently leads to systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). However, therapeutic targets for effective treatment and early intervention of AP are still urgently required to be identified. Here, we have observed that the expression of pancreatic lincRNA-EPS, a long intergenic non-coding RNA, is dynamically changed during both caerulein-induced AP (Cer-AP) and sodium taurocholate-induced severe AP (NaTc-SAP). The expression pattern of lincRNA-EPS is negatively correlated with the typical inflammatory genes such as IL-6, IL-1β, CXCL1, and CXCL2. Further studies indicate that knockout of lincRNA-EPS aggravates the pathological symptoms of AP including more induction of serum amylase and lipase, severe edema, inflammatory cells infiltration and acinar necrosis in both experimental AP mouse models. Besides these intrapancreatic effects, lincRNA-EPS also protects against tissue damages in the extra-pancreatic organs such as lung, liver, and gut in the NaTc-SAP mouse model. In addition, we have observed more serum pro-inflammatory cytokines TNF-α and IL-6 in the lincRNA-EPS-/- NaTc-SAP mice and more extracellular HMGB1 around injured acinar cells in the pancreas from lincRNA-EPS-/- NaTc-SAP mice, compared with their respective controls. Pharmacological inhibition of NF- κ B activity by BAY11-7082 significantly abolishes the suppressive effect of lincRNA-EPS on TLR4 ligand-induced inflammatory genes in macrophages. Our study has described a protective role of lincRNA-EPS in alleviating AP and SAP, outlined a novel pathway that lincRNA-EPS suppresses HMGB1-NF- κ B-dependent inflammatory response in pancreatic macrophages and provided a potential therapeutic target for SAP.
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Affiliation(s)
- Shengchuan Chen
- Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Synthetic Biology Regulatory Elements, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Suzhou Institute of Systems Medicine, Suzhou, China
| | - Jingfei Zhu
- Key Laboratory of Synthetic Biology Regulatory Elements, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Suzhou Institute of Systems Medicine, Suzhou, China
| | - Li-Qiong Sun
- Institute of Chinese Medicinal Materials, Nanjing Agricultural University, Nanjing, China
| | - Siying Liu
- Key Laboratory of Synthetic Biology Regulatory Elements, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Suzhou Institute of Systems Medicine, Suzhou, China
| | - Tan Zhang
- Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Synthetic Biology Regulatory Elements, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Suzhou Institute of Systems Medicine, Suzhou, China
| | - Yuepeng Jin
- Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chaohao Huang
- Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Synthetic Biology Regulatory Elements, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Suzhou Institute of Systems Medicine, Suzhou, China
| | - Dapei Li
- Key Laboratory of Synthetic Biology Regulatory Elements, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Suzhou Institute of Systems Medicine, Suzhou, China
| | - Haiping Yao
- Key Laboratory of Synthetic Biology Regulatory Elements, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Suzhou Institute of Systems Medicine, Suzhou, China
| | - Jian Huang
- Department of Emergency, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yanghua Qin
- Department of Laboratory Diagnosis, Changhai Hospital of the Second Military Medical University, Shanghai, China
| | - Mengtao Zhou
- Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Gang Chen
- Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Qiyu Zhang
- Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Feng Ma
- Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Synthetic Biology Regulatory Elements, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Suzhou Institute of Systems Medicine, Suzhou, China
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5
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Sherif AE, McFadyen R, Boyd J, Ventre C, Glenwright M, Walker K, Zheng X, White A, McFadyen L, Connon E, Damaskos D, Steven M, Wackett A, Thomson E, Cameron DC, MacLeod J, Baxter S, Semple S, Morris D, Clark-Stewart S, Graham C, Mole DJ. Study protocol for resolution of organ injury in acute pancreatitis (RESORP): an observational prospective cohort study. BMJ Open 2020; 10:e040200. [PMID: 33293311 PMCID: PMC7722833 DOI: 10.1136/bmjopen-2020-040200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/05/2020] [Accepted: 09/07/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Survivors of acute pancreatitis (AP) have shorter overall survival and increased incidence of new-onset cardiovascular, respiratory, liver and renal disease, diabetes mellitus and cancer compared with the general population, but the mechanisms that explain this are yet to be elucidated. Our aim is to characterise the precise nature and extent of organ dysfunction following an episode of AP. METHODS AND ANALYSIS This is an observational prospective cohort study in a single centre comprising a University hospital with an acute and emergency receiving unit and clinical research facility. Participants will be adult patient admitted with AP. Participants will undergo assessment at recruitment, 3 months and 3 years. At each time point, multiple biochemical and/or physiological assessments to measure cardiovascular, respiratory, liver, renal and cognitive function, diabetes mellitus and quality of life. Recruitment was from 30 November 2017 to 31 May 2020; last follow-up measurements is due on 31 May 2023. The primary outcome measure is the incidence of new-onset type 3c diabetes mellitus during follow-up. Secondary outcome measures include: quality of life analyses (SF-36, Gastrointestinal Quality of Life Index); montreal cognitive assessment; organ system physiological performance; multiomics predictors of AP severity, detection of premature cellular senescence. In a nested cohort within the main cohort, individuals may also consent to multiparameter MRI scan, echocardiography, pulmonary function testing, cardiopulmonary exercise testing and pulse-wave analysis. ETHICS AND DISSEMINATION This study has received the following approvals: UK IRAS Number 178615; South-east Scotland Research Ethics Committee number 16/SS/0065. Results will be made available to AP survivors, caregivers, funders and other researchers. Publications will be open-access. TRIAL REGISTRATION NUMBERS ClinicalTrials.gov Registry (NCT03342716) and ISRCTN50581876; Pre-results.
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Affiliation(s)
- Ahmed E Sherif
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Rory McFadyen
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Chiara Ventre
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | | | - Kim Walker
- Clinical Research Facility, NHS Lothian, Edinburgh, UK
| | - Xiaozhong Zheng
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Audrey White
- Clinical Research Facility, NHS Lothian, Edinburgh, UK
| | | | - Emma Connon
- Clinical Research Facility, NHS Lothian, Edinburgh, UK
| | | | - Michelle Steven
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Anthony Wackett
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Euan Thomson
- Anaesthesia and Critical Care, NHS Lothian, Edinburgh, UK
| | | | - Jill MacLeod
- Respiratory Physiology, NHS Lothian, Edinburgh, UK
| | - Shaun Baxter
- Respiratory Physiology, NHS Lothian, Edinburgh, UK
| | - Scott Semple
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - David Morris
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | | | - Catriona Graham
- Epidemiology and Statistics Core, Edinburgh Clinical Research Facility, University of Edinburgh, Edinburgh, UK
| | - Damian J Mole
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
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6
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Bálint ER, Fűr G, Kiss L, Németh DI, Soós A, Hegyi P, Szakács Z, Tinusz B, Varjú P, Vincze Á, Erőss B, Czimmer J, Szepes Z, Varga G, Rakonczay Z. Assessment of the course of acute pancreatitis in the light of aetiology: a systematic review and meta-analysis. Sci Rep 2020; 10:17936. [PMID: 33087766 PMCID: PMC7578029 DOI: 10.1038/s41598-020-74943-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 09/28/2020] [Indexed: 12/11/2022] Open
Abstract
The main causes of acute pancreatitis (AP) are biliary disease, alcohol consumption, hypertriglyceridaemia (HTG) and endoscopic retrograde cholangiopancreatography (ERCP). The aim of this meta-analysis was to evaluate the effects of these aetiological factors on the severity and outcome of AP. Pubmed and Embase were searched between 01/01/2012 and 31/05/2020. Included articles involved adult alcoholic, biliary, HTG- or post-ERCP AP (PAP) patients. Primary outcome was severity, secondary outcomes were organ failures, intensive care unit admission, recurrence rate, pancreatic necrosis, mortality, length of hospital stay, pseudocyst, fluid collection and systematic inflammatory response syndrome. Data were analysed from 127 eligible studies. The risk for non-mild (moderately severe and severe) condition was the highest in HTG-induced AP (HTG-AP) followed by alcoholic AP (AAP), biliary AP (BAP) and PAP. Recurrence rate was significantly lower among BAP vs. HTG-AP or AAP patients (OR = 2.69 and 2.98, 95% CI 1.55–4.65 and 2.22–4.01, respectively). Mortality rate was significantly greater in HTG-AP vs. AAP or BAP (OR = 1.72 and 1.50, 95% CI 1.04–2.84 and 0.96–2.35, respectively), pancreatic necrosis occurred more frequently in AAP than BAP patients (OR = 1.58, 95% CI 1.08–2.30). Overall, there is a potential association between aetiology and the development and course of AP. HTG-AP is associated with the highest number of complications. Furthermore, AAP is likely to be more severe than BAP or PAP. Greater emphasis should be placed on determining aetiology on admission.
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Affiliation(s)
- Emese Réka Bálint
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Gabriella Fűr
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Lóránd Kiss
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Dávid István Németh
- Institute for Translational Medicine and Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Alexandra Soós
- Institute for Translational Medicine and Szentágothai Research Centre, University of Pécs, Pécs, Hungary.,Clinical Medicine Doctoral School, University of Szeged, Szeged, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine and Szentágothai Research Centre, University of Pécs, Pécs, Hungary.,MTA-SZTE Momentum Translational Gastroenterology Research Group, Szeged, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine and Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Benedek Tinusz
- Institute for Translational Medicine and Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Péter Varjú
- First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Áron Vincze
- First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine and Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - József Czimmer
- Institute for Translational Medicine and Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Zoltán Szepes
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Gábor Varga
- Department of Oral Biology, Semmelweis University, Budapest, Hungary
| | - Zoltán Rakonczay
- Department of Pathophysiology, University of Szeged, Szeged, Hungary.
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7
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Ventre C, Nowell S, Graham C, Kidd D, Skouras C, Mole DJ. Survival and new-onset morbidity after critical care admission for acute pancreatitis in Scotland: a national electronic healthcare record linkage cohort study. BMJ Open 2018; 8:e023853. [PMID: 30552270 PMCID: PMC6303604 DOI: 10.1136/bmjopen-2018-023853] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 11/05/2018] [Accepted: 11/07/2018] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Severe acute pancreatitis (AP) requiring critical care admission (ccAP) impacts negatively on long-term survival. OBJECTIVE To document organ-specific new morbidity and identify risk factors associated with premature mortality after an episode of ccAP. DESIGN Cohort study. SETTING Electronic healthcare registries in Scotland. PARTICIPANTS The ccAP cohort included 1471 patients admitted to critical care with AP between 1 January 2008 and 31 December 2010 followed up until 31 December 2014. The population cohort included 3450 individuals from the general population of Scotland frequency-matched for age, sex and social deprivation. METHODS Record linkage of routinely collected electronic health data with population matching. PRIMARY AND SECONDARY OUTCOME MEASURES Patient demographics, comorbidity (Charlson Comorbidity Index), acute physiology, organ support and other critical care data were linked to records of mortality (death certificate data) and new-onset morbidity. Kaplan-Meier and Cox regression analyses were used to identify risk factors associated with mortality. RESULTS 310 patients with AP died during the index admission. Outcomes were not ascertained for five patients, and the deprivation quintile was not known for six patients. 340 of 1150 patients in the resulting postdischarge ccAP cohort died during the follow-up period. Greater comorbidity measured by the Charlson score, prior to ccAP, negatively influenced survival in the hospital and after discharge. The odds of developing new-onset diabetes mellitus after ccAP compared with the general population were 10.70 (95% CI 5.74 to 19.94). A new diagnosis of myocardial infarction, stroke, heart failure, liver disease, peptic ulcer, renal failure, cancer, peripheral vascular disease and lung disease was more frequent in the ccAP cohort than in the general population. CONCLUSIONS The persistent deleterious impact of severe AP on long-term outcome and survival is multifactorial in origin, influenced by pre-existing patient characteristics and acute episode features. Further mechanistic and epidemiological investigation is warranted.
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Affiliation(s)
- Chiara Ventre
- Surgery, School of Medicine, University of Edinburgh, Edinburgh, UK
| | - Sian Nowell
- Electronic Data Research and Innovation Service (eDRIS), NHS National Services Scotland, Edinburgh, UK
| | - Catriona Graham
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Doug Kidd
- Electronic Data Research and Innovation Service (eDRIS), NHS National Services Scotland, Edinburgh, UK
| | - Christos Skouras
- Surgery, School of Medicine, University of Edinburgh, Edinburgh, UK
| | - Damian J Mole
- Surgery, School of Medicine, University of Edinburgh, Edinburgh, UK
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
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Mira JC, Brakenridge SC, Moldawer LL, Moore FA. Persistent Inflammation, Immunosuppression and Catabolism Syndrome. Crit Care Clin 2017; 33:245-258. [PMID: 28284293 DOI: 10.1016/j.ccc.2016.12.001] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Following advances in critical care, in-hospital multiple organ failure-related mortality is declining. Consequently, incidence of chronic critical illness is increasing. These patients linger in the intensive care unit, have high resource utilization, and poor long-term outcomes. Within this population, the authors propose that a substantial subset of patients have a new phenotype: persistent inflammation, immunosuppression, and catabolism syndrome. There is evidence that myelodysplasia with expansion of myeloid-derived suppressor cells, innate and adaptive immune suppression, and protein catabolism with malnutrition are major contributors. Optimal care of these patients will require novel multimodality interventions.
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Affiliation(s)
- Juan C Mira
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, 1600 Southwest Archer Road, PO Box 100019, Gainesville, FL 32610-0019, USA
| | - Scott C Brakenridge
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, 1600 Southwest Archer Road, Room 6116, PO Box 100286, Gainesville, FL 32610-0286, USA
| | - Lyle L Moldawer
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, 1600 Southwest Archer Road, Room 6116, PO Box 100286, Gainesville, FL 32610-0286, USA
| | - Frederick A Moore
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, 1600 Southwest Archer Road, Room 6116, PO Box 100286, Gainesville, FL 32610-0286, USA.
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9
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Mole DJ, Gungabissoon U, Johnston P, Cochrane L, Hopkins L, Wyper GMA, Skouras C, Dibben C, Sullivan F, Morris A, Ward HJT, Lawton AM, Donnan PT. Identifying risk factors for progression to critical care admission and death among individuals with acute pancreatitis: a record linkage analysis of Scottish healthcare databases. BMJ Open 2016; 6:e011474. [PMID: 27311912 PMCID: PMC4916584 DOI: 10.1136/bmjopen-2016-011474] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 05/12/2016] [Accepted: 05/26/2016] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Acute pancreatitis (AP) can initiate systemic complications that require support in critical care (CC). Our objective was to use the unified national health record to define the epidemiology of AP in Scotland, with a specific focus on deterministic and prognostic factors for CC admission in AP. SETTING Health boards in Scotland (n=4). PARTICIPANTS We included all individuals in a retrospective observational cohort with at least one episode of AP (ICD10 code K85) occurring in Scotland from 1 April 2009 to 31 March 2012. 3340 individuals were coded as AP. METHODS Data from 16 sources, spanning general practice, community prescribing, Accident and Emergency attendances, hospital in-patient, CC and mortality registries, were linked by a unique patient identifier in a national safe haven. Logistic regression and gamma models were used to define independent predictive factors for severe AP (sAP) requiring CC admission or leading to death. RESULTS 2053 individuals (61.5% (95% CI 59.8% to 63.2%)) met the definition for true AP (tAP). 368 patients (17.9% of tAP (95% CI 16.2% to 19.6%)) were admitted to CC. Predictors of sAP were pre-existing angina or hypertension, hypocalcaemia and age 30-39 years, if type 2 diabetes mellitus was present. The risk of sAP was lower in patients with multiple previous episodes of AP. In-hospital mortality in tAP was 5.0% (95% CI 4.1% to 5.9%) overall and 21.7% (95% CI 19.9% to 23.5%) in those with tAP necessitating CC admission. CONCLUSIONS National record-linkage analysis of routinely collected data constitutes a powerful resource to model CC admission and prognosticate death during AP. Mortality in patients with AP who require CC admission remains high.
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Affiliation(s)
- Damian J Mole
- MRC Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Usha Gungabissoon
- Healthcare Information Factory, Observational Data Analytics Group, Worldwide Epidemiology, GSK, Uxbridge, UK
| | | | | | | | | | | | | | - Frank Sullivan
- Department of Family and Community Medicine, North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Andrew M Lawton
- Healthcare Information Factory, Observational Data Analytics Group, Worldwide Epidemiology, GSK, Uxbridge, UK
| | - Peter T Donnan
- Dundee Epidemiology and Biostatistics Unit (DEBU), Division of Population Health Sciences, Medical Research Institute, University of Dundee, Dundee, UK
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10
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Mole DJ, Webster SP, Uings I, Zheng X, Binnie M, Wilson K, Hutchinson JP, Mirguet O, Walker A, Beaufils B, Ancellin N, Trottet L, Bénéton V, Mowat CG, Wilkinson M, Rowland P, Haslam C, McBride A, Homer NZM, Baily JE, Sharp MGF, Garden OJ, Hughes J, Howie SEM, Holmes DS, Liddle J, Iredale JP. Kynurenine-3-monooxygenase inhibition prevents multiple organ failure in rodent models of acute pancreatitis. Nat Med 2016; 22:202-9. [PMID: 26752518 PMCID: PMC4871268 DOI: 10.1038/nm.4020] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 11/30/2015] [Indexed: 12/28/2022]
Abstract
Acute pancreatitis (AP) is a common and devastating inflammatory condition of the pancreas that is considered to be a paradigm of sterile inflammation leading to systemic multiple organ dysfunction syndrome (MODS) and death. Acute mortality from AP-MODS exceeds 20% (ref. 3), and the lifespans of those who survive the initial episode are typically shorter than those of the general population. There are no specific therapies available to protect individuals from AP-MODS. Here we show that kynurenine-3-monooxygenase (KMO), a key enzyme of tryptophan metabolism, is central to the pathogenesis of AP-MODS. We created a mouse strain that is deficient for Kmo (encoding KMO) and that has a robust biochemical phenotype that protects against extrapancreatic tissue injury to the lung, kidney and liver in experimental AP-MODS. A medicinal chemistry strategy based on modifications of the kynurenine substrate led to the discovery of the oxazolidinone GSK180 as a potent and specific inhibitor of KMO. The binding mode of the inhibitor in the active site was confirmed by X-ray co-crystallography at 3.2 Å resolution. Treatment with GSK180 resulted in rapid changes in the levels of kynurenine pathway metabolites in vivo, and it afforded therapeutic protection against MODS in a rat model of AP. Our findings establish KMO inhibition as a novel therapeutic strategy in the treatment of AP-MODS, and they open up a new area for drug discovery in critical illness.
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Affiliation(s)
- Damian J Mole
- Medical Research Council Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Scott P Webster
- University/British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Iain Uings
- Discovery Partnerships with Academia, GlaxoSmithKline, Stevenage, UK
| | - Xiaozhong Zheng
- Medical Research Council Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Margaret Binnie
- University/British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Kris Wilson
- University/British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | | | - Ann Walker
- Discovery Partnerships with Academia, GlaxoSmithKline, Stevenage, UK
| | | | | | | | | | | | - Martin Wilkinson
- EastChem School of Chemistry, University of Edinburgh, Edinburgh, UK
| | - Paul Rowland
- Molecular Discovery Research, GlaxoSmithKline, Stevenage, UK
| | - Carl Haslam
- Molecular Discovery Research, GlaxoSmithKline, Stevenage, UK
| | - Andrew McBride
- University/British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - James E Baily
- University/British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Matthew G F Sharp
- Central Bioresearch Services, University of Edinburgh, Edinburgh, UK
| | - O James Garden
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Jeremy Hughes
- Medical Research Council Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Sarah E M Howie
- Medical Research Council Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Duncan S Holmes
- Discovery Partnerships with Academia, GlaxoSmithKline, Stevenage, UK
| | - John Liddle
- Discovery Partnerships with Academia, GlaxoSmithKline, Stevenage, UK
| | - John P Iredale
- Medical Research Council Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
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Clinical outcomes of combined necrotizing pancreatitis versus extrapancreatic necrosis alone. Pancreatology 2015; 16:57-65. [PMID: 26626203 DOI: 10.1016/j.pan.2015.10.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 10/25/2015] [Accepted: 10/28/2015] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Extrapancreatic necrosis (EPN) alone, i.e., in the absence of pancreatic parenchyma necrosis has gradually come to be regarded as a separate entity of acute necrotizing pancreatitis (ANP). However, data regarding the prognostic significance of EPN are quite limited, and the outcomes of interventions for patients with EPN alone are not well elucidated. The aim of this study was to explore the differences in the outcomes of patients with EPN alone and patients with both the pancreatic parenchyma and extrapancreatic necrosis (combined necrosis). METHODS From January 2009 to December 2013, a total of 334 patients with ANP who had received interventions in the West China Hospital in China were included. Based on the extent of necrosis as assessed with contrast-enhanced CT, the patients were divided into Group 1 (n = 285) in which the necrosis involved both the pancreatic parenchyma and extrapancreatic tissues (combined necrosis) and Group 2 (n = 49) in which the necrosis involved only the extrapancreatic tissues. Additionally, Group 3 included 443 patients with interstitial pancreatitis who were also included in the analyses. The demographic characteristics, support treatment information, organ failure information, infection necrosis, persistent systemic inflammatory response syndrome (SIRS) in the first week of onset, CT severity index, and intervention types, as well as the postoperative stay lengths, ICU utility, and complications were collected and compared. RESULTS Compared with the patients in Group 1, the patients in Group 2 suffered less persistent SIRS in the first week of onset (12/24.5% vs. 145/50.9%; P < 0.05), less persistent organ failure (6/12.2% vs. 95/33.3%; P < 0.05), less persistent multiple organ failure (3/6.1% vs. 67/23.5%; P < 0.05), and less bacteremia (5/10.2% vs. 107/37.5%; P < 0.001). The intervention types were significantly different between the two groups (P < 0.001); initial open necrosectomy was performed in 174/61.6% and 8/16.3% of the patients in Groups 1 and 2, respectively, and initial percutaneous catheter drainage (PCD) was performed in 73/25.6% and 29/59.2% of the patients in the two respective groups. Second open necrosectomies following PCD were required in 61/83.5% and 9/31.0% of the patients in Groups 1 and 2, respectively (P < 0.001). A greater number of patients in Group 1 were diagnosed with infected necrosis (204/71.6% vs. 10/20.4%; P < 0.001) and had to be sent to the ICU for further postoperative care (221/77.5% vs. 23/46.9%; P < 0.001). The postoperative stay was longer for Group 1 (median: 43.0 vs. 26.5 days; P < 0.001). Residual necrotic tissue or abscess was the most common postoperative complication in both groups. The mortality was higher in Group 1 (52/18.2% vs. 1/2.1%; P < 0.05). Compared with the patients in Group 2, the patients with interstitial pancreatitis exhibited milder courses and better outcomes. Subgroup comparisons with Group 1 indicated that early multiple organ failure was significantly associated with higher mortality. CONCLUSION The patients with EPN alone exhibited significantly better prognoses than those with combined necrosis, and EPN alone should be regarded as a separate group of acute necrotizing pancreatitis. Open necrosectomy can be avoided in the majority of patients with EPN alone, who receive PCD as the initial first intervention.
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