Association Between the Pancreatic Enzyme Level and Organ Failure in Trauma Patients

Evidence showing lipotoxicity worsens outcomes in covid-19 patients and insights about the underlying mechanisms

We compared three hospitalized patient cohorts and conducted mechanistic studies to determine if lipotoxicity worsens COVID-19. Cohort-1 (n = 30) compared COVID-19 patients dismissed home to those requiring intensive-care unit (ICU) transfer. Cohort-2 (n = 116) compared critically ill ICU patients with and without COVID-19. Cohort-3 (n = 3969) studied hypoalbuminemia and hypocalcemia’s impact on COVID-19 mortality. Patients requiring ICU transfer had higher serum albumin unbound linoleic acid (LA). Unbound fatty acids and LA were elevated in ICU transfers, COVID-19 ICU patients and ICU non-survivors. COVID-19 ICU patients (cohort-2) had greater serum lipase, damage-associated molecular patterns (DAMPs), cytokines, hypocalcemia, hypoalbuminemia, organ failure and thrombotic events. Hypocalcemia and hypoalbuminemia independently associated with COVID-19 mortality in cohort-3. Experimentally, LA reacted with albumin, calcium and induced hypocalcemia, hypoalbuminemia in mice. Endothelial cells took up unbound LA, which depolarized their mitochondria. In mice, unbound LA increased DAMPs, cytokines, causing endothelial injury, organ failure and thrombosis. Therefore, excessive unbound LA in the circulation may worsen COVID-19 outcomes.

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Three cohorts of hospitalized COVID-19 patients with different severities were studied

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Severe COVID-19 increased serum linoleic acid (LA) and unbound fatty acid levels

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Endothelial cell uptake of unbound LA dose-dependently depolarized mitochondria

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Unbound LA increased cytokines, endothelial injury, organ failure and thrombosis

Adipose saturation reduces lipotoxic systemic inflammation and explains the obesity paradox

Obesity sometimes seems protective in disease. This obesity paradox is predominantly described in reports from the Western Hemisphere during acute illnesses. Since adipose triglyceride composition corresponds to long-term dietary patterns, we performed a meta-analysis modeling the effect of obesity on severity of acute pancreatitis, in the context of dietary patterns of the countries from which the studies originated. Increased severity was noted in leaner populations with a higher proportion of unsaturated fat intake. In mice, greater hydrolysis of unsaturated visceral triglyceride caused worse organ failure during pancreatitis, even when the mice were leaner than those having saturated triglyceride. Saturation interfered with triglyceride's interaction and lipolysis by pancreatic triglyceride lipase, which mediates organ failure. Unsaturation increased fatty acid monomers in vivo and aqueous media, resulting in greater lipotoxic cellular responses and organ failure. Therefore, visceral triglyceride saturation reduces the ensuing lipotoxicity despite higher adiposity, thus explaining the obesity paradox.

Extra Pancreatic Necrotic Volume: Can It Prognosticate Acute Necrotising Pancreatitis— A Prospective Study

Background Acute necrotizing pancreatitis (ANP) is associated with higher mortality and morbidity. We need a method which is accurate in predicting the prognosis, and when applied early in the disease process, can help in closer monitoring and early initiation of treatment for at-risk patients.

Objectives The aim of this prospective study was to assess the extra pancreatic necrosis (EPN) volume in patients with ANP and compare it with outcome variables such as organ failure, death and need for intervention as well as to compare the predictive power of EPN volume with modified CT severity index (CTSI).

Materials and Methods The study had 48 patients with clinical diagnosis of acute pancreatitis, who underwent Contrast enhanced CT (CECT) between 3–6 days of onset. In all these patients, EPN volume (in cubic centimetre) and modified CTSI score were calculated and compared with the patient outcome parameters such as duration of hospital/ICU stay, need for percutaneous/surgical intervention, evidence of infection and organ failure. The results were compared with assess the predictive power of EPN volume.

Statistical analysis The analysis was done in SPSS version 16.0 for windows. Pearson Correlation was used to assess the significant relationship between selected objective variables.

Results EPN volume (>/= to 360 cc) had a statistically significant correlation with outcome parameters as well as in predicting overall organ failure. In our study, Modified CTSI had no significant correlation with the above mentioned factors.

Conclusions The volume of EPN calculated between 3rd and 6th day of onset of symptoms showed a significant correlation with the outcome in patients with ANP.

Factors associated with increased pancreatic enzymes in septic patients: a prospective study

Background

The perfusion of splanchnic organs is deeply altered in patients with septic shock. The aim of the study is to identify the predictive factors of septic shock-induced increase of serum lipase and amylase and to assess and evaluate its prognostic impact.

Methods

We conducted a prospective observational study. All adult patients admitted with septic shock were eligible for our study. Serum lipase and amylase were measured on admission. Patients with and those without increased pancreatic enzymes were compared. Predictive factors of pancreatic insult identified by the univariate analysis were integrated in a stepwise multivariate analysis. Odds ratios (OR) with the 95% confidence interval (CI) were calculated accordingly. Second, the sensitivity and the specificity of amylase and lipase to predict intensive care unit (ICU) mortality were identified through the Receiver Operator Curve.

Results

Fifty patients were included. Median [quartiles] age was 68.5 [58–81] years. The APACHE II score was 26 [20–31]. Twenty-three patients (46%) had increased serum amylase and/or serum lipase. Diabetes mellitus (OR = 16; 95% CI [1.7–153.5]; p = 0.016), increased blood urea nitrogen (OR = 1.12; 95% CI [1.02–1.20], p = 0.016), and decreased C-reactive protein (OR = 0.97; 95% CI [0.96–0.99]; p = 0.027) were identified as independent factors predicting increased pancreatic enzymes. Twenty patients (40%) died in the ICU. Neither serum amylase level nor serum lipase level was significantly different between survivors and non-survivors (respectively 49 [27.7–106] versus 85.1 [20.1–165] UI/L; p = 0.7 and 165 [88–316] versus 120 [65.5–592] UI/L; p = 0.952).

Conclusion

Increase of pancreatic enzymes is common in patients with septic shock. Diabetes and impaired renal function are predictive of increased pancreatic enzymes. Such finding does not carry any negative prognostic value.

Urine Interleukin-18 (IL-18) as a Biomarker of Total-Body Irradiation: A Preliminary Study in Nonhuman Primates

We have reported that circulating IL-18 can be used as a radiation biomarker in mice, minipigs and nonhuman primates (NHPs, Macaca mulatta). Here, we report the levels of IL-18 in individual NHP's urine before and at 6 h-7 days after 5.0, 6.5 and 8.5 Gy ⁶⁰Co total-body irradiation (TBI) using enzyme linked immunosorbent assay (ELISA). Six animals (3.5-5.5 kg, 3-4 years old) per radiation dose were investigated. Correlation values between urine IL-18 and blood cell counts and serum chemistry parameters including lactate dehydrogenase (LDH), lipase, and serum total protein (TP), as well as between urine IL-18 and 60-day survival, were analyzed. Our data, to the best of our knowledge, for the first time, demonstrate that concentrations of urine IL-18 from irradiated NHPs were increased in a radiation dose-dependent manner compared to pre-TBI levels in samples from these animal (N = 18, 11.02 ± 1.3 pg/ml). A 5.0 Gy low dose of radiation (∼LD_10/60) did not increase urine IL-18 levels. In contrast, high-dose TBI significantly increased urine IL-18 at day 1 to day 5 in a bell-shaped time course, reaching a peak of 5- to 10-fold of control levels on day 3 after 6.5 Gy (∼LD_50/60) and 8.5 Gy (∼LD_90/60), respectively. Statistical analysis using receiver operator characteristic (ROC) and MultiROC analysis indicated that white blood cell and platelet counts, serum LDH, lipase and TP, when combined with urine IL-18, provide discriminatory predictors of total-body radiation injury with a very high ROC area of 0.98. Urine IL-18 measurement, as an early prognostic indicator of survival, may facilitate rapid detection of lethal doses of radiation, based on the currently available data set.