Mechanism and prevention of liver failure complicated by acute pancreatitis / 临床肝胆病杂志

Liver failure often has rapid progression， multiple complications， and dangerous conditions. Acute pancreatitis is a common comorbidity during the progression of liver failure， and since acute pancreatitis has extremely similar clinical symptoms and signs to liver failure complicated by spontaneous peritonitis， it is often neglected in clinical practice. This article elaborates on the mechanisms of liver failure complicated by acute pancreatitis from the five aspects of inflammatory response， duodenal papillary dysfunction， gut microbiota dysbiosis， oxidative stress， and microcirculatory disturbance and proposes corresponding preventive measures based on these mechanisms.

Insuficiencia pancreática endocrina transitoria secundaria a pancreatitis aguda necrotizante grave en una niña

Producto de una pancreatitis aguda (PA) puede haber una diabetes posterior o una hiperglicemia transitoria durante el episodio de PA. La incidencia de PA en edad pediátrica es de hasta 12,2 casos por 100 000 niños al año y sólo el 4 a 5% desarrollan luego diabetes. Con respecto a la hiperglicemia transitoria en niños, la información es escasa y no se ha hecho publicaciones al respecto en nuestro país. Se reporta el caso de una niña con hiperglicemia transitoria secundaria a una PA necrotizante grave. Es importante realizar un monitoreo constante de los niveles de glucosa y el tratamiento oportuno de la hiperglicemia en niños con PA ya que, al menos en adultos, se asocia a PA severa y mayor mortalidad.

As a result of acute pancreatitis (AP), there may be subsequent diabetes or transient hyperglycemia during the episode of AP. The incidence of AP in pediatric age is up to 12.2 cases per 100,000 children per year and only 4 to 5% later develop diabetes. Regarding transient hyperglycemia in children, information is scarce, and no publications have been made about it in our country. The case of a girl with transient hyperglycemia secondary to severe necrotizing AP is reported. It is important to constantly monitor glucose levels and timely manage hyperglycemia in children with AP since, at least in adults, it is associated with severe AP and higher mortality.

Changes in intestinal microbiota and application of probiotics in patients with acute pancreatitis / 临床肝胆病杂志

Intestinal microbiota is the most complex and important microecosystem in the human body， and gut microbiota dysbiosis is closely associated with the development and progression of acute pancreatitis. Targeted regulation of intestinal microecology in assisting the treatment of acute pancreatitis has attracted more attention in recent years. This article describes the changes in intestinal microbiota and related mechanisms in patients with acute pancreatitis， summarizes the current research status of the use of probiotics， points out the research direction of probiotics as the adjuvant treatment regime， and proposes a new method for predicting the dominant flora in patients with acute pancreatitis， in order to bring new ideas for the treatment of acute pancreatitis.

Research progress on continuous blood purification in the treatment of severe acute pancreatitis / 中国医师杂志

Severe acute pancreatitis (SAP) is a common gastrointestinal disease, often accompanied by systemic inflammatory reactions and organ dysfunction. SAP has an acute onset, severe condition, rapid progression, and poor prognosis. The development of SAP is closely related to the excessive release of inflammatory factors. In the comprehensive treatment of SAP, continuous blood purification (CBP) can clear inflammatory mediators, improve the stability of Internal environment, improve organ function, reduce blood lipids, regulate immunity, and significantly improve the condition of SAP patients. It is an important means of treating SAP. This article reviews the research progress of CBP in the treatment of SAP.

Correlation analysis of serum zonulin, ZO-1, TNF-α with severity of acute pancreatitis / 中国医师杂志

Objective:To analyze the correlation between the severity of acute pancreatitis (AP) and the levels of zonulin, zonula occludens protein-1 (ZO-1), tumor necrosis factor -α (TNF -α) in the peripheral blood of patients with acute pancreatitis (AP), and the value of predicting moderate and severe AP.Methods:The clinical data of 115 AP patients admitted to the Second Affiliated Hospital of Anhui Medical University from June 2020 to January 2022 were retrospectively analyzed. They were divided into mild group (69 cases) and moderate severe group (46 cases). The blood levels of zonulin, ZO-1, and TNF-α were measured for all patients on the 1st, 3rd, and 7th day after admission, and the results of the two group tests were compared. The correlation between zonulin, ZO-1, TNF -α and Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) scores on the 1st day was and the value of various indicators for predicting moderate to severe AP were analyzed.Results:The C-reactive protein (CRP) levels of AP patients in the moderate to severe group were higher than those in the mild group, and the difference was statistically significant (all P<0.05). The levels of zonulin, ZO-1, and TNF -α in AP patients in the moderate to severe group showed an upward trend on the 1st, 3rd, and 7th days after admission. The levels of zonulin, ZO-1, and TNF -α in AP patients in the moderate to severe group were higher than those in the mild group at the same time point, and the differences were statistically significant (all P<0.05). The APACHE Ⅱ score of AP patients on the first day of admission was positively correlated with the levels of zonulin, ZO-1, and TNF -α ( r=0.736, 0.552, 0.621, all P<0.05). Zonulin had the highest area under the curve (AUC) for predicting moderate to severe AP, at 0.892, with an optimal threshold of 2.075 pg/ml. Zonulin had the highest sensitivity, at 0.804, and ZO-1 had the highest specificity, at 0.926. Using zonulin ≥2.075 pg/ml, ZO-1≥399.4 ng/ml, and TNF -α≥40.88 pg/ml as thresholds; the sensitivity and specificity obtained from parallel experiments were 0.976 and 0.710, respectively; The sensitivity and specificity obtained from the series of experiments were 0.326 and 0.999, respectively. Conclusions:There is a correlation between the serum levels of zonulin, ZO-1, and TNF -α in AP patients and the severity of AP. Zonulin, ZO-1, and TNF -α have certain clinical value in predicting moderate to severe AP.

The value of serum related cytokines in predicting intestinal mucosal injury in severe acute pancreatitis patients / 中国医师杂志

Objective:To analyze the value of serum related cytokines in predicting intestinal mucosal injury in patients with severe acute pancreatitis (SAP) and its correlation with intestinal mucosal injury.Methods:A total of 92 patients with SAP admitted to the First Hospital of Qinhuangdao from January 2020 to December 2021 were included in the study. According to the presence or absence of intestinal mucosal barrier dysfunction, the patients were divided into intestinal mucosal barrier dysfunction group (33 cases) and non-intestinal mucosal barrier dysfunction group (59 cases). Another 100 healthy subjects were selected as the control group. Clinical data of the subjects were collected. Serum levels of procalcitonin (PCT), D-lactic acid (D-L), endotoxin, diamine oxidase (DAO), citrulline and intestinal fatty acid binding protein (I-FABP) of the three groups were compared, and the correlation between the above indexes was analyzed by Pearson correlation analysis. Receiver operating characteristic (ROC) curve was used to analyze the value of each indicator in predicting intestinal mucosal barrier dysfunction in SAP patients.Results:The levels of serum PCT, D-L, endotoxin, DAO and I-FABP in intestinal mucosal barrier dysfunction group, non-intestinal mucosal barrier dysfunction group and control group showed a downward trend, while the level of serum citrulline showed an upward trend, with statistically significant difference (all P<0.05). Pearson correlation analysis showed that serum citrulline was negatively correlated with serum PCT, D-L, and endotoxin levels ( r=-0.740, -0.629, -0.310, all P<0.05); There was a positive correlation between serum DAO and serum PCT, D-L and endotoxin levels ( r=0.482, 0.779, 0.338, all P<0.05); There was a positive correlation between serum I-FABP and serum PCT, D-L and endotoxin levels ( r=0.613, 0.421, 0.341, all P<0.05). The ROC curve results showed that the area under the curve (AUC) of serum PCT, D-L, endotoxin, DAO, citrulline, and I-FABP predicting intestinal mucosal injury in SAP patients were 0.816, 0.789, 0.732, 0.801, 0.812, and 0.857, respectively. The AUC of the combination of the above indicators predicting intestinal mucosal barrier dysfunction in SAP patients was 0.909, significantly higher than that predicted by each index alone (all P<0.05). Conclusions:The occurrence of intestinal mucosal barrier dysfunction in SAP patients may be related to the increase of serum PCT, D-L, endotoxin, DAO, I-FABP levels and the decrease of citrulline levels. It may be considered to predict the risk of intestinal mucosal injury by detecting the levels of various indicators in patients′ serum.

Predictive value of atherogenic index of plasma in the assessment of acute pancreatitis / 中国医师杂志

Objective:To investigate the predictive value of atherogenic index of plasma (AIP) in the assessment of acute pancreatitis (AP).Methods:598 patients diagnosed with AP admitted to the Affiliated Hospital of Yangzhou University between January 2016 and December 2020 were recruited and divided into severe acute pancreatitis group (SAP group, n=57) and non-severe acute pancreatitis group (non SAP group, n=541) according to the Atlanta Classification (2012 revision). General clinical data and related biochemical indicators of all enrolled patients were collected, and Bedside Index of Acute Pancreatitis Severity (BISAP) score, Ranson score and CT Severity Index (CTSI) score were performed. The risk factors of SAP were analyzed by logistic regression. Receiver operating characteristic (ROC) curve was used to analyze the evaluation value of AIP and various scoring systems on the severity of pancreatitis. Results:The AIP, white blood cell (WBC), neutrophil count (NEUT), fasting blood glucose (FBG), serum total cholesterol (TC) level, proportion of hyperlipidemia, proportion of diabetes, Ranson score, BISAP score, CTSI score of patients in SAP group were higher than those in non SAP group, and the difference was statistically significant (all P<0.05). Multivariate logistic regression analysis showed that AIP was an independent risk factor for SAP ( P<0.05). ROC curve showed that the are under the curve (AUC) of SAP predicted by AIP was 0.706(95% CI: 0.631-0.782, P<0.001). Conclusions:AIP is an independent risk factor for SAP, which helps to assess the severity of AP.

Relationship between serum interleukin-6 and interleukin-10 levels and the clinical prognosis of severe acute pancreatitis / 中国基层医药

Objective:To investigate the relationship between serum interleukin-6 and interleukin-10 levels and clinical prognosis in patients with severe acute pancreatitis.Methods:Ninety-two patients with severe acute pancreatitis who received treatment in The Second People's Hospital of Liaocheng from August 2018 to July 2021 were included in this study. Serum interleukin (IL)-6 and IL-10 levels were detected. The Bedside Index of Severity in Acute Pancreatitis (BISAP) score was evaluated. Clinical interventions were performed. The relationship between serum IL-6 and IL-10 levels and the clinical prognosis of severe acute pancreatitis was investigated.Results:Serum IL-6 level [(103.75 ± 15.53) ng/L] was highest in patients who died. Serum IL-10 level [(97.33 ± 13.06) ng/L] was highest in patients with local complications. The highest number of patients with a prognostic outcome of death [26 (37.14%)] was found in patients with a BISAP score ≥ 3. Serum IL-6 level in patients with severe acute pancreatitis was positively correlated with the BISAP score ( r = 0.62, P < 0.05), and serum IL-6 level and BISAP score were negatively correlated with serum IL-10 level ( r = -0.57, -0.61, both P < 0.05). Conclusion:Increased or decreased serum IL-6 and IL-10 levels in patients with severe acute pancreatitis indicate that the patient's condition tends to worsen, and timely intervention according to serum IL-6 and IL-10 levels can improve the clinical prognosis of severe acute pancreatitis.

Establishment of prediction model for severe acute pancreatitis complicated with abdominal hypertension / 中华胰腺病杂志

Objective:To construct the prediction model of SAP complicated with intra-abdominal hypertension (IAH), and evaluate the prediction efficiency of the model.Methods:The clinical data of 322 SAP patients admitted to the emergency department of Cangzhou Hospital of Integrated Chinese and Western Medicine in Hebei Province from January 2017 to December 2021 were retrospectively analyzed. They were divided into IAH group ( n=153) and control group ( n=169) according to whether they had IAH complications or not. The clinical characteristics and laboratory test results of the two groups were compared. Multifactor logistic step-up regression was used to analyze the risk factors of SAP patients complicated with IAH. A nomogram model for predicting SAP complicated with IAH was established by using R software. The receiver operating characteristic curve (ROC) of the model was plotted, and the area under the curve (AUC) was calculated to evaluate its prediction efficiency. Calibration chart, Hosmer-Lemesshow test and decision curve analysis were used to evaluate the prediction accuracy and clinical application value of the model. The Bootstrap method was applied to verify the model internally. Results:In IAH group, cases with body mass index, CRP, procalcitonin (PCT), WBC, acute physiological and chronic health assessmentⅡ (APACHEⅡ) score, modified CT Severity Index score (MCTSI), incidence of complications (abdominal effusion, abdominal infection, gastrointestinal dysfunction, shock, multiple organ dysfunction syndrome), mechanical ventilation, the number of high-volume fluid reactivation (24 h≥4 L) were more than those in control group; serum albumin and serum calcium in IAH group were lower than those in control group, and the differences were statistically significant (all P value <0.05). Multivariate logistic regression analysis showed that serum albumin ( OR=0.815, 95% CI 0.710-0.937), CRP ( OR=1.005, 95% CI 1.002-1.008), MCTSI ( OR=2.043, 95% CI 1.695-2.463), complication of gastrointestinal dysfunction ( OR=4.179, 95% CI 2.170-8.049), and high-volume fluid resuscitation ( OR=4.265, 95% CI 2.269-8.015) were independent risk factors for IAH in SAP.The Nomogram prediction model was established using the five factors above as parameters, and the AUC value for predicting IAH complication was 0.886. The Hosmer-Lemesshow test showed a high consistency between the prediction results and the actual clinical observation results ( P=0.189). The results of decision curve analysis showed that the prediction probability of the model was between 10% and 85%, which could bring more benefits to patients. Conclusions:The early prediction model of SAP with concurrent IAH is successfully established, which can better predict the risk of SAP with concurrent IAH.

Effect of Lactobacillus plantarum WCFS1 on pancreatic and ileal injury in mice with acute necrotizing pancreatitis / 中华胰腺病杂志

Objective:To explore the effect of probiotics Lactiplantibacillus plantarum(LP) WCFS1 by gavage on acute necrotizing pancreatitis (ANP) and associated ileum injury in mice. Methods:Twenty-four healthy male mice were gavaged with broad-spectrum antibiotics for 3 weeks to establish microbiota-depleted mice, and then randomly divided into control group (CON), ANP model group (ANP), LP gavage group (LP) and LP gavage and ANP induced group (LP+ ANP) , with 6 mice in each group. Mice in LP and LP+ ANP group were treated by gavage of LP (1×10 9 CFU/ml, 0.2 ml/day per mouse) for 1 week, while CON and ANP were gavaged with sterile phosphate buffered saline for 1 week instead. The ANP model was induced by intraperitoneal injection with caerulein (100 μg/kg) for 10 times with 1-hour interval between two injections and the 10th injection with lipopolysaccharide(LPS) 5 mg/kg intraperitoneally, and the mice were sacrificed 2 h later. Levels of LP in stool and ileal mucosa were detected by real-time PCR; the pancreas and ileum were collected for pathological examination to observe the extent of tissue inflammation and to score the pathology. Serum amylase activities were determined by enzymatic kinetic chemistry; serum inflammators levels and intestinal permeability were detected by ELISA; levels of inflammators in pancreatic and ileal tissues were detected by real-time PCR; ileal tight-junction proteins (occludin, claudin-1 and ZO-1) were measured by immunofluorescence staining. Results:LP levels in the stool and ileal mucosa of mice were significantly increased after LP gavage, and the differences were statistically significant (913.30±39.12 vs 2.39±1.39, 23.11±0.50 vs 1.38±0.28, all P value <0.05). The pathological scores of pancreatic tissue of CON, LP, ANP and LP+ ANP group were (0.26±0.41), (0.17±0.26), (8.55±0.46) and (6.30±0.45); the serum amylase activities were (219.70±19.73), (217.60±11.30), (2896.24±98.32) and (1837.13±131.60)U/L, IL-1β were (0.87±0.28), (1.4±0.85), (67.41±6.45) and (36.33±5.65)pg/ml, IL-6 were (0.74±0.27), (0.16±0.16), (280586.12±39163.92) and (107912.75±31283.47)pg/ml, IL-10 were (35.52±5.27), (50.99±15.34), (2008.45±184.83) and (3070.35±403.71)pg/ml; the expression level of pancreatic IL-1β mRNA was 1.42±0.39, 0.95±25, 20.53±0.50 and 10.69±1.01, IL-6 mRNA was 1.31±0.44, 0.93±0.023, 21.97±1.71 and 11.54±1.75, IL-10 mRNA was 0.93±0.14, 0.75±0.15, 0.99±0.21 and 1.76±0.19; there was no significant difference between LP and CON group, and pancreatic pathological scores, serum amylase、IL-1β and IL-6 levels, and the expression level of pancreatic IL-1β and IL-6 mRNA were significantly decreased in LP+ ANP group compared with those in ANP group, while serum IL-10 levels and the expression level of pancreatic IL-10 mRNA were significantly increased compared with ANP group, and all the differences were statistically significant (all P values <0.05). The pathological scores of ileal tissue of CON, LP, ANP and LP+ ANP group were 0, 0, (3.17±0.41) and (1.67±0.52); the levels of serum DAO of CON, LP, ANP and LP+ ANP group were (0.03±0.03), (0.02±0.02), (0.50±0.05) and (0.49±0.06)ng/ml; LPS levels were (2.75±0.35), (3.74±0.28), (7.19±0.92) and (5.88±0.38)ng/ml; the expression level of ileal IL-1β mRNA was 1.21±0.20, 1.17±0.09, 1.81±0.25 and 1.63±0.21; IL-6 mRNA was 1.01±0.29, 2.83±0.42, 54.45±8.50 and 16.87±4.42; IL-10 mRNA was 1.12±0.41, 6.09±2.51, 11.65±1.47 and 29.86±2.93. There was no significant difference between LP and CON group, except that the ileal IL-10 mRNA expression was significantly higher than that of CON group. Ileal pathological scores, serum LPS levels and the expression level of ileal IL-6 mRNA were significantly lower in LP+ ANP group than those in ANP group, while the expression level of ileal IL-10 mRNA was significantly higher than that of ANP group; the expression of ileal tight junction proteins (ocludin, claudin-1, ZO-1) was significantly higher than those in ANP group, and all the differences were statistically significant (all P values <0.05). Conclusions:LP WCFS1 gavage could ameliorate the injury of pancreatic and ileal barrier in caerulein-induced ANP mice.

Clinical efficacy and outcome analysis of early abdominal paracentesis drainage for treating patients with severe acute pancreatitis / 中华胰腺病杂志

Objective:To analyse the clinical efficacy and outcome of early abdominal paracentesis drainage (APD) in the treatment of severe acute pancreatitis (SAP).Methods:The clinical data of 107 SAP patients with massive abdominal fluid in Shanghai General People Hospital from May 2017 to December 2021 were collected and analyzed. Patients were divided into APD group ( n=56) and NO-APD group ( n=51) according to whether they underwent APD or not within 3 days after admission. The APD group was then divided into abdominal compartment syndrome (ACS) subgroup ( n=29) and NO-ACS subgroup ( n=27) according to whether ACS had occurred or not at the time of puncture. Patients' general data, the duration of systemic inflammatory response (SIRS), length of ICU stay, the trends of intra-abdominal pressure and inflammatory indicators (white blood cell count and the content of C-reactive protein) within 1-3 days after admission, incidence of infection complication, step-up therapy, discharge or death were recorded. Results:The intra-abdominal pressure were 18.6±5.6mmHg , 13.7±4.2mmHg (1 mmHg=0.133 kpa) in APD group and NO-APD group, respectively. The intra-abdominal pressure of APD group was significantly higher than that of NO-APD group, and the difference was statistically significant ( P=0.000). Compared with NO-APD group, the duration of SIRS was significantly shortened in APD group [3(2, 4) days vs 4(3, 6) days, P=0.029]. On day 1, 2 and 3 after admission, the intra-abdominal pressure was 18.6±5.6 mmHg, 16.4±4.7 mmHg and 13.5±3.9 mmHg in APD group, and was 13.7±4.2 mmHg, 12.3±3.6 mmHg and 11.0±2.6 mmHg in NO-APD group, respectively. The intra-abdominal pressure of the APD group dropped faster than the NO-APD group ( P=0.004). The white blood cell count was (14.8±4.8), (10.5±4.5) and (9.0±3.8)×10 9/L in APD group, and was (14.2±5.4), (12.3±7.3), (11.7±5.3)×10 9/L in NO-APD group, respectively. Compared with the NO-APD group, the decrease rate of white blood cell count was faster in APD group ( P=0.006). The C-reactive protein content was (153.6±47.1), (150.4±10.5) and (108.8±49.4)mg/L in APD group, and were (174.8±31.1), (191.6±29.4) and (186.8±45.5)mg/L in NO-APD group . The content of C-reactive protein in APD group decreased significantly, while that in NO-APD group did not decrease. There was a significant difference between the two groups ( P=0.009). In the subgroup comparisons, the duration of SIRS in the ACS subgroup was significant longer than that in the NO-ACS subgroup [4(3, 5) days vs 2(1, 3)days, P=0.000]. Compared between the two groups and two subgroups respectively, there were no statistically significant differences on length of ICU stay, infection complication rate, advanced treatment rate and mortality. Conclusions:For SAP patients with abdominal fluid, APD in the early stage could shorten the duration of SIRS, decrease intra-abdominal pressure rapidly, improve inflammatory indicators, but could not improve the clinical outcome.

Observation on the clinical efficacy of continuous renal replacement therapy with adsorptive filter oXiris in the treatment of patients with severe acute pancreatitis / 中华胰腺病杂志

Objective:To evaluate the clinical efficacy of continuous renal replacement therapy (CRRT) with adsorptive filter oXiris in the treatment of severe acute pancreatitis (SAP).Methods:The clinical data of 5 SAP patients who received the treatment of absorptive filter oXiris in Department of Critical Care Medicine of Shanghai General Hospital from February 2021 to February 2022 were collected. The changes of inflammatory indicators, hemodynamics, acid-base balance indicators and organ function indicators were compared before and 24 h after treatment.Results:Before the treatment of oXiris, 3 patients had pancreatic necrotic infection, and all the five patients had systemic inflammatory response syndrome(SIRS), acute respiratory and circulatory failure and acute renal injury. At 24 h after the treatment with oXiris, the levels of inflammatory indicators such as white blood cell count [(13.4±5.0)×10 9/L vs (25.8±10.0)×10 9/L), CRP [(149.6±68.3)mg/L] vs (289.0±129.4)mg/L] and procalcitonin [3.7(1.4, 17.7)ng/ml vs 12.2(3.2, 62.9)ng/ml] in the blood samples from the patients were greatly decreased. Hemodynamics were obviously improved; heart rate [(107.4±9.5)bpm/min vs (143.4±9.7)bpm/min] was decreased, and the mean artery pressure [(87±5)mmHg vs (73±13)mmHg], 1 mmHg=0.133 kPa] tended to be stabilized. Metabolic acidosis was significantly improved; pH value (7.4±0.0 vs 7.2±0.1) and base excess (-2.1±2.5 vs -14.5±6.1) were increased, while lactic acid [(2.6±1.2)mmol/L vs (10.62±6.55)mmol/L] was decreased. Organ dysfunctions were improved; PaO 2/FiO 2 value (241.7±58.5 vs 115.9±53.6) was increased, while serum creatinine [(148.0±42.5)μmol/L vs (232.8±77.4)μmol/L], intra-abdominal pressure [(18.6±4.5)mmHg vs (24.2±4.0)]mmHg, modified Marshall score [3(3.0, 4.0) vs 6(5.5, 9.0)] and APACHEⅡ score (17.6±2.9 vs 26.0±5.2) were decreased. All the differences above were statistically significant (all P value <0.05). Conclusions:It is safe and feasible to treat SAP patients with CRRT by using oXiris in clinical practice, which may have the functions of clearing inflammatory mediators, stabilizing hemodynamics and acid-base balance and improving organ function.

Effect of T-lymphocyte and subpopulation counts on the prognosis of patients with severe acute pancreatitis / 中华胰腺病杂志

Objective:To investigate the effect of T-lymphocyte and subpopulation counts on the prognosis of severe acute pancreatitis (SAP) patients.Methods:The clinical data of 90 patients with SAP diagnosed at the Shanghai General Hospital between January 2019 and June 2022 were retrospectively analyzed, and the patients were divided into good prognosis and poor prognosis group according to whether they were diagnosed for 28 d. The general information of the patients was recorded, including blood-related immunological indicators within 24 h of diagnosis, including leukocytes, neutrophils, lymphocytes, monocytes, CD 3+ , CD 4+ , CD 8+ T-lymphocyte count and CD 4+ /CD 8+ T-lymphocyte ratio, IgG4 level; blood inflammation index procalcitonin, albumin level and APACHEⅡ score at admission; survival and complication status of patients at 28 d of diagnosis. Non-parametric Mann-Whitney U test was used to analyze the correlation between each index and the prognosis of the patients. The subject operating characteristic curve (ROC) of patients was plotted, and area under curve (AUC) was calculated to assess the value of CD 3+ and CD 4+ T-lymphocytes in predicting the prognosis of SAP. Results:The majority of SAP patients were male (65.6%). The main cause of SAP was gallstone (56.7%), followed by hyperlipidemia (35.6%). At 28 days after diagnosis, 85(94.4%) patients survived, and 39 of them were cured and included in the good prognosis group. Forty-six cases were complicated with infection, multiple organ dysfunction syndrome (MODS) and local pancreatic complications, and 5 cases (5.56%) died; and a total of 51 cases were included in the poor prognosis group. Compared with the good prognosis group, the number of CD 3+ T-lymphocytes [366(268, 498) cells /μl vs 709(578, 999) cells /μl], CD 4+ T-lymphocytes [209(120, 298) cells /μl vs 486(303, 548) cells /μl] and albumin level (33.9 g/L vs 35.9 g/L) within 24 hours in the poor prognosis group were significantly lower, while the level of procalcitonin (1.02 ng/ml vs 0.43 ng/ml) and APACHEⅡ score [7(4, 10) vs 5(3, 8)] were significantly increased, and all the differences were statistically significant (all P value <0.05). ROC curve analysis showed that the AUC values for CD 3+ and CD 4+ T-lymphocyte counts within 24 hours for predicting poor prognosis of SAP were 0.857 (95% CI 0.696-1.000) and 0.867 (95% CI 0.708-1.000), respectively. The cut-off values were 524 cells /μl and 301 cells /μl, the sensitivity were both 85.7%, and the specificity were 78.6% and 85.7%, respectively. Conclusions:The significant decrease of peripheral blood CD 3+ and CD 4+ T-lymphocyte count within 24 h of SAP diagnosis has a certain predictive value for the prognosis of patients with SAP.

LASSO regression based risk prediction model establishment for Klebsiella pneumonia infection in patients with severe acute pancreatitis / 中华胰腺病杂志

Objective:To construct a risk prediction model for infection with Klebsiella pneumonia (KP) for patients with severe acute pancreatitis (SAP).Methods:Retrospective analysis was done on the clinical data of 109 SAP patients who were admitted to Shanghai General Hospital, between March 2016 and December 2021. Patients were classified into infection group ( n=25) and non-infection group ( n=84) based on the presence or absence of KP infection, and the clinical characteristics of the two groups were compared. The least absolute shrinkage and selection operator (LASSO) algorithm was used to reduce the dimension of the variables with statistical significance in univariate analysis. A nomogram prediction model was created by incorporating the optimized features from the LASSO regression model into the multivariate logistic regression analysis. Receiver operating characteristic curve (ROC) was drawn and the area under curve (AUC) was calculated; and consistency index (C-index) were used to assess the prediction model's diagnostic ability. Results:A total of 25 strains of KP were isolated from 109 patients with SAP, of which 21(84.0%) had multi-drug resistance. 20 risk factors (SOFA score, APACHEⅡ score, Ranson score, MCTSI score, mechanical ventilation time, fasting time, duration of indwelling of the peritoneal drainage tube, duration of deep vein indwelling, number of invasive procedures, without or with surgical intervention, without or with endoscopic retrograde cholangiopancreatography (ERCP), types of high-level antibiotics used, digestion disorders, abnormalities in blood coagulation, metabolic acidosis, pancreatic necrosis, intra-abdominal hemorrhage, intra-abdominal hypertension, length of ICU stay and total length of hospital stay) were found to be associated with KP infection in SAP patients by univariate analysis. The four variables (APACHEⅡ score, duration of indwelling of the peritoneal drainage tube, types of high-level antibiotics used, and total length of hospital stay) were extracted after reduced by LASSO regression. These four variables were found to be risk factors for KP infection in SAP patients by multiple logistic regression analysis (all P value <0.05). Nomogram prediction model for KP infection in SAP was established based on the four variables above. The verification results of the model showed that the C-index of the model was 0.939, and the AUC was 0.939 (95% CI 0.888-0.991), indicating that the nomogram model had relatively accurate prediction ability. Conclusions:This prediction model establishes integrated the basic clinical data of patients, which could facilitate the risk prediction for KP infection in patients with SAP and thus help to formulate better therapeutic plans for patients.

Influencing factors for acute necrotizing pancreatitis in Eastern and Western countries: A meta-analysis / 临床肝胆病杂志

Objective To investigate the differences in the influencing factors for acute necrotizing pancreatitis (ANP) and infectious pancreatic necrosis (IPN) between Eastern and Western countries, and to provide a theoretical basis for the prediction and prevention of ANP. Methods Databases including PubMed, Embase, the Cochrane Library, and Web of Science were searched for articles on the influencing factors for ANP and IPN published up to January 21, 2021, and a Meta-analysis was performed. Results A total of 59 studies were included, with 22 studies from Eastern countries and 37 studies from Western countries.The Meta-analysis showed that in Eastern countries, male sex (odds ratio[ OR ]=1.51, 95% confidence interval[ CI ]: 1.18-1.91, P < 0.01), C-reactive protein (CRP)(standardized mean difference[ SMD ]=1.39, 95% CI : 1.06-1.71, P < 0.01), D-dimer ( SMD =0.44, 95% CI : 0.07-0.81, P =0.02), Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE-Ⅱ) score (mean difference[ MD ]=3.51, 95% CI : 1.38-5.64, P < 0.01), alcoholic etiology ( OR =3.57, 95% CI : 2.68-4.75, P < 0.01), and biliary etiology ( OR =0.60, 95% CI : 0.46-0.77, P < 0.01) were the influencing factors for ANP, and in Western countries, male sex ( OR =1.63, 95% CI : 1.30-2.05, P < 0.01), CRP ( SMD =2.09, 95% CI : 1.12-3.05, P < 0.01), APACHE-Ⅱ score ( MD =4.28, 95% CI : 2.73-5.83, P < 0.01), Ranson score ( MD =2.99, 95% CI : 2.50-3.47, P < 0.01), and organ failure ( OR =10.87, 95% CI : 2.62-45.04, P < 0.01) were the influencing factors for ANP.In Eastern countries, age ( MD =2.16, 95% CI : 0.43-3.89, P =0.01), body mass index (BMI)( MD =1.74, 95% CI : 1.23-2.25, P < 0.01), albumin level ( SMD =-0.43, 95% CI : -0.75 to-0.12, P < 0.01), CRP ( SMD =0.58, 95% CI : 0.04-1.11, P =0.03), procalcitonin ( SMD =0.80, 95% CI : 0.56-1.04, P < 0.01), D-dimer ( MD =0.23, 95% CI : 0.15-0.31, P < 0.01), APACHE-Ⅱ score ( MD =2.47, 95% CI : 0.73-4.22, P < 0.01), Ranson score ( MD =1.60, 95% CI : 1.46-1.73, P < 0.01), and extent of necrosis ≥30%( OR =2.52, 95% CI : 1.26-5.06, P < 0.01) were the influencing factors for IPN, while in Western countries, age ( MD =4.07, 95% CI : 1.82-6.31, P < 0.01), APACHE-Ⅱ score ( MD =3.28, 95% CI : 1.39-5.17, P < 0.01), Ranson score ( MD =2.18, 95% CI : 1.75-2.62, P < 0.01), SIRS score ( OR =3.88, 95% CI : 1.58-9.51, P < 0.01), alcoholic etiology ( OR =0.61, 95% CI : 0.42-0.87, P < 0.01), and organ failure ( OR =3.63, 95% CI : 1.11-11.92, P =0.03) were the influencing factors for IPN. Conclusion Current evidence shows that biliary etiology and alcoholic etiology are unique influencing factors for ANP in the Eastern population, while Ranson score is a unique influencing factor in the Western population.BMI and extent of necrosis ≥30% are unique influencing factors for IPN in the Eastern population, while alcoholic etiology is a unique influencing factor in the Western population.

Value of five scoring systems in predicting the severity of hyperlipidemic acute pancreatitis: A comparative analysis / 临床肝胆病杂志

Objective To investigate the value of pancreatitis activity scoring system (PASS) score, Bedside Index for Severity in Acute Pancreatitis (BISAP) score, Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE-Ⅱ) score, harmless acute pancreatitis score (HAPS), and Ranson score in evaluating the severity and prognosis of hypertriglyceridemia acute pancreatitis (HTGAP). Methods A retrospective analysis was performed for the clinical data of 300 patients with HTGAP who were admitted to General Hospital of Ningxia Medical University from January 2016 to January 2022, and according to the disease severity, these patients were divided into mild acute pancreatitis (MAP) group, moderate-severe acute pancreatitis (MSAP) group, and severe acute pancreatitis (SAP) group. Clinical data and the above scores were compared between the three groups. The chi-square test was used for comparison of categorical data between groups; an analysis of variance was used for continuous data with homogeneity of variance, and the Kruskal-Wallis H test was used for comparison of non-normally distributed continuous data between groups. The receiver operating characteristic (ROC) curve was plotted according to disease severity, and related indicators were compared in terms of the area under the ROC curve (AUC). Results There were significant differences between the three groups in PASS score ( F =219.351, P < 0.01), Ranson score ( χ 2 =83.084, P < 0.01), APACHE-Ⅱ score ( χ 2 =43.388, P < 0.01), and BISAP score ( χ 2 = 50.785, P < 0.01). Compared with the other four scoring systems in evaluating and predicting disease severity, PASS score had the highest sensitivity of 0.945 and the largest AUC of 0.963, followed by Ranson score with a sensitivity of 0.655 and an AUC of 0.819. Conclusion For patients with HTGAP, PASS score can more accurately assess the severity and prognosis of HTGAP patients and thus holds promise for clinical application.

Alcoholic foamy degeneration: an unusual presentation of the alcoholic liver disease diagnosed on autopsy

ABSTRACT Alcoholic foamy degeneration (AFD) is an uncommon presentation of alcoholic liver disease (ALD) with characteristic histologic findings of foamy-looking hepatocytes due to the presence of abundant microvesicles of fat within the cytoplasm predominantly in perivenular and midzonal regions without inflammation and fibrosis. It is underdiagnosed as the patients quickly recover after alcoholic abstinence and are rarely caught on biopsies. AFD has better prognosis than alcoholic hepatitis, and the injury mechanism is different, warranting a different diagnosis. We present an uncommon case of AFD incidentally diagnosed during autopsy in a chronic alcoholic and diabetic man.

Rotura de Pseudoaneurisma tras Pancreatitis Aguda Necrotizante que debuta como Hemorragia Digestiva Alta por Fistulización del Duodeno

Presentamos el caso de un varón de 64 años quien, tras un primer episodio de pancreatitis aguda necrotizante, reingresa a los 20 días por cuadro de dolor epigástrico intenso y posteriormente episodio de hemorragia digestiva alta en forma de hematemesis y melenas con inestabilización hemodinámica. Se realiza en ese momento gastroscopia urgente objetivándose probable fistula gastrointestinal en bulbo duodenal con coágulo adherido sin sangrado activo en ese momento por lo que se realiza angio-TC urgente que revela colección peripancreática necrótica con presencia de sangrado activo en su interior, procedente de la arteria pancreatoduodenal. La arteriografía urgente identificó imagen compatible con pseudoaneurisma arterial dependiente de la rama de arteria pancreatoduodenal, que fue embolizada con éxito. Desgraciadamente el paciente falleció en las horas posteriores, como consecuencia de un shock séptico secundario a colección pancreática infectada.

We present the case of a 64-year-old man who, after a first episode of acute pancreatitis, was readmitted 20 days later due to severe epigastric pain and later an episode of upper gastrointestinal bleeding in the form of hematemesis and melena with hemodynamic instability. An urgent gastroscopy was performed at that time, revealing a probable gastrointestinal fistula in the duodenal bulb with an adherent clot without active bleeding at that time, so an urgent CT angiography was performed that revealed a necrotic peripancreatic collection with the presence of active bleeding inside from the pancreatoduodenal artery. Urgent arteriography identified an image compatible with arterial pseudoaneurysm dependent on the pancreaticoduodenal artery branch, which was successfully embolized. Unfortunately, the patient died a few hours later as a result of septic shock secondary to an infected pancreatic collection.

Caracterización de pacientes con pancreatitis aguda en una unidad de cuidados intensivos polivalente / Characterization of patients with Acute Pancreatitis in the multipurpose intensive care unit

RESUMEN Introducción: La pancreatitis es la inflamación del páncreas exocrino, resultado del daño a las células acinares. Sus características clínicas principales son el dolor abdominal y la elevación de los niveles séricos de amilasa y lipasa. La evolución es muy variable, desde una recuperación completa de un primer episodio, hasta una enfermedad crónica debilitante, o la muerte. Objetivos: Caracterizar a los pacientes ingresados en la unidad de cuidados intensivos, con el diagnóstico de pancreatitis aguda y evaluarlos según los criterios de gravedad. Métodos: Se realizó un estudio descriptivo en el que se revisaron 46 historias clínicas de pacientes ingresados con diagnóstico de pancreatitis aguda en la unidad de terapia intensiva polivalente, desde enero del 2014 a diciembre del 2019. Se confeccionó una base de datos con las variables edad, etiología, complicaciones, letalidad y la aplicación de escalas de Ranson, APACHE II y Balthazar-Hill, para evaluar evolutivamente la gravedad y pronóstico. Se hizo un análisis de frecuencias de dichas variables. Resultados: La edad de mayor incidencia correspondió a los grupos menores de 61 años, con predominio del sexo masculino. La causa más frecuente fue la litiasis vesicular y el alcoholismo, para un 43,4 % y 34,7 % respectivamente. El 47,8 % presentó la forma leve de la enfermedad. La letalidad fue del 21,7 %. Conclusiones: Son más frecuentes las formas graves de la enfermedad; la insuficiencia renal aguda y la insuficiencia respiratoria aguda son las complicaciones más representativas.

ABSTRACT Introduction: Pancreatitis is the inflammation of the exocrine pancreas, as a result of damage to the acinar cells. Its main clinical features are abdominal pain and elevated serum levels of amylase and lipase. The evolution is very variable, from a complete recovery from a first episode, to a debilitating chronic disease, or death. Objectives: To characterize patients admitted to the intensive care unit with a diagnosis of acute pancreatitis and to evaluate them according to severity criteria. Methods: A descriptive study was carried out in which 46 medical records of patients admitted with a diagnosis of acute pancreatitis in the multipurpose intensive care unit were reviewed, from January 2014 to December 2019. A database was created with the variables age, etiology, complications, lethality and the application of the Ranson, APACHE II and Balthazar-Hill scales, to evaluate severity and prognosis. An analysis of the frequencies of these variables was carried out. Results: The age with the highest incidence corresponded to groups under 61 years of age, with a predominance of males. The most frequent cause was gallstones and alcoholism, for 43.4 % and 34.7 % respectively. 47.8 % presented the mild form of the disease. The lethality was 21.7 %. Conclusions: Severe forms of the disease are more frequent; acute renal failure and acute respiratory failure are the most representative complications.

The value of CT based radiomics in predicting progression of early acute pancreatitis / 中华放射学杂志

Objection To investigate the value of CT based radiomics in predicting progression of early acute pancreatitis (AP). Methods:From November 2013 to February 2021, 109 patients diagnosed with AP according to the new revised Atlanta classification in Yijishan Hospital of Wannan Medical College were retrospectively analyzed. The patients were divided into progressive group (40 cases) and non-progressive group (69 cases) according to the follow-up results. All patients underwent plain and enhanced abdominal CT scan within a week of onset. The patients were divided into training set (77 cases, including 28 cases in progressive group and 49 cases in non-progressive group) and validation set (32 cases, including 12 cases in progressive group and 20 cases in non-progressive group) in a ratio of 7∶3 using a computer completely random method. Manual region of interest mapping was performed on all levels of pancreas on the plain scan, arterial phase, venous phase and delayed phase CT images, then performed 3D fusion. AK software was used to extract texture features. The minimum redundancy maximum relevance and minimum absolute shrinkage and selection operator regression analysis were used to select features and establish radiomics labels of the plain scan, arterial phase, venous phase, delayed phase and combining the 4 sequences. The multiple logistic regression analysis was used to establish the clinical model by combining clinical features and CT features, and the comprehensive model was established by combining clinical features, CT features and imaging radiomics label. The receiver operating characteristic (ROC) curve was used to evaluate the efficacy of each model in predicting early AP progression and the decision curve analysis (DCA) was used to evaluate the clinical application value of each model.Results:In the training set, logistic regression results showed that edge was an independent predictor (OR=0.16, P=0.033). The clinical model was established using edge and serum calcium level, and its areas under the ROC curve (AUC) in the training set and validation set were 0.69 and 0.70, respectively. Totally 14, 11, 13, 13 and 9 optimal texture features were extracted from the plain scan, arterial phase, venous phase, delayed phase and combined sequence images, respectively. The delay phase image radiomics label had relatively better predictive performance in training set and validation set, and the AUC were both 0.85. The comprehensive model was established based on the delayed phase image radiomics label (OR=2.22, P<0.001) and edge (OR=0.02, P=0.042), and the AUC in the training set and validation set was 0.90 and 0.86, respectively. DCA showed that both the comprehensive model and the delayed phase radiomics label had better benefits. Conclusions:CT radiomics model has high value for predicting progression of AP, and its clinical benefits exhibited superior performance of clinical model.