Establishment and validation of prediction model for severity of acute pancreatitis / 中华消化杂志

Objective:To establish and internally validate a visualized model for predicting the severity of acute pancreatitis (AP).Methods:From September 1st 2017 to August 31st 2020, 600 patients with AP diagnosed in the First Affiliated Hospital of Kunming Medical University were enrolled. According to the Atlanta classification of AP, the 600 patients were divided into severe acute pancreatitis (SAP) group (128 cases) and non-severe acute pancreatitis (NSAP) group (472 cases). The general clinical data (age, gender, body mass index, etc), laboratory indicators (fasting blood glucose, urea nitrogen, creatinine, etc.), complicated with ascites or pleural effusion, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) scores and bedside index of severity in acute pancreatitis (BISAP) score between the two groups were compared. The potential predictors of SAP were screened with least absolute shrinkage and selection operator (LASSO). The screened predictors were included in the multivariate logistic regression analysis to establish the logistic regression model. The operation characteristic curves of the model, APACHE Ⅱ scores and BISAP were drawn, the discriminative capability of the model was evaluated by comparing the area under the curve (AUC). Calibration, Hosmer-Lemesshow test and decision curve analysis (DCA) were used to evaluate the accuracy and clinical practicability of the prediction model. Bootstrap was used for internally validation of the model. Independent sample t test, Wilcoxon test and chi-square test were used for statistical analysis. Results:The difference of gender composition ratio between SAP and NSAP group was statistically significant ( χ2=4.092, P<0.05). The fatality rate of SAP group was higher than that of NSAP group(21.1%, 27/128 vs. 0, 0/472); the length of hospital stay of SAP group was longer than that of NSAP group((20.33±16.21) d vs. (8.42±4.26) d); the hospitalization cost, fasting blood glucose level, urea nitrogen level, creatinine level, C-reactive protein(CRP) level, D-dimer level, fibrinogen level, white blood cell count, percentage of neutrophils, neutrophil-lymphocyte ratio, APACHEⅡ and BISAP scores, the incidence of complicated with pleural effusion or ascites and the constituent ratio of alcoholic etiology of SAP group were all higher than those of NASP group (44 837.58 yuan (23 017.73 yuan, 102 579.77 yuan) vs. 12 301.46 yuan (8 649.26 yuan, 18 823.88 yuan); (10.48±4.84) mmol/L vs. (8.45±4.80) mmol/L; (8.80±6.50) mmol/L vs. (4.90±2.33) mmol/L; (139.56±127.75) mmol/L vs. (80.05±38.54) mmol/L; (187.33±87.25) mg/L vs. (90.81±82.53) mg/L; 5.19 mg/L (2.96 mg/L, 8.52 mg/L) vs.1.29 mg/L (0.53 mg/L, 2.87 mg/L); 6.13 mg/L (4.64 mg/L, 7.31 mg/L) vs. 4.58 mg/L (3.50 mg/L, 5.98 mg/L); (14.87±5.82)×10 9/L vs. (11.79±4.86)×10 9/L; 0.84±0.12 vs.0.78±0.12; 13.16±7.57 vs. 8.77±7.28; 9.80±6.09 vs. 3.79±2.59; 2.12±0.89 vs. 1.04±0.78; 65.6%, 84/128 vs. 12.9%, 61/472; 70.3%, 90/128 vs. 20.3%, 96/472; 18.8%, 24/128 vs. 11.4%, 54/472); serum albumin level, blood calcium level, and hematocrit level of SAP group were all lower than those of NSAP group ((30.86±4.95) g/L vs. (37.14±5.44) g/L; (1.98±0.31) mmol/L vs. (2.16±0.20) mmol/L; (42.40±8.67)% vs.(44.30±6.45)%), and the differences were all statistically significant ( χ2=99.403, t=8.235, Z=-13.330, t=4.239, 10.759, 5.207 and 11.227, Z=-11.406 and -6.234, t=6.097, 4.829, 6.011, 10.899 and 12.395, χ2=152.604, 117.563 and 4.757, t=-11.788, -6.180 and -2.310, all P<0.05). LASSO regression analysis screened out four predictors of CRP, urea nitrogen, D-dimer and ascites. The results of multivariate logistic regression analysis showed that CRP (odds ratio ( OR)=1.009, 95% (confidence interval) CI 1.006 to 1.012), urea nitrogen( OR=1.185, 95% CI 1.097 to 1.280), D-dimer( OR=1.166 95% CI 1.082 to 1.256), ascites ( OR= 4.848, 95% CI 2.829 to 8.307) were the independent predictors of SAP (all P<0.01). The AUC of the model (0.895 , 95% CI 0.865 to 0.926) was higher than those of the APACHE Ⅱ(AUC=0.835, 95% CI 0.791 to 0.878)and BISAP score (AUC=0.803, 95% CI 0.760 to 0.846), and the differences were statistically significant ( Z=2.578 and 4.466, both P<0.05). The results predicted by the model in the calibration chart and the Hosmer-Lemesshow test were highly consistent with the results of actual clinical observation. When the probability of SAP in the model was 10% to 95%, the DCA curve of the model was higher than the two extreme lines, which had certain clinical practical value. After bootstrap internal validation, the model had a high discrimination ability (AUC=0.892), and its predicted AP severity curve was still in good agreement with the actual clinical AP severity curve. Conclusion:The prediction model established based on CRP, urea nitrogen, D-dimer and ascites can predict the severity of AP, and help doctors to make more scientific clinical decision.

Clinical features and prediction of 152 patients of acute pancreatitis complicated with portal vein system thrombosis / 中华消化杂志

Objective:To explore the clinical features of acute pancreatitis (AP) complicated with portal vein system thrombosis (PVST) and the clinical prediction of symptomatic PVST.Methods:From January 2014 to December 2019, at First Affiliated Hospital and Second Affiliated Hospital of Kunming Medical University, 152 hospitalized patients who met the diagnostic criteria of AP complicated with PVST and had complete clinical data were retrospectively analyzed, and the clinical characteristics of them were analyzed. According to whether there were clinical manifestations caused by PVST (esophago-gastric variceal bleeding, persistent ascites, intestinal ischemia), AP patients complicated with PVST were divided into symptomatic group ( n=48) and asymptomatic group ( n=104). The differences in general information, laboratory test indicators, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ), Balthazar computed tomography (CT) score, local and systemic complications were compared between symptomatic group and asymptomatic group. Two independent sample t test, two sample rank sum test, and chi-square test were used for statistical analysis. The binary logistic regression was used for multivariate analysis. Results:The severe acute pancreatitis (SAP) complicated with PVST was common, accounted for 73.0% (111/152), and the hospital mortality rate was 14.5% (22/152). The splenic vein (46.1%, 70/152) was the most common single vessel involved. The hospital stay of the symptomatic group was longer than that of the asymptomatic group, the hospitalization costs and hospital mortality of the symptomatic group were both higher than those of the asymptomatic group ((26.31±19.38) d vs. (15.11±9.31) d, (103 463.68±15 312.74) yuan vs. (37 199.38±4 647.17) yuan, 25.0%, 12/48 vs. 9.6%, 10/104, respectively), and the differences were statistically significant ( t=-3.809 and -4.141, χ2=6.280; all P<0.05). The lactic acid dehydrogenase, C-reactive protein, and prothrombin time of the symptomatic group were all higher than those of the asymptomatic group (4.78 μmol·s -1·L -1, 2.96 μmol·s -1·L -1 to 7.82 μmol·s -1·L -1 vs. 4.42 μmol·s -1·L -1, 3.29 μmol·s -1·L -1 to 9.30 μmol·s -1·L -1; 69.53 mg/L, 29.49 mg/L to 147.14 mg/L vs. 40.90 mg/L, 8.88 mg/L to 104.89 mg/L; (16.88±8.23) s vs. (14.12±1.59) s), however the hematocrit and blood calcium in the symptomatic group were both lower than those of the asymptomatic group ((34.97±8.96)% vs. (39.18±7.17)%, (2.01±0.32) mmol/L vs. (2.17±0.19) mmol/L), and the differences were all statistically significant ( Z=-2.067 and -1.977, t=-2.281, 3.072 and 3.083; all P<0.05). The scores of APACHE Ⅱand Balthazar CT, the rate of local complications of pancreatic necrosis, and systemic complications including abdominal hemorrhage, septic shock, acute respiratory distress syndrome, lung infection and pleural effusion of the symptomatic group were higher than those of the asymptomatic group (7.21±3.84 vs. 5.27±2.31, 7.10±1.57 vs. 4.83±1.87, 87.5%, 42/48 vs. 28.8%, 30/104; 10.4%, 5/48 vs. 1.9%, 2/104; 18.8%, 9/48 vs. 1.9%, 2/104; 25.0%, 12/48 vs. 3.8%, 4/104; 91.7%, 44/48 vs. 60.6%, 63/104; 85.4%, 41/48 vs. 49.0%, 51/104; respectively), and the differences were statistically significant ( t=-3.241 and -7.331, χ2=45.320, 5.393, 13.852, 15.604, 15.323 and 18.191; all P<0.05). The results of binary logistic regression showed that Balthazar CT score was an independent risk factor for symptomatic PVST ( P<0.01), and odds ratio (95% confidence interval) was 1.79 (1.41 to 2.29). Conclusions:Balthazar CT score is an influencing factor of symptomatic PVST in AP patients, and patients with high scores should be treated early to improve the prognosis.

Role of exosomes in the metastasis of pancreatic cancer / 临床肝胆病杂志

Although great achievements have been made in the diagnosis and treatment of pancreatic cancer in the past several decades, the 5-year survival rate of this disease is still below 10% due to high degree of malignancy, rapid progression, and strong invasion and metastasis. Exosomes are a class of nanoscale membranous vesicles that can be secreted by a variety of cells, and they carry various substances including proteins, lipids, and nucleic acids and participate in various physiological and pathological processes, such as intercellular material transport, information transmission, and development, progression, and metastasis of tumor. Studies have shown that exosomes play an important role in the metastasis of pancreatic cancer and can regulate the metastasis of pancreatic cancer by promoting epithelial-mesenchymal transition and angiogenesis to act on tumor microenvironment, affecting the formation of premetastatic microenvironment, and participating in the formation of immunosuppression microenvironment. This article reviews the research advances in exosomes in the metastasis of pancreatic cancer.

Research advances in continuous blood purification in treatment of severe acute pancreatitis / 临床肝胆病杂志

Severe acute pancreatitis (SAP) is a disease with dangerous course and poor prognosis, and although medical technology keeps improving over the years, the mortality rate of SAP remains high. As the latest achievement in the field of blood purification over the past 30 years, continuous blood purification has made great achievements in the treatment of SAP; however, there are still many controversies, and further studies are needed to explore therapeutic effect and mechanism. This article reviews the studies on continuous blood purification in the treatment of SAP in recent years and elaborates on its therapeutic mechanism, treatment mode, and treatment effect.