Metagenomic next-generation sequencing, instead of procalcitonin, could guide antibiotic usage in patients with febrile acute necrotizing pancreatitis: a multicenter, prospective cohort study.

BACKGROUNDS: The effectiveness of procalcitonin-based algorithms in guiding antibiotic usage for febrile acute necrotizing pancreatitis (ANP) remains controversial. Metagenomic next-generation sequencing (mNGS) has been applied to diagnose infectious diseases. The authors aimed to evaluate the effectiveness of blood mNGS in guiding antibiotic stewardship for febrile ANP. MATERIALS AND METHODS: The prospective multicenter clinical trial was conducted at seven hospitals in China. Blood samples were collected during fever (T ≥38.5°C) from ANP patients. The effectiveness of blood mNGS, procalcitonin, and blood culture in diagnosing pancreatic infection was evaluated and compared. Additionally, the real-world utilization of antibiotics and the potential mNGS-guided antimicrobial strategy in febrile ANP were also analyzed. RESULTS: From May 2023 to October 2023, a total of 78 patients with febrile ANP were enrolled and 30 patients (38.5%) were confirmed infected pancreatic necrosis (IPN). Compared with procalcitonin and blood culture, mNGS showed a significantly higher sensitivity rate (86.7% vs. 56.7% vs. 26.7%, P <0.001). Moreover, mNGS outperformed procalcitonin (89.5 vs. 61.4%, P <0.01) and blood culture (89.5 vs. 69.0%, P <0.01) in terms of negative predictive value. Blood mNGS exhibited the highest accuracy (85.7%) in diagnosing IPN and sterile pancreatic necrosis, significantly superior to both procalcitonin (65.7%) and blood culture (61.4%). In the multivariate analysis, positive blood mNGS (OR=60.2, P <0.001) and lower fibrinogen level (OR=2.0, P <0.05) were identified as independent predictors associated with IPN, whereas procalcitonin was not associated with IPN, but with increased mortality (Odds ratio=11.7, P =0.006). Overall, the rate of correct use of antibiotics in the cohort was only 18.6% (13/70) and would be improved to 81.4% (57/70) if adjusted according to the mNGS results. CONCLUSION: Blood mNGS represents important progress in the early diagnosis of IPN, with particular importance in guiding antibiotic usage for patients with febrile ANP.

Is Contemporary Open Pancreatic Necrosectomy Still Useful In The Minimally Invasive Era?

BACKGROUND: Previous studies have shown that open pancreatic necrosectomy for infected pancreatic necrosis was associated with high morbidity and mortality. However, these results were mostly concluded from historical cohorts with traditional early necrosectomy in the absence of a minimally invasive step-up approach. OBJECTIVE: To explore the value of contemporary open pancreatic necrosectomy for infected pancreatic necrosis in the minimally invasive era. METHODS: A post hoc analysis was performed in a prospective maintained database of 320 patients with infected pancreatic necrosis from January 2011 to December 2022 at a large Chinese tertiary hospital. RESULTS: A total of 320 patients with infected pancreatic necrosis received either a minimally invasive step-up approach (245, 76.6%) or open pancreatic necrosectomy (75, 23.4%), which included upfront open pancreatic necrosectomy (32, 10.0%) and salvage open pancreatic necrosectomy (43, 13.4%). Upfront open pancreatic necrosectomy was associated with similar morbidity and mortality rates but fewer surgical interventions compared with a minimally invasive step-up approach. However, salvage open pancreatic necrosectomy was associated with significantly higher mortality (48.8% vs 18.8%, P = .007), gastrointestinal fistula (44.2% vs 18.8%, P = .021), hemorrhage (48.8% vs 15.6%, P = .003), and intensive care unit stay (25 vs 7 days, P = .040) compared with upfront open pancreatic necrosectomy. Multivariate analysis suggested that multiple organ failure (hazard ratio = 5.1; 95% confidence interval, 1.4-18.2, P = .013) and synchronous critical acute pancreatitis (hazard ratio = 3.0; 95% confidence interval, 1.1-8.6, P = .040) were 2 independent risk factors of death for patients who received open pancreatic necrosectomy. CONCLUSION: Patients undergoing upfront open pancreatic necrosectomy received fewer surgical interventions with comparable efficacy compared to the minimally invasive step-up approach. Salvage open pancreatic necrosectomy was potentially lifesaving, though it carried high morbidity and mortality. Multiple organ failure and synchronous critical acute pancreatitis were 2 independent risk factors of death for patients who received open pancreatic necrosectomy.

Prediction of survival in patients with infected pancreatic necrosis: a prospective cohort study.

BACKGROUND: Infected pancreatic necrosis (IPN) is a severe complication of acute pancreatitis, with mortality rates ranging from 15 to 35%. However, limited studies exist to predict the survival of IPN patients and nomogram has never been built. This study aimed to identify predictors of mortality, estimate conditional survival (CS), and develop a CS nomogram and logistic regression nomogram for real-time prediction of survival in IPN patients. METHODS: A prospective cohort study was performed in 335 IPN patients consecutively enrolled at a large Chinese tertiary hospital from January 2011 to December 2022. The random survival forest method was first employed to identify the most significant predictors and capture clinically relevant nonlinear threshold effects. Instantaneous death risk and CS was first utilized to reveal the dynamic changes in the survival of IPN patients. A Cox model-based nomogram incorporating CS and a logistic regression-based nomogram were first developed and internally validated with a bootstrap method. RESULTS: The random survival forest model identified seven foremost predictors of mortality, including the number of organ failures, duration of organ failure, age, time from onset to first intervention, hemorrhage, bloodstream infection, and severity classification. Duration of organ failure and time from onset to first intervention showed distinct thresholds and nonlinear relationships with mortality. Instantaneous death risk reduced progressively within the first 30 days, and CS analysis indicated gradual improvement in real-time survival since diagnosis, with 90-day survival rates gradually increasing from 0.778 to 0.838, 0.881, 0.974, and 0.992 after surviving 15, 30, 45, 60, and 75 days, respectively. After further variables selection using step regression, five predictors (age, number of organ failures, hemorrhage, time from onset to first intervention, and bloodstream infection) were utilized to construct both the CS nomogram and logistic regression nomogram, both of which demonstrated excellent performance with 1000 bootstrap. CONCLUSION: Number of organ failures, duration of organ failure, age, time from onset to first intervention, hemorrhage, bloodstream infection, and severity classification were the most crucial predictors of mortality of IPN patients. The CS nomogram and logistic regression nomogram constructed by these predictors could help clinicians to predict real-time survival and optimize clinical decisions.

Novel insights into biomarkers of progression in Desmoid tumor.

Desmoid tumor (DT) is a rare neoplasm characterized by the proliferation of myofibroblastic cells that infiltrates and invades adjacent tissues. Due to its locally aggressive and recurrent nature, DT often causes local symptoms and can be challenging to manage clinically. Therefore, identifying biomarkers that can predict the progression of DT and guide treatment decisions is critical. This review summarizes several biomarkers that have been implicated in active surveillance (AS) and the prediction of postoperative recurrence and attempts to elucidate their underlying mechanisms. Some of these novel markers could provide prognostic value for clinicians, and ultimately help facilitate optimal and accurate therapeutic decisions for DT.

CONSTRUCTION OF SEPSIS DIAGNOSTIC MODELS AND IDENTIFICATION OF MACROPHAGE SUBPOPULATIONS BASED ON PYROPTOSIS-RELATED GENES.

ABSTRACT: Background: Numerous studies have shown that pyroptosis is associated with sepsis progression, which can lead to dysregulated host immune responses and organ dysfunction. Therefore, investigating the potential prognostic and diagnostic values of pyroptosis in patients with sepsis is essential. Methods: We conducted a study using bulk and single-cell RNA sequencing (scRNA-seq) from the Gene Expression Omnibus database to examine the role of pyroptosis in sepsis. Univariate logistic analysis, least absolute shrinkage, and selection operator regression analysis were used to identify pyroptosis-related genes (PRGs), construct a diagnostic risk score model, and evaluate the selected genes' diagnostic value. Consensus clustering analysis was used to identify the PRG-related sepsis subtypes with varying prognoses. Functional and immune infiltration analyses were used to explain the subtypes' distinct prognoses, and scRNA-seq data were used to differentiate immune-infiltrating cells and macrophage subsets and study cell-cell communication. Results: A risk model was established based on 10 key PRGs ( NAIP , ELANE , GSDMB , DHX9 , NLRP3 , CASP8 , GSDMD , CASP4 , APIP , and DPP9 ), of which four ( ELANE , DHX9 , GSDMD , and CASP4 ) were associated with prognosis. Two subtypes with different prognoses were identified based on the key PRG expressions. Functional enrichment analysis revealed diminished nucleotide oligomerization domain-like receptor pathway activity and enhanced neutrophil extracellular trap formation in the subtype with a poor prognosis. Immune infiltration analysis suggested a different immune status between the two sepsis subtypes, with the subtype with a poor prognosis exhibiting stronger immunosuppression. The single-cell analysis identified a macrophage subpopulation characterized by gasdermin D (GSDMD) expression that may be involved in pyroptosis regulation, which was associated with the prognosis of sepsis. Conclusion: We developed and validated a risk score for sepsis identification based on 10 PRGs, four of which also have potential value in the prognosis of sepsis. We identified a subset of gasdermin D macrophages associated with poor prognosis, providing new insights into the role of pyroptosis in sepsis.

RNA demethylase ALKBH5 promotes colorectal cancer progression by posttranscriptional activation of RAB5A in an m6A-YTHDF2-dependent manner.

BACKGROUND: N6-methyladenosine (m6A) modification is an emerging epigenetic regulatory mechanism in tumourigenesis. Considering that AlkB homolog 5 (ALKBH5) is a well-described m6A demethylase in previous enzyme assays, we aimed to investigate the role of m6A methylation alteration conferred by disturbed ALKBH5 in colorectal cancer (CRC) development. METHODS: Expression of ALKBH5 and its correlation with clinicopathological characteristics of CRC were evaluated using the prospectively maintained institutional database. The molecular role and underlying mechanism of ALKBH5 in CRC were explored using in vitro and in vivo experiments with methylated RNA immunoprecipitation sequencing (MeRIP-seq), RNA-seq, MeRIP-qPCR, RIP-qPCR and luciferase reporter assays. RESULTS: ALKBH5 expression was significantly upregulated in CRC tissues compared to the paired adjacent normal tissues, and higher expression of ALKBH5 was independently associated with worse overall survival in CRC patients. Functionally, ALKBH5 promoted the proliferative, migrative and invasive abilities of CRC cells in vitro and enhanced subcutaneous tumour growth in vivo. Mechanistically, RAB5A was identified as the downstream target of ALKBH5 in CRC development, and ALKBH5 posttranscriptionally activated RAB5A by m6A demethylation, which impeded the YTHDF2-mediated degradation of RAB5A mRNA. In addition, we demonstrated that dysregulation of the ALKBH5-RAB5A axis could affect the tumourigenicity of CRC. CONCLUSIONS: ALKBH5 facilitates the progression of CRC by augmenting the expression of RAB5A via an m6A-YTHDF2-dependent manner. Our findings suggested that ALKBH5-RAB5A axis might serve as valuable biomarkers and effective therapeutic targets for CRC.

Escherichia coli infection indicates favorable outcomes in patients with infected pancreatic necrosis.

Introduction: Infected pancreatic necrosis (IPN) is a severe complication of acute necrotizing pancreatitis with increasing morbidity. Escherichia coli is the most frequently cultured microorganism in IPN. However, the implications of Escherichia coli infection on the outcomes of patients with IPN remain unclear. Therefore, this study aimed to evaluate the clinical impacts of Escherichia coli infection on IPN. Methods: A prospective database with consecutive patients with IPN between January 2010 and April 2022 at a tertiary hospital was post-hoc analyzed. The clinical and microbiological characteristics, surgical management, and follow-up data of patients with and without Escherichia coli infection were compared. Results: A total of 294 IPN patients were enrolled in this cohort. Compared with non-Escherichia coli infection cases (n=80, 27.2%), patients with Escherichia coli infection (n=214, 72.8%) were characterized by more frequent polymicrobial infections (77.5% vs. 65.0%, P=0.04) but a lower occurrence of severe acute pancreatitis (SAP) (42.5% vs. 61.7%, P=0.003). In addition, significantly lower mortality (12.5% vs. 30.4%, p=0.002), fewer step-up surgical interventions (73.8% vs. 85.1%, P=0.025), and a lower rate of multiple organ failure (MOF) (25.0% vs. 40.2%, P=0.016) were also observed in patients with Escherichia coli infection. Multivariate analysis of mortality predictors indicated that MOF (odds ratio [OR], 6.197; 95% confidence interval [CI], 2.373-16.187; P<0.001) and hemorrhage (OR, 3.485; 95% CI, 1.623-7.487; P=0.001) were independent predictors associated with higher mortality in patients with IPN. Escherichia coli infection was significantly associated with a lower mortality (OR, 0.302; 95% CI, 0.121-0.751; P= 0.01). Conclusion: Escherichia coli infection indicates a favorable prognosis in patients with IPN, although the mechanism needs further investigation.

Aberrant methylation in neurofunctional gene serves as a hallmark of tumorigenesis and progression in colorectal cancer.

BACKGROUND: DNA methylation is one of the most promising biomarkers in predicting the prognosis of colorectal cancer (CRC). We aimed to develop a DNA methylation biomarker that could evaluate the prognosis of CRC. METHODS: A promising DNA methylation biomarker was developed by hypermethylated genes in cancer tissue that were identified from Illumina EPIC methylation arrays. A cohort comprising 30 pairs of snap-frozen tumor tissue and adjacent normal tissue was used for correlation analysis between the methylation and expression status of the marker. The other cohort comprising 254 formalin-fixed paraffin-embedded (FFPE) tumor tissue from 254 CRC patients was used for prognosis analysis. RESULTS: Regulating synaptic membrane exocytosis 2 (RIMS2) was hypermethylated and lowly expressed in CRC comparing to adjacent normal tissue. Hypermethylation of RIMS2 in CRC was correlated with less frequent KRAS mutant and high differentiation. RIMS2 promoter methylation showed independent predictive value for survival outcome (P = 0.015, HR 1.992, 95% CI [(1.140-3.48)]), and a combination of RIMS2 methylation with KRAS status could predict prognosis better. CONCLUSIONS: RIMS2 is frequently hypermethylated in CRC, which can silence the expression of RIMS2. RIMS2 methylation is a novel biomarker for predicting the prognosis of CRC.

Fasting-mimicking diet synergizes with ferroptosis against quiescent, chemotherapy-resistant cells.

BACKGROUND: More than ten randomized clinical trials are being tested to evaluate the efficacy, effectiveness and safety of a fasting-mimicking diet (FMD) combined with different antitumor agents. METHODS: UMI-mRNA sequencing, Cell-cycle analysis, Label retention, metabolomics, Multilabeling et al. were used to explore mechanisms. A tandem mRFP-GFP-tagged LC3B, Annexin-V-FITC Apoptosis, TUNEL, H&E, Ki-67 and animal model was used to search for synergistic drugs. FINDINGS: Here we showed that fasting or FMD retards tumor growth more effectively but does not increase 5-fluorouracil/oxaliplatin (5-FU/OXA) sensitivity to apoptosis in vitro and in vivo. Mechanistically, we demonstrated that CRC cells would switch from an active proliferative to a slow-cycling state during fasting. Furthermore, metabolomics shows cell proliferation was decreased to survive nutrient stress in vivo, as evidenced by a low level of adenosine and deoxyadenosine monophosphate. CRC cells would decrease proliferation to achieve increased survival and relapse after chemotherapy. In addition, these fasting-induced quiescent cells were more prone to develop drug-tolerant persister (DTP) tumor cells postulated to be responsible for cancer relapse and metastasis. Then, UMI-mRNA sequencing uncovered the ferroptosis pathway as the pathway most influenced by fasting. Combining fasting with ferroptosis inducer treatment leads to tumor inhibition and eradication of quiescent cells by boosting autophagy. INTERPRETATION: Our results suggest that ferroptosis could improve the antitumor activity of FMD + chemotherapy and highlight a potential therapeutic opportunity to avoid DTP cells-driven tumor relapse and therapy failure. FUNDING: A full list of funding bodies can be found in the Acknowledgements section.

Prevalent Pseudoprogression and Pseudoresidue in Patients With Rectal Cancer Treated With Neoadjuvant Immune Checkpoint Inhibitors.

BACKGROUND: Immune checkpoint inhibitor (ICI) treatment in patients with microsatellite instability-high/mismatch repair deficient (MSI-H/dMMR) tumors holds promise in reshaping organ preservation in rectal cancer. However, the benefits are accompanied by distinctive patterns of response, introducing a dilemma in the response evaluation for clinical decision-making. PATIENTS AND METHODS: Patients with locally advanced rectal cancer with MSI-H/dMMR tumors receiving neoadjuvant ICI (nICI) treatment (n=13) and matched patients receiving neoadjuvant chemoradiotherapy (nCRT; n=13) were included to compare clinical response and histopathologic features. RESULTS: Among the 13 patients receiving nICI treatment, in the final radiologic evaluation prior to surgery (at a median of 103 days after initiation of therapy), progressive disease (n=3), stable disease (n=1), partial response (n=7), and complete response (n=2) were observed. However, these patients were later confirmed as having pathologic complete response, resulting in pseudoprogression and pseudoresidue with incidences of 23.1% (n=3) and 76.9% (n=10), respectively, whereas no pseudoprogression was found in the 13 patients receiving nCRT. We further revealed the histopathologic basis underlying the pseudoprogression and pseudoresidue by discovering the distinctive immune-related regression features after nICI treatment, including fibrogenesis, dense lymphocytes, and plasma cell infiltration. CONCLUSIONS: Pseudoprogression and pseudoresidue were unique and prevalent response patterns in MSI-H/dMMR rectal cancer after nICI treatment. Our findings highlight the importance of developing specific strategies for response evaluation in neoadjuvant immunotherapy to identify patients with a good response in whom sphincter/organ-preserving or watch-and-wait strategies may be considered.

Clinical spectrum of rectal cancer identifies hallmarks of early-onset patients and next-generation treatment strategies.

BACKGROUND: The incidence of colorectal cancer is increasing among young adults and more rectal cancers are reported. This study aimed to identify the clinical features specific for early-onset rectal cancer and provide insights on cancer management. METHODS: Early-onset (<50 years) and late-onset (≥50 years) rectal cancer patients from a referral tertiary care center (SYSU cohort) and Surveillance Epidemiology and End Results database (SEER cohort) were included to perform a comprehensive comparison on clinical information. RESULTS: A total of 552 and 80,341 patients with stages I-III rectal cancer were included in the SYSU and SEER cohorts, respectively. In the SYSU cohort, early-onset diseases had significantly higher prevalence of family history of cancer and history of HBV infection and lower incidence of comorbidities (p < 0.05). In addition, early-onset patients presented more frequently with advanced node stage (N2 stage: 16.9 vs. 9.3%, p = 0.017) and high-risk features, including mucinous or signet cell carcinomas (21.8 vs. 12.9%, p = 0.014), poorly differentiated tumors (28.8 vs. 15.4%, p = 0.002), and perineural invasion (14.5 vs. 7.9%, p = 0.027) compared with late-onset patients. However, early-onset patients received more neoadjuvant (18.5 vs. 11.2%, p = 0.032) and adjuvant treatments (71.0 vs. 45.8%, p < 0.001), and they had better overall survival in both SYSU (HR 0.57, 95% CI: 0.34-0.95; p = 0.029) and SEER (HR 0.38, 95% CI: 0.37-0.40; p < 0.001) cohorts. CONCLUSION: Early-onset rectal cancers are distinct from late-onset cases in clinicopathological features, treatment modalities, and outcomes. The clinical trials and studies that are specific for young populations are needed to develop optimal strategies for cancer screening, treatment, and surveillance.

Application of metagenomic next-generation sequencing for suspected infected pancreatic necrosis.

BACKGROUND: Metagenomic next-generation sequencing (mNGS) is increasingly used for the clinical diagnosis of infectious diseases, but there is a paucity of data regarding the application of mNGS in the early diagnosis of infected pancreatic necrosis (IPN). OBJECTIVE: To investigate the clinical application value of mNGS in the pathogenic diagnosis of IPN. METHODS: Forty-two patients with suspected IPN were prospectively and consecutively enrolled from August 2019 to August 2021. Blood samples were collected for mNGS and microbial culture simultaneously during fever (T ≥ 38.5 °C). For patients who had indications of surgical interventions, peri-pancreatic specimens were collected for mNGS and microbial culture simultaneously during the first surgical intervention to confirm IPN. The clinical performance of mNGS and microbial culture were compared. RESULTS: A total of 21 patients (50.0%) were confirmed to have IPN during hospitalization. The sensitivity of blood mNGS was significantly higher than blood culture (95.2% vs. 23.8%, P < 0.001) in diagnosing IPN. The negative predictive value of blood mNGS was 90.0%. The turnaround time of mNGS was significantly shorter than that of microbial culture [(37.70 ± 1.44) vs. (115.23 ± 8.79) h, P < 0.01] and the average costs of mNGS accounted for 1.7% of the average total cost of hospitalization. The survival analysis demonstrates that the positive blood mNGS result was not associated with increased mortality (P = 0.119). CONCLUSIONS: With more valuable diagnostic performance and shorter turnaround time, clinical mNGS represents a potential step forward in the early diagnosis of IPN.

Early-onset emphysematous pancreatitis indicates poor outcomes in patients with infected pancreatic necrosis.

BACKGROUND: Emphysematous pancreatitis (EP) is a subtype of infected pancreatic necrosis (IPN) characterized by presence of gas in (peri)pancreatic necrosis. However, the impacts of EP on outcomes of IPN are still controversial. METHODS: A prospective database of consecutive patients with IPN in a tertiary hospital was post-hoc analyzed. Patients were assigned to EP and non-EP groups to perform a comprehensive comparison. RESULTS: A total of 178 patients with IPN were enrolled and the overall mortality was 30.9%. EP accounted for 20.8% (n = 37) of cases and was significantly associated with higher incidences of Escherichia coli (45.9 versus 18.4%, P = 0.001) and Klebsiella pneumoniae (56.8 versus 33.3%, P = 0.009) infection. There was scarcely any disparity in clinical characteristics and outcomes between IPN patients with and without EP. However, patients with early-onset EP defined as air bubble signs occurring within 2 weeks from disease onset were significantly older and have higher prevalence of history of diabetes, and they were also associated with significantly higher mortality (57.1 versus 8.7%, P = 0.015) compared with late-onset patients. CONCLUSIONS: The clinical outcomes of EP might be like those of non-emphysematous infection. However, when EP occurs within 2 weeks from disease onset, it is highly lethal.

Current Surveillance After Treatment is Not Sufficient for Patients With Rectal Cancer With Negative Baseline CEA.

BACKGROUND: Serum CEA has been widely used to screen for potential recurrent disease after resection in rectal cancer. However, the influence of baseline CEA on the performance of CEA in recurrence surveillance needs to be investigated. PATIENTS AND METHODS: This longitudinal cohort study included 484 patients with nonmetastatic rectal cancer from 18,013 patients in a prospectively enrolled institutional database program of colorectal disease. Baseline CEA levels were determined before treatment, and CEA-based follow-up tests and examinations were applied in the surveillance after treatment. RESULTS: A total of 62.6% (62/99) overall, 53.5% (23/43) local, and 64.9% (50/77) distant recurrences were seen in patients who had similar CEA levels with their baseline statuses. The sensitivity of elevated CEA levels during surveillance for overall recurrence was significantly lower in patients with negative baseline CEA than in those with elevated baseline CEA levels (41.3% vs 69.4%; P =.007). Moreover, similar results were observed in the surveillance for local (50% vs 61.5%; P =.048) and distant (39.6% vs 72.4%; P =.005) recurrences between these 2 patient groups. However, CEA had comparable and excellent specificity during surveillance for recurrent disease in these groups. The addition of CA19-9 to the CEA assay significantly improved the sensitivity in recurrence surveillance for patients with negative baseline CEA (49.2% vs 41.3%; P =.037). Finally, we identified a subgroup of CEA-turn recurrences characterized by negative CEA at baseline, elevated CEA at recurrence, and worse survival outcomes after recurrence (hazard ratio, 1.88; 95% CI, 1.07-3.30; P =.026). CONCLUSIONS: In patients with rectal cancer with negative baseline CEA, serum CEA had insufficient sensitivity in recurrence surveillance after treatment, and additional surveillance may improve oncologic outcomes. Baseline CEA should be considered before CEA-based surveillance can be applied in the follow-up trials.

Current treatment and surveillance modalities are not sufficient for advanced stage III colon cancer: Result from a multicenter cohort analysis.

OBJECTIVE: We conducted this multicenter cohort study to evaluate the current tumor-node-metastasis staging system and treatment modality by analyzing the survival outcomes of patient groups with stage III and IV colon cancer. PATIENTS AND METHODS: Stage III and IV colon cancer patients from the Surveillance, Epidemiology, and End Results (SEER) database (SEER cohort) and prospectively maintained Sun Yat-sen University (SYSU) cohort were included in this study. Kaplan-Meier method was used to estimate the cumulative rate of overall survival (OS) between patient groups, and the inverse probability weighting method was used to calculated age and sex-adjusted survival curves. The Cox regression model was used to identify the risk factors for OS. RESULTS: A total of 17,911 and 1135 stage III-IV cases were included in the SEER and SYSU cohorts, respectively. Among them, 1448 and 124 resectable stage IV cases underwent curative-intent treatment in the SEER and SYSU cohorts, respectively. The T4N2b group showed a significantly worse survival outcome compared with the M1a subset receiving curative-intent treatment (HR, 1.46; p < 0.001). This finding was validated in the SYSU cohort, in which the T4N2 group had a worse outcome than that of the M1 group receiving curative-intent treatment (HR, 2.44; p < 0.001). These findings were confirmed in the adjusted survival analysis. In the multivariate analysis, the right-side tumor, poor-undifferentiated tumor, and age over 60 years were identified as independent risk factors for T4N2b patients. Based on this multivariate model, the high-risk T4N2b subgroup had a worse survival outcome compared with resectable M1b patients (HR, 1.24; p = 0.03). CONCLUSION: By comparing stage III with stage IV colon cancer patients, we identified a subgroup of stage III patients at a higher risk of death than more advanced stages, implying that current cancer care modalities are not sufficient for these high-risk substages.

Synchronous organ failure and infected pancreatic necrosis define genuine critical acute pancreatitis.

BACKGROUND: Critical acute pancreatitis (CAP) was supposed to be strongly associated with the highest risk of adverse outcomes. However, the definition of CAP needs to be further clarified. METHODS: A prospective database with consecutive patients of infected pancreatic necrosis (IPN) at a tertiary hospital was post-hoc analyzed. Patients were assigned to IPN alone, Metachronous-CAP (MCAP) and Synchronous-CAP group (SCAP) according to presence or absence of organ failure (OF) and the crosstalk between OF and IPN. Clinical interventions and outcomes were compared among groups. RESULTS: A total of 248 IPN patients were enrolled and the overall mortality was 25.8%. Compared with MCAP, SCAP was associated with higher mortality (66.2 versus 10.0%) and morbidity (41.2 versus 18.0%), longer duration of OF (median 35.5 versus 12.0 days), ICU length of stay (LOS) (median 28.0 versus 16.0 days) and hospital LOS (median 67.0 versus 60.0 days) (all P < 0.05). The IPN alone and MCAP had comparable mortality (10.8 versus 10.0%), morbidity and hospital LOS, except that MCAP patients were characterized with longer duration of OF and ICU LOS (P < 0.05). CONCLUSIONS: SCAP, characterized with synchronous persistent OF and IPN, was associated with higher mortality and morbidity and should be defined as genuine CAP.

Multiple organ failure might be an indication for prophylactic antifungal therapy in acute pancreatitis.

PURPOSE: Significant conflicts regarding prophylactic antifungal treatment in acute pancreatitis (AP) exist among current literatures and guidelines. The key to resolving this controversial issue is to identify risk factors for intra-abdominal fungal infection (AFI) among patients with AP. METHODS: A single-center, retrospective cohort of 826 patients with AP between January 2014 to December 2019 was analysed to study the risk factors of AFI. RESULTS: Of the 826 patients with AP, 10 patients (1.2%) developed AFI, including 2 cases in moderately severe AP (MSAP) and 8 in severe AP (SAP). The incidence of AFI was significantly higher in patients with SAP compared with MSAP and mild AP (10.3 vs. 0.8% vs. 0, P < 0.001). SAP patients with AFI were more likely to have multiple organ failure (MOF) (OR = 13.4; 95% CI 1.6-115.5), organ failure lasting more than 1 week (OR = 5.1; 95% CI 1.0-27.0), and surgical intervention within first week of admission (OR = 7.4; 95% CI 1.0-53.6). Multivariable analysis identified MOF (OR = 14.3; 95% CI 1.2-173.8) as the only independent risk factor of AFI. CONCLUSION: MOF might be the indication of prophylactic antifungal therapy in patients with AP.

Candidemia indicates poor outcome in patients with infected pancreatic necrosis.

BACKGROUND: Intra-abdominal fungal infection (AFI) and candidemia are common in patients with acute pancreatitis (AP), but with limited and conflicting reports on their clinical impacts. This study aims to evaluate the clinical impacts of AFI and candidemia in infected pancreatic necrosis (IPN). METHODS: A single-centre, prospective cohort including 235 consecutive patients with IPN between January 2010 and September 2020 was analysed to study the clinical impacts of AFI and candidemia. RESULTS: Of the 235 patients with IPN, 69 patients (29.4%) developed AFI and 13 patients (5.5%) developed candidemia. AFI was associated with higher intestinal leakage rate (27.5% vs 12.7%, P = .006), higher pancreatic fistula rate (53.6% vs 34.3%, P = .006) and longer hospital stays (72 vs 58 days, P = .003), but with similar mortality rate compared with patients without AFI (23.2% vs 24.7%, P = .806). However, candidemia was associated with significantly higher mortality rate compared with patients without candidemia (69.2% vs 21.6%, P < .001). Patients with candidemia had higher rate of multiple organ failure and AFI (69.2% vs 36.5%, P = .018; 69.2% vs 27.0%, P = .001, respectively). Multivariable analysis showed that age ≥ 50 years (OR = 2.8; 95% CI, 1.3-5.8; P = .007), severe category (OR = 11.2; 95% CI, 3.5-35.7; P < .001), multidrug-resistant organisms infection (OR = 2.5; 95% CI, 1.0-6.2; P = .039), candidemia (OR = 11.8; 95% CI, 2.5-56.5; P = .002), step-down surgical approach (OR = 3.2; 95% CI, 1.5-7.0; P = .004) were the independent predictors associated with higher mortality in IPN patients. CONCLUSION: Although AFI did not increase the mortality of IPN, patients with candidemia carried significantly higher mortality.

Macrophage migration inhibitory factor is an early marker of severe acute pancreatitis based on the revised Atlanta classification.

BACKGROUND: Various serum markers for early identification of severe acute pancreatitis (SAP) have been studied. Serum macrophage migration inhibitory factor (MIF) was reported to be correlated with severity of acute pancreatitis (AP) based on the 1992 Atlanta classification. However, MIF has never been proven to be predictive of disease severity based on the revised Atlanta classification (RAC). The potential predictive value of MIF needs to be further validated. METHODS: Consecutive patients with AP within 48 h after symptom onset and 10 healthy control volunteers were enrolled prospectively. Serum MIF levels were measured by enzyme-linked immunosorbent assay (ELISA). The predictive value of MIF, clinical scores and other serum markers were determined. RESULTS: Among 143 patients with AP, there were 52 (36.4%), 65 (45.5%) and 26 (18.1%) with mild, moderate and severe disease based on the RAC respectively. Compared with healthy volunteers, serum levels of MIF were significantly higher in AP patients, especially those with SAP (P < 0.001). Multivariate regression analysis indicated that increased serum MIF (cut-off 2.30 ng/ml, OR = 3.16, P = 0.008), IL-6 (cut-off 46.8 pg/ml, OR = 1.21, P = 0.043), APACHE II score (cut-off 7.5, OR = 2.57, P = 0.011) and BISAP score (cut-off 1.5, OR = 1.01, P = 0.038) were independent risk factors for predicting SAP (P < 0.05). By using the area under the receiver operating characteristic (ROC) curve (AUC), MIF (AUC 0.950) demonstrated more excellent discriminative power for predicting SAP than APACHE II (AUC 0.899), BISAP (AUC 0.886), and IL-6 (AUC 0.826). CONCLUSIONS: Serum MIF is a valuable early marker for predicting the severity of AP based on the RAC.