CT Severity Index Research Articles

Evaluation of severity and prognosis of acute pancreatitis by CT severity index and modified CT severity index

Objectives: To explore the role of computed tomography (CT) severity index (CTSI) and modified CT severity index (MCTSI) in assessing the severity of acute pancreatitis (AP) under the revised Atlanta classification (RAC) and predicting the clinical prognosis. Methods: Based on the prospectively entered AP database, the clinical data of consecutive adult AP inpatients admitted to the Department of Gastroenterology of the First Affiliated Hospital of Nanchang University from January 2012 to December 2020 were retrospectively screened. The imaging data were independently evaluated by two radiologists and entered to the database to calculate the CTSI and MCTSI scores. Their relationship with the difference of RAC severity grade and clinical prognosis was analyzed. Compared with Acute Physiology and Chronic Health Assessment Ⅱ (APACHE Ⅱ) score, the receiver operating characteristic curve was used to evaluate the predictive value of CTSI and MCTSI scores for persistent organ failure and infectious pancreatic necrosis (IPN). Results: A total of 2 612 patients with AP, aged (50±15) years, were included in the study, including 1 547 males (59.2%) and 1 065 females (40.8%). According to RAC standard, AP was divided into 699 cases (26.8%) of mild pancreatitis (MAP), 1 098 cases (42.0%) of moderately severe pancreatitis (MSAP), and 815 cases (31.2%) of severe pancreatitis (SAP). MCTSI judged AP severity similarly to RAC, with 668 cases of MAP (25.6%), 1 207 cases of MSAP (46.2%) and 737 cases of SAP (28.2%), while CTSI judged SAP patients less(400 cases, 15.3%). The severity of AP determined by CTSI and MCTSI scores was significantly correlated with clinical prognosis (r=0.06-0.43, all P<0.05). Compared with APACHE Ⅱ score, CTSI had the highest area under the curve (AUC) for predicting IPN (AUC=0.85, 95%CI: 0.83-0.87), followed by MCTSI (AUC=0.82, 95%CI: 0.80-0.85). APACHE Ⅱ was more accurate in predicting persistent organ failure than CTSI and MCTSI scores,with AUC of 0.73 (95%CI: 0.71-0.75), 0.72 (95%CI: 0.70-0.74) and 0.72 (95%CI: 0.70-0.74), respectively. Conclusions: AP severity judged by MCTSI is consistent with RAC, and SAP patients judged by CTSI are less than RAC. CTSI and MCTSI are significantly correlated with clinical prognosis. CTSI and MCTSI have higher accuracy in predicting IPN, but lower accuracy in predicting persistent organ failure than APACHE Ⅱ.

Etiology and classification of acute pancreatitis in children admitted to ICU using the Pediatric Sequential Organ Failure Assessment (pSOFA) score

BackgroundPediatric acute pancreatitis (AP) is rare but increasing. Severe AP is associated with higher morbidity and mortality. However, there are no universally accepted prognostic criteria for AP. MethodsThis retrospective study included children with AP admitted to an intensive care unit (ICU) of our tertiary pediatric center between January 2009 and December 2018. The severity of organ dysfunction in AP was assessed according to the modified Atlanta criteria using the Pediatric Sequential Organ Failure Assessment (pSOFA) and Computed Tomography Severity Index (CTSI). ResultsSeventy acute episodes of AP were evaluated in 55 children with primary pancreatitis. In addition, secondary AP was diagnosed in 15 patients originally admitted to ICU for different indications. Mild AP [no organ dysfunction, normal computed tomography (CT) finding] was the most prevalent (64/85 episodes in 49 children), followed by moderate AP (15 children; pSOFA 2-9 points, CTSI 3-4 points on admission). Severe AP (pSOFA 4-17 points, CTSI 6-10 points) was diagnosed in 6 children with traumatic or secondary AP. The most frequent etiologies of primary AP episodes were idiopathic (39%) and biliary (31%). Children with idiopathic AP had frequent relapses and comorbidities. Hereditary AP was typically mild, but presented with high pancreatic enzyme levels and recurrence rates. Admission at ICU and an interval without enteral nutrition (EN) were relatively short in drug-induced AP and relatively long in secondary and traumatic AP. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 13 patients with biliary AP and in 4 patients with traumatic AP. No AP-related death was observed. ConclusionpSOFA score accurately reflects the severity and prognosis of AP in children.

Clinical value of activin A in early identification of moderate and severe acute pancreatitis: a prospective study

To explore the value of serum activin A (ACT-A) level in early identification of moderate and severe acute pancreatitis (AP). A prospective case control study was conducted. A total of 120 patients with AP admitted to department of hepatobiliary surgery of Affiliated Nanhua Hospital of Hengyang Medical College of University of South China between October 2020 and April 2022 were recruited. According to the revised Atlanta classification, all patients were classified into mild AP group and moderate-to-severe AP group. The blood samples within 24 hours of onset were drawn, and the serum ACT-A and C-reactive protein (CRP) levels were detected by enzyme-linked immunosorbent assay (ELISA). The Ranson score and the modified CT severity index (MCTSI) were performed. Pearson correlation method was used to analyze the correlation of various parameters. The receiver operator characteristic curve (ROC curve) was plotted to analyze the predictive value of ACT-A and CRP for moderate-to-severe AP. A total of 120 patients with AP were enrolled, including 83 patients with mild AP and 37 patients with moderate-to-severe AP. Serum ACT-A and CRP levels within 24 hours of onset in the moderate-to-severe AP group were significantly higher than those in the mild AP group [ACT-A (ng/L): 140.4±37.7 vs. 53.9±30.5, lg CRP: 1.42±0.91 vs. 0.77±0.70, both P < 0.01], and the Ranson score and MCTSI score were also significantly higher than those in the mild AP group (Ranson score: 5.3±1.3 vs. 1.8±1.6, MCTSI score: 5.5±1.0 vs. 2.7±1.2, both P < 0.01). Correlation analysis showed that the serum ACT-A level was positively correlated with serum CRP level, Ranson score and MCTSI score (R2 value was 0.272, 0.841, 0.616, respectively, all P < 0.05). ROC curve analysis showed that the serum ACT-A, CRP and Ranson score had predictive value for moderate-to-severe AP. The area under the ROC curve (AUC) was 0.948 [95% confidence interval (95%CI) was 0.909-0.986], 0.711 (95%CI was 0.606-0.815), 0.946 (95%CI was 0.910-0.982), respectively. When serum ACT-A > 112.6 ng/L, the sensitivity and specificity of predicting moderate-to-severe AP were 78.38% and 96.39%, respectively, which was better than serum CRP with sensitivity and specificity of 72.92% and 66.27%, respectively, and the specificity was better than Ranson score (71.08%). ACT-A can be detected in the early stage of AP, and it is positively correlated with the disease severity, which can early identify moderate-to-severe AP.

THE DIAGNOSTIC ACCURACY OF NUMERICAL COMPUTED TOMOGRAPHY SEVERITY INDEX AND RANSON SCORE IN PREDICTING SEVERE ACUTE PANCREATITIS

Objective: To determine the diagnostic accuracy of numerical CT severity index (CTSI) and Ranson score in pre­dicting severe Acute Pancreatitis (AP) keeping organ failure as the gold standard. Methodology: This descriptive cross-sectional study was carried out in the Department of Surgery, Medical Teaching Institute, Lady Reading Hospital Peshawar, from November 2020 to May 2021 on 238 patients with acute pancreatitis. All patients were subjected to the prediction of Severe Acute Pancreatitis (SAP)/organ failure on CTSI and Ranson criteria. Results: The mean age of the participants was 30.7+7.6 years. There were 54.2% male and 45.8% female as per gender distribution. The mean duration of AP at presentation was 3.8 +1.8 days. Prediction of SAP in terms of organ failure was predicted in 55.9% of patients on Ranson criteria and 59.2% of patients on CTSI. The sensi­tivity of Ranson criteria was 37.5% and specificity of 25.4% with a Positive Predictive Value (PPV) of 33.8% and a Negative Predictive Value (NPV) of 28.5%. The sensitivity of CTSI was 88.9% and specificity 71.1% with PPV of 75.9% &amp; NPV of 86.6%. Conclusion: CTSI is a highly sensitive and specific tool for predicting the severity of acute pancreatitis when compared to the Ranson criteria in patients presenting with acute pancreatitis.

The modified computed tomography severity index combined with low skeletal muscle mass can better predict the severity of hypertriglyceridemia-induced pancreatitis.

Body composition parameters are associated with hypertriglyceridemia-induced pancreatitis (HTGP). This study investigated the association between the quantity of muscle assessed using computed tomography (CT) and the severity of HTGP. The modified CT severity index (MCTSI) was calculated from admission examination data. Patients' characteristics and body composition parameters were collected. Univariate and multivariate logistic regression analyses were also performed. The receiver operating characteristic curves and corresponding area under the curves (AUC) were calculated to test the efficiency of the model. A nomogram was then constructed. Of the 175 included patients, 138 were male, of which 85 had moderately severe to severe HTGP. Patients with low skeletal muscle mass (LSMM) and high MCTSI were significantly more likely to have moderately severe to severe HTGP. Patients with LSMM had lower body mass index, lower HDL-C level, higher amylase level, prevalence of surgery, shorter umbilical waist circumference, and longer length of hospital stay. Univariate and multivariate logistic regression analyses confirmed that female sex, lipase, total cholesterol, LSMM-MCTSI (P= .004, odds ratio=23.105), and albumin were risk factors. The TOTAL model that combined LSMM-MCTSI and clinical risk parameters performed best (AUCs=0.875), followed by other models (LSMM-MCTSI: AUCs=0.762, MCTSI: AUCs=0.728). The Delong test revealed significant difference. Finally, a nomogram was developed to predict the severity of HTGP. The performance of MCTSI in predicting severity can be improved by considering LSMM, which is a promising strategy for the treatment of HTGP.

Pancreatic necrosis volume for predicting readmission and reintervention in acute necrotizing pancreatitis

PurposeTo determine the correlation between the pancreatic necrosis volume (PNV) and readmission as well as reintervention. MethodThis was a retrospective cohort study that included necrotizing pancreatitis (NP) patients who were examined with contrast-enhanced computed tomography (CT) one week before discharge. The PNV was calculated manually based on the postprocessing workstation software. Multivariate logistic regression analysis was employed to determine the independent risk factors for readmission and reintervention. ResultsA total of 167 NP patients were included. Among them, 94 (56.3%) patients were readmitted after discharge, and 55 (32.9%) patients needed further invasive intervention. The median PNV of all patients was 376.6 (interquartile range (IQR), 129.3–820.5) cm3, and the PNV was significantly higher in patients needing readmission or reintervention. Multivariate analysis showed that PNV ≥ 620 cm3 (adjusted odds ratio (adjOR), 3.08; 95% confidence interval (CI), 1.47–6.43; P = 0.003) and modified computed tomography severity index (CTSI) score ≥ 7 points (adjOR, 6.36; 95% CI, 2.05–10.70; P = 0.001) were independently associated with readmission. Stent or drainage tube placement at discharge (adjOR, 2.94; 95% CI, 1.27–6.77; P = 0.011), PNV ≥ 620 cm3 (adjOR, 5.11; 95% CI, 2.19–11.95; P < 0.001), pancreatic parenchymal necrosis (adjOR, 3.37; 95% CI, 1.42–7.96; P = 0.006), and modified CTSI score ≥ 7 points (adjOR, 4.23; 95% CI, 1.46–12.27; P = 0.008) were independent risk factors for reintervention. ConclusionsThe PNV is a useful tool for quantifying pancreatic necrosis and is strongly associated with readmission and reintervention. Additional prospective studies with larger sample sizes are needed to confirm these findings.

Prevalence of Cardiovascular Dysfunction and its Association with Outcomes in Patients with Acute Pancreatitis

Background and Aim: Acute pancreatitis is a rapid progressive abdominal inflammatory disease with acute onset in clinics which turns into severe acute pancreatitis. In approximately 20% of patients characterized by different parameters such as gland flaky necrosis, multiple organ dysfunction syndrome (MODS), inflammatory cell infiltration in large number, and hemorrhage. Electrocardiography and electromyography variations are the common cardiac failure in patients with acute pancreatitis. Elevated cardiac enzymes could be other factors for cardiac failure with acute pancreatitis. The present study aimed to assess the prevalence of cardiovascular dysfunction and its association in patients with acute pancreatitis. Methodology: This cross-sectional study was carried out on 120 acute appendicitis patients in the department of Gastroenterology at Northwest General Hospital &amp; Research Centre, Hayatabad Peshawar for the duration of six months from June 2021 to November 2021. All the patients who met the inclusion criteria were enrolled. Echocardiography and CK-MB (creatine phosphokinase isoenzyme) was measured for evaluating myocardial function after admission. All the patients underwent physical, clinical, and laboratory examination. The findings of Electrocardiography (ECG) were recorded. Acute appendicitis severity, duration of hospital stay, infection, computed tomography severity index (CTSI), and mortality were different outcomes. Results: Of the total 120 patients, about 83 (69.2%) were males and 37 (30.8%) were females. The overall mean age was 37.84±12.46 years. Out of 120 acute pancreatitis patients, the prevalence of gallstone disease, organic failure, respiratory failure, acute kidney failure, and cardiovascular dysfunction was 51 (43.3%), 47 (39.2%), 37 (30.8%), 19 (15.8%), and 9 (7.5%) respectively. Elevated CK-MB and ECG changes were seen in 32 (26.7%) and 42 (35%) respectively. The ECG variations and elevated CK-MB were related with severity of acute pancreatitis (p&lt;0.05), duration of hospital (OR: 18.9 ± 10.6 vs. 11.7 ± 6.8, p = 0.005), CTSI (6.9 ± 3.1 vs. 4.7 ± 2.9, p = 0.001), increased necrosis (2.34, 95%CI= 0.3-11.8, p=0.011), and mortality (OR= 5.46, 95% CI= 1.2-34.9, p=0.05). The incidence of Left ventricular systolic dysfunction (LVEF) and left ventricular diastolic dysfunction (LVDD) was 15 (12.5%) and 31 (25.8%) respectively. Conclusion: The present study found that elevated CK-MB were significantly associated with higher CTSI, Prolonged hospital stay, severity of acute pancreatitis, LVDD, increased necrosis, and mortality. CK-MB increased levels have been reported as an indicator for cardiac failure and acute pancreatitis. There was a significant association between increased CK-MB levels and cardiovascular organ failure, pancreatic necrosis, and left ventricular diastolic dysfunction. Keywords: Cardiovascular dysfunction, Acute pancreatitis, Outcomes

Comparative Evaluation of Bedside Index of Severity in Acute Pancreatitis Bisap) &amp; Modified Computed Tomography Severity Index (MCTSI) in Assessing Severity of Acute Pancreatitis

Objective: To compare diagnostic accuracy of BISAP and MCTSI in predicting the severity of Acute pancreatitis. Study design: cross sectional study. Setting: Surgical department Khyber Teaching Hospital, Peshawar and Bacha Khan Medical Complex, Swabi. Duration: 6 months Jan, 2021 to June, 2021 Material and Methods: In this study a total of 246 patients were observed. The demographic, clinical and laboratory data of all consecutive patients with a primary diagnosis of AP admitted/transferred to our ward were prospectively collected and then this data were retrospectively analyzed. The day of admission is defined as the first 24hr of hospitalization in our ward or in the referring hospital/ward. Contrast enhanced CT(CECT) and BISAP score were calculated after 72hrs in all patients and they were categorized into three severity grades of Acute pancreatitis based on Atlanta classification 2012 as discussed in operational definition. BISAP score greater than 4 and MCTSI score greater than 8 were considered severe acute pancreatitis. Results: In this study mean age was 45 years with SD ± 16.21. Forty three percent patients were male while 57% patients were female. MCTSI had sensitivity 89.83%, specificity 60%, Positive predictive value was 98.14%, Negative predictive value was 20% and the overall diagnostic accuracy was 88.61%. While BISAP had sensitivity 82.05%, specificity 70%, Positive predictive value was 98.49%, Negative predictive value was 14.89% and the overall diagnostic accuracy was 82.52%. Conclusion: Our study concludes that the diagnostic accuracy of MCTSI is better than BISAP score in predicting the severity of acute pancreatitis. Keywords: MCTSI, BISAP score, severe acute pancreatitis.

Hyperlipemia pancreatitis onset time affects the association between elevated serum triglyceride levels and disease severity

BackgroundThe association of serum triglyceride (TG) levels with the severity of hypertriglyceridaemia-induced acute pancreatitis (HTG-AP) remains controversial. This study aimed to comprehensively assess the TG levels from the initial onset and their predictive value in the disease assessment of HTG-AP.MethodsData collected from January 2018 to July 2021 in one institute were assessed retrospectively. HTG-AP was defined as a TG level > 500 mg/dL in the absence of other common aetiologies of AP. The TG levels within 24 hours (24 h), 48 hours (48 h), 3-4 days (3-4 d), and 5-7 days (5-7 d) after symptom onset and their correlations with disease severity in HTG-AP patients were analysed by cross-sectional and longitudinal studies.ResultsIn the cross-sectional study, 377 HTG-AP patients were included before lipid-lowering intervention: 216 subjects had their first TG levels measured within 24 h after onset, 91 within 48 h, 50 in 3-4 d, and 20 in 5-7 d. TG levels decreased in the 24 h, 48 h and 3-4 d groups (P < 0.001), however, the TG decline in the 5-7 d group had no difference compared with the 3-4 d group. HTG-AP patients with severe or moderately severe disease displayed higher TG levels than those with mild disease in the 24 h and 48 h groups (P < 0.050) but not in the 3-4 d or 5-7 d groups. Furthermore, the TG levels were correlated with the modified computed tomography severity index only in the 24 h and 48 h groups, while an association between serum calcium levels and C-reactive protein levels was only present in the 24 h group. Similarly, the TG levels were related to hospital days and ICU days in the 24 h and/or 48 h groups. In the longitudinal study, 165 patients with complete records of TG levels from 24 h to 5-7 d were enrolled. With supportive care and lipid-lowering treatment after admission, the TG levels declined rapidly (P < 0.001), and the correlations with disease severity weakened or even disappeared from 24 h to 5-7 d.ConclusionTG levels decreased and attenuated the association with disease severity of HTG-AP over the time of onset. The TG levels within the initial 48 h after onset were most useful for the diagnosis and disease assessment of HTG-AP.

Procalcitonin as a predictor of severity in acute pancreatitis

Background: Outcomes and severity of acute pancreatitis is a challenging condition to diagnose. However, multiple clinico-biochemical scores, imaging, radiological imaging, and biochemical markers are used. Aims: To evaluate procalcitonin as a predictor of severity in acute pancreatitis and to correlate the levels of procalcitonin to the CT Severity Index score. Materials and Methods: In 65 study subjects, prolactin levels, CRP, blood glucose, liver function tests, BUN, creatinine, urea, CBC, and radiological investigations including whole abdomen USG, X-ray abdomen-supine and erect, and chest X-ray PA view. Following 48-72 hours of admission, a CT abdomen was done on subjects with diagnostic dilemmas. In subjects where CECT was done, necrosis scores and Balthazar grading were used for grading the CT severity index. Results: For the cut-off PCT value of 1.77 ng/ml the sensitivity, specificity, PPV, NPV, accuracy, and likelihood ratio were 74.8, 76.88, 74.8, 76.94, 74, and 15.154 respective. In the PCT cut-off value of 3.29 ng/ml, the respective values of sensitivity, specificity, PPV, NPV, accuracy, and likelihood ratio were 66.65, 84.58, 79.8, 73.31, 74, and 14.426. BCTSI score of ≥4, the respective values of sensitivity, specificity, PPV, NPV, accuracy and likelihood ratio were 62.3, 65.36, 62.3, 65.36, 65, and 3.936.

Evaluation of CT Scan Diagnostic Value in the Novel Coronavirus Disease and Presenting a Corona CT Severity Index.

Several diagnostic methods were proposed and evaluated for the COVID-19 disease. However, published studies have reported different diagnostic values for these methods. The present study aimed to evaluate the diagnostic performance and accuracy of CT in the novel coronavirus disease (COVID-19) and developed and presented a Corona CT severity index. In this retrospective study, CT diagnostic performance was measured based on sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy, and RT-PCR was regarded as a standard. Patients' CT reports were evaluated by a radiologist, and scoring and calculating of the CT severity index were performed. Of 208 patients, 82 showed positive, and 126 showed negative RT-PCR results with a positive frequency of 39.4% (95% CI, 32.7-46.4). The chest CT scan related to 136 patients indicated COVID- 19, whereas the initial RT-PCR assays of 56 patients were negative. Considering RT-PCR results as the reference standard, the sensitivity, specificity, and accuracy of chest CT to indicate COVID-19 infection were 100%, 55.6% (95% CI 46.4-64.4%), and 72.8% (95% CI 66.2-78.8%), respectively. The severity of pulmonary involvement was assigned with different grades. For 60.7% of patients with severity grades of 2 to 6, who showed the involvement of at least one lung lobe in CT, PCR retrieved negative results. CT scan shows an acceptable sensitivity as well as a consistently better specificity to identify COVID-19 pneumonia than PCR. It may be considered a major method to identify COVID-19 in epidemic locations.

Liver spontaneous hypoattenuation on CT is an imaging biomarker of the severity of acute pancreatitis

PurposeThe purpose of this study was to evaluate the relationship between liver spontaneous attenuation (LSA) on computed tomography (CT) reflecting the degree of steatosis, and the severity of acute pancreatitis (AP). Materials and methodsAll consecutive patients admitted from December 2014 to September 2020 for an episode of AP were retrospectively reviewed. LSA was evaluated on early CT examination and all abdominal CT examinations were reviewed by two abdominal radiologists. Severity of AP was categorized using Atlanta classification and CT severity index. Univariable and multivariable statistical analyses were performed. ResultsA total of 467 patients were included. There were 297 men and 170 women, with a mean age of 57 ± 19 (SD) years (range: 18–98 years). Among them, 236 patients (51%) had acute biliary pancreatitis, 134 (29%) had acute alcoholic pancreatitis and 97 (20%) had AP due to other etiologies. A total of 44 (9%) patients had severe AP and 423 (91%) had non severe AP. Median LSA was significantly lower in patients with severe AP (36 Hounsfield units [HU]; interquartile range [IQR]:18; 54) than in patients with non-severe AP (45 HU; IQR: 35; 51) (P < 0.001). In patients with alcoholic AP, median LSA was significantly lower in patients with severe AP (29 HU; IQR: 3; 43) than in those with non-severe AP (42 HU; IQR: 27; 50) (P = 0.022). At multivariable analysis, the third and fourth quartiles of liver spontaneous attenuation values (i.e., < 45 HU/>30 HU and < 30 HU) were independently associated with severe AP (OR, 3.23; 95% CI: 1.33–51.2; P = 0.038 and OR, 8.82; 95% CI: 1.91–69.7; P = 0.014; respectively). ConclusionLSA on CT is associated with clinical severity of AP and may be used as an additional marker of disease severity.

Impact of low-molecular-weight heparin in the treatment of moderately severe and severe acute pancreatitis; a randomized, single blind, phase 3 control trial

IntroductionAcute pancreatitis is inflammation of pancreatic parenchyma which is an emergency condition. It is classified as mild, moderately severe, and severe categories. In severe acute pancreatitis, mortality is up to 10%–30%. Pancreatic abscess increases the mortality to 40%, and infected pancreatitis carries 100% mortality without surgical drainage. Anti-coagulant, anti-inflammatory and anti-protease activities of low-molecular-weight heparin are involved in preventing pancreatic necrosis and curbing the adverse outcomes of acute pancreatitis. AimTo determine the effect of low-molecular-weight heparin on the outcome of moderately severe and severe acute pancreatitis. Materials and methodologyHospital based, single centre, randomized, single blind, phase 3 control trial. First 140 patients with moderately severe and severe acute pancreatitis admitted in hospital in the given period who met the inclusion and exclusion criteria were taken. 70 patients were placed in the control and the trial group each by simple randomization (closed envelope method). The control group received conventional treatment for pancreatitis & the trial group received 1mg/kg body weight Enoxaperin, subcutaneously, 12 hourly for seven days along with the conventional treatment.Progression of disease in Computed Tomography Severity Index and incidence of pancreatic necrosis were the main outcomes studied at the end of 7 days of treatment. Results1386 acute abdomen cases were screened, of which 269 were diagnosed with acute pancreatitis. 147 patients with acute pancreatitis met the selection criteria and 7 were dropouts. Recruitment started on April 9, 2021 and closed on December 5, 2021. Computed Tomography Severity Index progressed in 22(31.40%) patients in control group and 6(8.6%) patients in the trial group and 18(25.71%) in the control group and 4(5.71%) in the trial group showed the presence of necrosis. The differences are significant (P value is 0.001 in each). No adverse events were seen. ConclusionUse of low-molecular-weight heparin in early stage of moderately severe and severe acute pancreatitis significantly reduces the chance of disease progression and pancreatic necrosis.

Is Fatty Liver Associated with Increased Mortality and Morbidity in Coronavirus Disease 2019 (COVID-19) Pneumonia?

BackgroundFatty liver has been shown to be associated with severe COVID-19 disease without any impact on mortality. This is based on heterogenous criteria for defining both fatty liver as well as the severity parameters. This study aimed to study the impact of fatty liver on the mortality and severity of disease in patients with COVID-19 pneumonia.MethodsIn a case control study design, patients with COVID-19 pneumonia (COVID-19 computed tomography severity index [CTSI] on high-resolution computed tomography chest of ≥1) with fatty liver (defined as liver to spleen attenuation index ≤5 on noncontrast computed tomography cuts of upper abdomen) were compared with those without fatty liver. The primary outcome measure was in-hospital mortality, and the secondary outcome measures were CTSI score, need for intensive care unit (ICU) care, need for ventilatory support, duration of ICU stay, and duration of hospital stay.ResultsOf 446 patients with COVID-19 pneumonia, 289 (64.7%)admitted to Max Hospital, Saket, India, between January 1, 2021, and October 30, 2021, had fatty liver. Fifty-nine of 446 patients died during the index admission. In-hospital mortality was not different between patients with fatty liver (38 [13.24%]) or without fatty liver (21 [13.81%]). COVID-19 CTSI score was found to be significantly higher among patients who had fatty liver (13.40 [5.16] vs 11.81 [5.50]; P = 0.003). There was no difference in the requirement of ICU (94 [32%] vs 62 [39.49%]; P = 0.752), requirement of ventilatory support (27 [9.34%] vs 14 [8.91%]; P = 0.385), duration of ICU stay (8.29 [6.87] vs 7.07 [5.71] days; P = 0.208), and duration of hospital stay (10.10 [7.14] vs 10.69 [8.13] days; P = 0.430) between the groups with fatty liver or no fatty liver. Similarly, no difference was found in primary or secondary outcomes measure between the group with severe fatty liver vs mild/moderate or no fatty liver. High total leucocyte count and Fibrosis-4 (FIB-4) index were independently associated with mortality.ConclusionsFatty liver may not be associated with increased mortality or clinical morbidity in patients who have COVID-19 pneumonia.

Low dose Lung-CT as COVID-19 diagnostic tool while waiting for RT-PCR result

Reverse transcription‐polymerase chain reaction (RT‐PCR) assay as the standard of COVID19 diagnosis takes time, can only be done in limited laboratories, and sometimes produced false negative result; which made diagnosis and intervention become delayed. Meanwhile, chest CT takes little time and has high sensitivity in diagnosing COVID19. This study aimed to see the correlation of Chest CT with RT-PCR results in COVID19 patients. We performed a retrospective cohort study from symptomatic patients at Pantai Indah Kapuk Hospital in Jakarta, Indonesia. Multi-detector scanner CT was done, RT-PCR samples were taken and sent to the government appointed laboratory. Main outcome measures include correlation of CT patterns and CT severity index with RT-PCR. Data were processed with SPSS ver. 25.0 using gamma coefficient measure of agreement. Seventy-three patients were included and underwent chest CT and compared the result with RT-PCR. This study showed the very strong correlation (Gamma +0.897, p-value &lt;0.05, CI 95%) between CT pattern with RT-PCR and no correlation (Gamma +0.241, p-value = 0.379, CI 95%) between CT severity index with RT-PCR. Chest CT has proven its superiority to be used as one of the most capable diagnostic devices for COVID19 patients.

Contemporary Intervention in Necrotizing Pancreatitis: Improved Understanding Changing Practice

BackgroundTreatment of necrotizing pancreatitis (NP) has shifted in favor of a minimally invasive step-up approach rather than early open pancreatic debridement. We hypothesized that this paradigm shift would be reflected in the intervention, morbidity, and mortality profile of NP patients. Study DesignSingle-institution retrospective review of 767 NP patients treated between 2005 and 2019. Two eras of NP intervention were identified relative to the introduction of a minimally invasive approach to NP. Patients treated between 2005 and 2010 were classified as the “early” group and compared with patients treated between 2011 and 2019, classified as the “late” group. ResultsIn total, 299 NP patients comprised the early group and 468 patients comprised the late group. No differences were seen in patient demographics, comorbidity profile, or NP etiology between groups. Necrosis volume, necrosis location, CT severity index (CTSI), and rates of infected necrosis were similar between groups. No difference was seen in mortality. Mechanical intervention for NP was more common in the early than the late group (86% vs. 73%, p < 0.001). Time to first intervention was similar between groups (79 ± 7d vs. 75 ± 6d). The early group had higher rates of open pancreatic debridement (72% vs. 55%, p < 0.001). Endoscopic intervention was less common in the early than the late group (7% vs. 16%, p < 0.001). NP disease duration was longer in the early than the late group (223 ± 12d vs. 179 ± 7d, p = 0.001). ConclusionContemporary management of necrotizing pancreatitis is marked by less frequent operative debridement and shorter disease duration.

The predictive value of procalcitonin combined with C-reactive protein and D dimer in moderately severe and severe acute pancreatitis.

ObjectiveThe objective of this study is to investigate the predictive value of a parametric model constructed by using procalcitonin, C-reactive protein (CRP) and D dimer within 48 h after admission in moderately severe and severe acute pancreatitis.MethodsA total of 238 patients were enrolled, of which 170 patients were moderately severe and severe acute pancreatitis (MSAP+SAP). The concentrations of procalcitonin, CRP and D dimer within 48 h after admission were obtained. The predictive value of the parametric model, modified computed tomography severity index (MCTSI), bedside index for severity in acute pancreatitis (BISAP), Ranson score, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, modified Marshall score and systemic inflammatory response syndrome (SIRS) score of all patients was calculated and compared.ResultsThe area under receiver operator characteristic curve, sensitivity, specificity, Youden index and critical value of the parametric model for predicting MSAP+SAP were 0.853 (95% CI, 0.804–0.903), 84.71%, 70.59%, 55.30% and 0.2833, respectively. The sensitivity of the parametric model was higher than that of MCTSI (84.00%), Ranson score (73.53%), BISAP (56.47%), APACHE II score (27.65%), modified Marshall score (17.06%) and SIRS score (78.24%); the specificity of it were higher than that of MCTSI (52.94%) and Ranson score (67.65%), but lower than BISAP (73.53%), APACHE II score (76.47%), modified Marshall score (100%)and SIRS score (100.00%).ConclusionThe parametric model constructed by using procalcitonin 48 h, CRP 48 h and D dimer 48 h can be regarded as an evaluation model for predicting moderately severe and severe acute pancreatitis.

Establishment of Early Multi-Indicator Prediction Models of Moderately Severe Acute Pancreatitis and Severe Acute Pancreatitis

Background It is critical to accurately identify patients with severe acute pancreatitis (SAP) and moderately SAP (MSAP) in a timely manner. The study was done to establish two early multi-indicator prediction models of MSAP and SAP. Methods Clinical data of 469 patients with acute pancreatitis (AP) between 2015 and 2020, at the First Affiliated Hospital of Fujian Medical University, and between 2012 and 2020, at the Affiliated Union Hospital of Fujian Medical University, were retrospectively analyzed. The unweighted predictive score (unwScore) and weighted predictive score (wScore) for MSAP and SAP were derived using logistic regression analysis and were compared with four existing systems using receiver operating characteristic curves. Results Seven prognostic indicators were selected for incorporation into models, including white blood cell count, lactate dehydrogenase, C-reactive protein, triglyceride, D-dimer, serum potassium, and serum calcium. The cut-offs of the unwScore and wScore for predicting severity were set as 3 points and 0.513 points, respectively. The unwScore (AUC = 0.854) and wScore (AUC = 0.837) were superior to the acute physiology and chronic health evaluation II score (AUC = 0.526), the bedside index for severity in AP score (AUC = 0.766), and the Ranson score (AUC = 0.693) in predicting MSAP and SAP, which were equivalent to the modified computed tomography severity index score (AUC = 0.823). Conclusions The unwScore and wScore have good predictive value for MSAP and SAP, which could provide a valuable clinical reference for management and treatment.

Biochemical and Radiological Parameters in Acute Pancreatitis among Patients from a Rural Community of South India

Background and Purpose: Acute pancreatitis is one of the major causes of acute abdominal pain that requires hospital admission worldwide. Our objective was to find the proportion of acute pancreatitis in acute abdomen cases among the rural population and to assess pancreatic enzymes (lipase and amylase) for the severity of acute pancreatitis. By doing so, we can establish the importance of a single enzymatic marker in acute pancreatitis. Methods: A retrospective and observational study was undertaken on men and women of all age groups admitted over 1 year with acute pancreatitis at a rural tertiary care hospital located at the tristate junction of South India. Pancreatic enzymes (lipase and amylase) were compared based on the grading and severity of pancreatitis according to the modified computed tomography severity index. Results: The proportion of acute pancreatitis was 40% among all acute abdomen cases. Most patients with acute pancreatitis were chronic alcoholic men (62.5%). The common finding in abdominal ultrasonography (USG) was the enlargement of the pancreas (97.5%). There was an overall rise in serum lipase levels in all acute pancreatitis patients, especially in alcoholic patients. The median lipase levels were higher in severe acute pancreatitis than in moderate acute pancreatitis, with P = 0.006. In comparison, there was no significant difference in amylase values between them. Conclusions: In this study, we could conclude that acute pancreatitis is one of the major emergency conditions in this region of rural India, especially among men who are chronic alcoholics. The enlargement of the pancreas was the most frequent finding in USG among these patients. We suggest that a single pancreatic marker (serum lipase) in acute pancreatitis can be cost-effective. Moreover, serum lipase can also be a marker for assessing the severity of acute pancreatitis.

HIGH RESOLUTION COMPUTED TOMOGRAPHY CHEST FINDINGS DURING ADMISSION AND FOLLOW-UP IN SEVERE COVID-19 INFECTION

Background: The full extent of pulmonary damage and long-term prognosis due to severe COVID-19 pneumonia is still unclear. This study was aimed to characterize and compare changes in the radiological pattern of HRCT chest in severe COVID-19 pneumonia patients from admission to that of follow-up. Methods: This was a one-year prospective study done at Chitwan Medical College from April 2020 to April 2021. Total 56 patients with severe COVID-19 pneumonia who had at least one HRCT chest during admission and another during follow-up within 5 weeks. Based on the total number of days on systemic steroids, patients were separated into three follow-up groups. Statistical Package for Social Science version 20 was used for data input and descriptive analysis. Point estimate at 95% Confidence interval was calculated along with frequency and descriptive statistics. Results: The median CT severity index scores of follow-up HRCT chest improved from 14.5 to 10.0 in the 3rd week and from 16.0 to 11.5 in the 5th week. Ground Glass Opacity resolved early and steadily. The prevalence of bronchiectasis and fibrosis was considerable, with no meaningful improvement up to 5th week. Conclusions: Significant radiological improvement can be seen as early as 3rd week from recovery phase of severe COVID-19 pneumonia where systemic steroids have a key contributory role. High frequency of bronchiectasis and fibrosis from in-patient HRCT chest may be due to acute COVID-19 pneumonia lesions on the preexisting undiagnosed lung diseases which may be falsely ascribed to the post-COVID.