Persistent Systemic Inflammatory Response Syndrome Research Articles

Hypocoagulability in Children With Decompensated Chronic Liver Disease and Sepsis: Assessment by Thromboelastography.

To evaluate the coagulation status of children with decompensated chronic liver disease (DCLD) and infection and factors affecting it using thromboelastography (TEG). Coagulation status of children admitted with DCLD and infection was assessed by international normalized ratio (INR), platelet count, and TEG [reaction time (R), kinetic time (K), α-angle (AA), maximum amplitude (MA), coagulation index (CI), and lysis index (LY30)] at admission and at 7-14 days after treatment. CI < -3 represents hypocoagulable state. Clinical profile including systemic inflammatory response syndrome (SIRS), infection severity, bleeding, treatment response, and outcome were noted. Thirty children (21 boys, median (IQR) age 78 [15.7-180] months) were studied prospectively. At admission, 29 (96.7%) had prolonged INR, 24 (80%) had thrombocytopenia, and 17 (56.6%) were hypocoagulable by TEG. Nine of 30 (30%) had normal TEG but deranged INR and platelets. Nineteen (63.3%) cases had SIRS, 11 (36.6%) had severe sepsis, and 8 (26.6%) had bleeding. Hypocoagulable state was common in severe sepsis than sepsis/infection (81.1% versus 42.1%; P = 0.05) and persistent (n = 4) versus recovered SIRS (n = 15, 100% versus 33%; P = 0.03). Bleeders had prolonged R-time (7.8 versus 5.4 min; P = 0.03), smaller MA (30.2 versus 47 mm; P = 0.05), and α-angle (40.4 versus 62.9; P = 0.03) but similar INR and platelets than nonbleeders. Six patients (20%) had poor in-hospital outcomes; R-time ≥8.5 min predicted mortality with high sensitivity (83%) and specificity (100%). Fifth-seven percent of children with DCLD and infection were hypocoagulable by TEG. Severe sepsis and persistent SIRS worsened the coagulation status. TEG identifies bleeders better than INR and platelet count. R-time ≥8.5 min predicts a poor hospital outcome.

CT Characteristics of Acute Pancreatitis with Preexisting Fatty Liver and Its Impact on Pancreatitis Severity and Persistent Systemic Inflammatory Response Syndrome.

PurposeTo study the CT characteristics of acute pancreatitis (AP) associated with preexisting fatty liver (FL) and the impact of preexisting FL on the severity of AP and persistent systemic inflammatory response syndrome (SIRS).Patients and MethodsA total of 189 patients with AP were divided into AP with and without preexisting FL. The CT features, clinical characteristics, severity of AP, and presence of persistent SIRS between the two groups were compared. Univariate and multivariate analyses were performed to determine the risk factors for predicting SIRS. The diagnostic performances of the risk factors were evaluated by receiver operating characteristic (ROC) curve analysis.ResultsAmong the 189 patients, 49.7% (94/189) had preexisting FL. On CT, AP patients with preexisting FL were more likely to develop necrosis (23.4% vs 10.5%, p=0.021), local complications (45.7% vs 29.5%, p=0.025) and persistent SIRS (59.6% vs 27.4%, p<0.001). Multivariate analysis showed that preexisting FL (OR=2.863, 95% CI: 1.264–6.486, p=0.012), APACHE II≥6 (OR=1.334, 95% CI: 1.117–1.594, p=0.002), and MCTSI ≥4 (OR=1.489, 95% CI: 1.046–2.119, p=0.027) could be independent risk factors for persistent SIRS. The areas under the ROC curve of preexisting FL, APACHE II, and MCISI in diagnosing AP patients with persistent SIRS were 0.664, 0.703, and 0.783, respectively.ConclusionPatients with preexisting FL were more likely to develop necrosis and local complications on CT and present more severe AP and persistent SIRS. Preexisting FL can be an independent risk factor in predicting the presence of persistent SIRS in patients with AP.

Development of a Score for Predicting Severe Acute Pancreatitis at Admission.

The identification of patients at risk of developing a severe form of acute pancreatitis is a major issue. The goal of this study was to identify parameters at admission associated with severe pancreatitis to develop a predictive severity score. We conducted a retrospective study at Caen University Hospital between January 2014 and December 2017, including 504 patients hospitalized for acute pancreatitis, of whom 74 had a severe form. We developed a predictive score named Admission Severe Acute Pancreatitis (ASAP) score based on parameters associated with a severe form in multivariate analysis. We validated our score in an independent validation cohort of 80 patients. Hypothermia, low oxygen saturation or albumin levels, and high creatinine levels were significantly associated with severe pancreatitis. The ASAP score showed notable predictive accuracy (area under receiver operating characteristic, 0.82), which was significantly higher than Sequential Organ Failure Assessment, persistent Systemic Inflammatory Response Syndrome, and Balthazar. Using the -2.1742 threshold, the ASAP score had a sensitivity and specificity of 74% and a negative predictive value of 95%. These predictive performances for ASAP score were confirmed in the validation cohort. The ASAP score demonstrates remarkable predictive accuracy in distinguishing severe forms of acute pancreatitis.

51-Year-Old Man With Ascites and Abdominal Pain

51-Year-Old Man With Ascites and Abdominal Pain

Mortality in acute pancreatitis with persistent organ failure is determined by the number, type, and sequence of organ systems affected

BackgroundPersistent organ failure (POF) is the strongest determinant of mortality in acute pancreatitis (AP). There is a paucity of data regarding the impact of different POF attributes on mortality and the role of different characteristics of systemic inflammatory response syndrome (SIRS) in the risk of developing POF.ObjectiveWe aimed to assess the association of POF dynamic features with mortality and SIRS characteristics with POF.MethodsWe studied 1544 AP subjects prospectively enrolled at 22 international centers (APPRENTICE consortium). First, we estimated the association of onset, duration, and maximal score of SIRS with POF. Then, we evaluated the risk of mortality based on POF onset, duration, number, type, and sequence of organs affected. Analyses were adjusted for potential confounders.Results58% had SIRS, 11% developed POF, and 2.5% died. Early SIRS, persistent SIRS, and maximal SIRS score ≥ 3 were independently associated with higher risk of POF (p < 0.05). Mortality risk in POF was higher with two (33%, odds ratio [OR] = 10.8, 3.3–34.9) and three (48%, OR = 20.2, 5.9–68.6) organs failing, in comparison to single POF (4%). In subjects with multiple POF, mortality was higher when the cardiovascular and respiratory systems failed first or concurrently as compared to when the renal system failed first or concurrently with other organ (p < 0.05). In multivariate regression model, the number and sequence of organs affected in POF were associated with mortality (p < 0.05). Onset and duration of POF had no impact mortality.ConclusionIn AP patients with POF, the risk of mortality is influenced by the number, type, and sequence of organs affected. These results are useful for future revisions of AP severity classification systems.

Abdominal free fluid in acute pancreatitis predicts necrotizing pancreatitis and organ failure.

BackgroundAbdominal free fluid is frequently encountered on cross-sectional imaging for acute pancreatitis and may be a sign of increased severity and complications. This study examines the ability of free fluid to predict necrotizing pancreatitis and other adverse outcomes.MethodsWe conducted a single-center retrospective study of patients with acute pancreatitis and multiple cross-sectional imaging studies. Patients were divided into those who demonstrated free fluid on initial imaging and those without free fluid. The primary outcome was developing necrotizing pancreatitis. Logistic regression analysis assessed the performance of several predictors.ResultsA total of 245 acute pancreatitis patients were included. Pancreatic necrosis occurred more frequently in the free fluid group (31.3 vs. 1.3%, P<0.001). The free fluid group also had higher rates of transient organ failure (17.7 vs. 3.4%, P<0.001), persistent organ failure (17.7 vs. 2.0%, P<0.001), in-hospital mortality (7.3 vs. 1.3%, P=0.016), length of stay (16.2 vs. 5.5 days, P<0.001), and intensive care unit admission (30.2 vs. 4.7%, P<0.001). On multivariate logistic regression, free fluid was the strongest predictor (adjusted odds ratio 17.11, 95% confidence interval 3.68-79.65; P<0.001) for necrotizing pancreatitis, with an excellent performance (area under the curve 0.92). When neither fluid on initial imaging nor persistent systemic inflammatory response syndrome was present, the negative predictive value for developing pancreatic necrosis was 100%.ConclusionsFree fluid in acute pancreatitis is a strong predictor for necrotizing pancreatitis, organ failure and mortality, and outperformed current predictors. Patients who lacked both free fluid on imaging and persistent systemic inflammatory response syndrome are at low risk for adverse outcomes and may be considered for early discharge.

Immunotherapy for acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is a life-threatening disease with a high risk of multiple organ failure, sepsis, and death. ACLF activates innate and acquired immune responses in human body and thus leads to the progression of persistent systemic inflammatory response syndrome and multiple organ dysfunction, leading to the high mortality rate of this disease. Dysregulated immune response plays a key role in disease progression, and immunotherapy may help to target immune-mediated organ damage and inhibit the progression of liver failure. This article reviews the role and mechanism of drugs and means with a potential immune regulatory effect in ACLF, in order to provide a reference for immunotherapy for ACLF.

Peritoneal cavity circumference on computed tomography predicts outcomes in acute pancreatitis

ObjectivesWe investigated the role of novel intra-abdominal parameters measured by computed tomography (CT) in the prediction of clinical outcomes in acute pancreatitis (AP). MethodsPatients with AP underwent an abdominal CT scan on admission to define different intra-abdominal parameters (abdominal circumference, peritoneal cavity circumference, intraabdominal visceral fat area, and subcutaneous fat area) at the L2-L3 level using the open-source image analysis software Osirix Lite v.11.0.4 to predict clinical outcomes. ResultsEighty patients with AP were analyzed. Peritoneal cavity circumference (PCC) was the only variable independently associated with outcomes. PCC showed an area under ROC for prediction of severity in AP of 0.830. A PCC ≥ 85 cm increased the risk of severity of AP (RR 15.7), persistent systemic inflammatory response syndrome (RR 9.3), acute peripancreatic fluid collection (RR 6.4), necrotizing pancreatitis (RR 21.50), and mortality (RR 2.4). We found a 4.7-fold increase in the risk of developing severe AP for each 10 cm increase in PCC. ConclusionsPCC measurement at the L2-L3 level using a non-enhanced abdominal CT scan on admission in patients with AP is useful in the early prediction of severity, persistent systemic inflammatory response syndrome, local complications, and mortality.

A single center randomized double blind controlled trial of pentoxifylline in acute pancreatitis: Challenges and opportunities

ObjectivesDespite substantial morbidity and mortality associated with acute pancreatitis (AP), only one small randomized controlled drug trial (RCT) is available in the past few decades from the United States. Hence, we conducted a single-center, double-blind, placebo-controlled RCT of pentoxifylline in AP. MethodsA total of 9 doses of oral pentoxifylline 400 mg or placebo tablet, three times daily, was administered within 72 h of diagnosis, using randomization blocks by pharmacy. Primary outcome was a composite outcome including any of the following: death, peripancreatic and/or pancreatic necrosis, infected pancreatic necrosis, persistent organ failure, persistent systemic inflammatory response syndrome, hospital stay longer than 4 days, need for intensive care, and need for intervention for necrosis. ResultsBetween July 7, 2015, and April 4, 2017, we identified 685 patients with AP, 233 met eligibility criteria and 176 were approached for the study. Of these, 91 (51.7%) declined and finally 45 in pentoxifylline group and 38 in placebo group (83 total) were compared. There were no significant differences in primary outcome (27 [60.0%] vs 15 [39.5%]; P = .06). Pentoxifylline group was not associated with any benefit, but withlonger stay (42% vs. 21%; P = .04) and higher readmission rates (16 %vs 3%; P = .047). ConclusionsWe could not demonstrate superiority of pentoxifylline over placebo. Smaller sample size and inclusion of all types of severity might be the reasons for lack of efficacy. The challenges observed in the present study indicate that, in order to conduct a successful drug trial in AP, a multi center collaboration is essential.

A FATAL CASE OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS DUE TO EXTRA-PULMONARY SARCOIDOSIS

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening condition of overwhelming systemic inflammation. It can lead to multi-organ failure and circulatory shock with high reported intensive care unit mortality rate of 50-80%. Sarcoidosis association with HLH is very rare, as only eight previous cases have been reported in literature so far. In our case report, we present a fatal case of HLH associated with non-pulmonary sarcoidosis to raise awareness of the diagnosis and facilitate earlier treatment. CASE PRESENTATION: The patient was a 48-year-old male newly diagnosed with sarcoidosis who was transferred to our intensive care unit with persistent fever and chest pain. Two months prior to his presentation, imaging of his abdomen showed a large mesenteric mass, large splenic masses, and heterogeneous liver parenchyma. Biopsies showed non- necrotizing granulomatous inflammation. The patient was diagnosed with sarcoidosis and started on oral steroids. On presentation, he was febrile, tachycardic and hypotensive. His blood work was significant for pancytopenia, elevated liver function, low fibrinogen and high serum ferritin. He was fluid resuscitated and empirically treated with broad spectrum antibiotics for presumed severe sepsis. An extensive infectious work up was negative. A bone marrow biopsy exhibited a hypo-cellular bone marrow with histiocytic hemophagocytosis. Patient was started on dexamethasone, intravenous immunoglobulin and etoposide as part of the HLH treatment protocol. His medical condition deteriorated, as he developed a shock state unresponsive to maximum vasopressors. Patient expired soon after. DISCUSSION: HLH results from uncontrolled activation of histiocytes, natural killer cells and cytotoxic T-cells which lead to persistent systemic inflammatory response syndrome. The HLH -2004 protocol defines the diagnostic criteria as fever, splenomegaly, cytopenia, hypertriglyceridemia and/or hypofibrinogenemia, low NK -cell activity, hyperferritinemia, elevated serum soluble interleukin 2 receptor and hemophagocytosis in tissue biopsy. The presentation of HLH in the intensive care unit is very similar to sepsis, however the development of cytopenia in the setting of severe sepsis and multi-organ failure should raise the suspicion of HLH. Infections and malignancies are the most common triggers of HLH. Some autoimmune diseases such as systemic lupus erythematous are also complicated by HLH. Association with sarcoidosis, however, is extremely rare. Out of the eight cases of HLH associated with sarcoidosis, four were triggered by an infectious cause. In our patient no infectious trigger was identified CONCLUSIONS: It is imperative to diagnose and differentiate HLH from sepsis in the ICU in a timely manner. Early recognition and prompt treatment of this disorder is needed to prevent fatal outcomes. Reference #1: Henter JI, Horne A, Aricó M, et al. HLH-2004: Diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer. 2007. https://doi.org/10.1002/pbc.21039 Reference #2: Kapoor S, Morgan CK, Siddique MA, Kalpalatha K Guntupalli. Intensive care unit complications and outcomes of adult patients with hemophagocytic lymphohistiocytosis: A retrospective study of 16 cases. World J Crit Care Med. 2018;7(6):73-83. Reference #3: Filipovich AH. Hemophagocytic Lymphohistiocytosis and Other Hemophagocytic Disorders. Immunol Allergy Clin North Am. 2008. https://doi.org/10.1016/j.iac.2008.01.010 DISCLOSURES: No relevant relationships by Hassan Nasser, source=Web Response No relevant relationships by Daniel Ouellette, source=Web Response No relevant relationships by Dania Shakaroun, source=Web Response

Predictive value of immature granulocytes for persistent systemic inflammatory response syndrome in patients with acute pancreatitis: analysis of 1 973 cases

To analyze the clinical value of immature granulocytes in peripheral blood for prediction of persistent systemic inflammatory response syndrome (SIRS) in patients with acute pancreatitis (AP). 1 973 patients with AP in Hunan People's Hospital from 2012 to 2017 were retrospectively enrolled and divided by SIRS duration into the persistent SIRS group, temporary SIRS group and non-SIRS group. The independent risk factor for persistent SIRS in AP patients was evaluated by Logistic regression analysis, and predictive value of immature granulocytes for persistent SIRS in AP patients was analyzed by the receiver operating characteristic (ROC) curve. These 1 973 AP patients (1 165 males, 59.0%) with an average age of 49 (40, 60) years old, including 288 persistent SIRS, 189 temporary SIRS and 1 496 non-SIRS cases. There was no significant difference in gender, age and etiology among three groups. Compared with non-SIRS group, more severe symptoms were observed in the temporary and persistent SIRS groups. Moreover, The acute physiology and chronic health evaluation II (APACHE II), CT severity index (CTSI), multiple organ failure (MOF) and acute respiratory distress syndrome (ARDS) incidence, mortality and C-reactive protein (CRP), white blood cell count (WBC), procalcitonin (PCT) and immature granulocytes in persistent SIRS group were further higher than those in the temporary SIRS group [APACHE II: 9 (6, 12) vs. 5 (3, 7), CTSI: 6 (4, 6) vs. 4 (3, 6), MOF incidence: 92.0% vs. 32.8%, ARDS incidence: 39.9% vs. 10.1%, morbidity: 11.1% vs. 4.2%, CRP (mg/L): 25.00 (0.80, 212.25) vs. 0.80 (0.80, 123.50), WBC (×109/L): 15.17±6.78 vs. 14.84±5.86, PCT (g/L): 0.23 (0.10, 1.76) vs. 0.10 (0.10, 0.31), immature granulocytes: 1.95 (0.90, 4.95) % vs. 0.80 (0.40, 2.10) %, all P < 0.05]. Logistic regression analysis showed that besides pancreatic necrosis, WBC and CRP, immature granulocyte was an independent risk factor for persistent SIRS associated with AP [odds ratio (OR) = 1.844, 95% confidence interval (95%CI) = 1.372-2.220]. ROC curve showed that immature granulocytes had better predictive value for persistent SIRS, the area under the curve (AUC) was 0.806, which was significantly higher than the APACHE II (AUC = 0.783), CTSI (AUC = 0.752), PCT (AUC = 0.676), CRP (AUC = 0.677), WBC (AUC = 0.644). The cut-off value of immature granulocyte was 0.65%, the sensitivity was 84.0%, the specificity was 66.3%, the positive predictive value was 62.4%, and the negative predictive value was 76.3%. Immature granulocyte in peripheral blood is a potential indicator for persistent SIRS in AP patients.

Ringer’s Lactate vs Normal Saline in Acute Pancreatitis: A Systematic Review and Meta-Analysis

Introduction: Acute Pancreatitis (AP) is one of the most common causes of hospitalization in the United States. Aggressive intravenous hydration with crystalloids is the first step in management, and is associated with improved survival. Guidelines are unclear regarding the choice of crystalloids. Normal saline (NS) is the most commonly used, but recent studies have shown that use of Ringer’s lactate (RL) may improve mortality rates and decrease development of systemic inflammatory response syndrome (SIRS), which is one of the markers of poor outcomes, compared to NS. Methods: A comprehensive literature review was conducted by searching the Embase, MEDLINE, PubMed, and Google Scholar databases through December 2017 to identify all studies that compared the use of NS with RL for the management of AP. Primary endpoint was to evaluate difference in mortality and secondary end point was to evaluate development of SIRS in 24 hours among two groups. Results: Five studies, three randomized controlled trials (RCTs) and two retrospective cohort studies, including 428 patients, were included in this analysis. Only 3 studies, including 127 patients, reported secondary outcome of SIRS at 24 hours. Mortality trended lower in the RL group, but was not statistically significant (pooled odds ratio 0.61 (0.28-1.29; P=0.20)). Patients in the RL group had significantly decreased odds of developing SIRS at 24 hours (pooled odds ratio 0.38 (0.15-0.98; P=0.05)). Heterogeneity among studies was low as seen by the I2 of 46% for the mortality outcome. Conclusion: In this systematic review, we demonstrated that RL is associated with decreased odds of persistent SIRS at 24 hours. This anti-inflammatory effect of RL has two possible explanations. First, RL has a slightly higher pH compared to NS. Studies show that acidosis enhances inflammation and necrosis in AP. Lactate in RL is metabolized in the liver, which results in lower metabolic acidosis and hence protective effects.Second, RL may directly decrease inflammatory response in these patients. The presence of RL in-vitro prevents activation of NF-KB, the transcription factor involved in the inflammatory process. Mortality also trended lower in RL patients, but was not statistically significant. Larger RCTs are necessary to further strengthen the association of RL with favorable outcomes in patients with AP, however, our findings may help clinicians in making decisions regarding the choice of fluid for management of AP.2_A Figure 1. Forest Plot of all studies for mortality2_B Figure 2. Forest Plot of all studies for SIRS at 24 hours2_C Figure 3. Literature review process

Interleukin-6 significantly improves predictive value of systemic inflammatory response syndrome for predicting severe acute pancreatitis

BackgroundPredicting severe acute pancreatitis (AP) is important for triage, prognosis, and designing therapeutic trials. Persistent systemic inflammatory response syndrome (SIRS) predicts severe AP but its diagnostic accuracy is suboptimal. Our objective was to study if cytokine levels could improve the predictive value of clinical variables for the development of severe AP. MethodsConsecutive patients with AP were included in a prospective cohort study at a tertiary care center. Serum levels of IL-6, TNF-α, IL-10, MCP-1, GM-CSF and IL-1β were measured at day 3 of onset of AP. Variables such as age, co-morbidity, etiology, SIRS, and cytokines were modeled to predict severe AP by multivariable regression analysis. Genotyping was done to correlate IL-6, TNF-α and MCP-1 gene polymorphisms with cytokine levels. ResultsOf 236 patients with AP, 115 patients admitted within 7 days of onset formed the study group. 37 of the 115 (32%) patients developed organ failure. Independent predictors of organ failure were persistent SIRS (OR 34; 95% CI: 7.2–159) and day 3 serum IL-6 of >160 pg/ml (OR 16.1; 95% CI:1.8–142). IL-6 gene (−174 G/C) GG genotype was associated with significantly higher levels of IL-6 compared to CC/CG genotype. Serum IL-6 >160 pg/ml increased the positive predictive value of persistent SIRS from 56% to 85% and specificity from 64% to 95% for predicting OF without compromising its sensitivity and negative predictive value. ConclusionSerum IL-6 of >160 ng/ml added significantly to the predictive value of SIRS for severe AP.

Association Between Splenic Contraction and the Systemic Inflammatory Response After Acute Ischemic Stroke Varies with Age and Race.

Animal models have demonstrated the deleterious contribution of splenic immunocytes on secondary brain injury after stroke. While previous work has demonstrated splenic contraction (SC) in patients with acute ischemic stroke (AIS) and intracranial hemorrhage (ICH), no clinical studies have examined the relationship between the systemic inflammatory response syndrome (SIRS) with SC in stroke patients. This is a retrospective analysis of a previous prospective observational study where daily spleen sizes were evaluated in 178 acute stroke patients. Spleen contraction was based on previously established normograms of healthy volunteers from the same study. SC from the first 24h of stroke onset was evaluated against criteria for SIRS for the first 5days of admission after AIS. Ninety-one patients had verified AIS without concurrent infection at admission. SIRS was not associated with SC at admission. African-American patients with early SIRS had higher odds of having SC. Older patients with persistent SIRS at 72h had lower odds of SC. At 48h, there was significantly higher lymphocytosis and lower neutrophils present in patients with SC. Patients with SIRS at 72h were more likely to have worse discharge mRS. This study provides evidence for an association among SC and SIRS in African-American patients suggesting that spleen changes could be a biomarker for detecting SIRS in this population. Our data also indicate a counter association between SC and a lack of SIRS in patients older than 75. Further studies are needed to ascertain how age affects this association.

Is There a Weather Seasonal Effect on Acute Pancreatitis Etiology and Outcomes?

Introduction: Approximately 20% of Acute pancreatitis (AP) cases are deemed to be idiopathic. Gallstone disease has been reported to have increased incidence during summer and this could be due to variations in temperature during these months. The aim of this study was to identify the prevalence of different AP etiologies during the weather seasons and to investigate the association between temperature variation, seasonal effect and the onset of acute pancreatitis, its severity and outcomes. Methods: We performed a retrospective cohort study of consecutive patients admitted with a very first episode of acute pancreatitis at a large public hospital in Chicago between 01/2013 and 12/2014. We identified acute pancreatitis diagnosis by ICD9 code and/or lipase ≥ 3 times the normal upper limit. Two physicians reviewed each case to include only first episodes of acute pancreatitis. We excluded patients who were transferred to our center. We included a detailed weather season history and temperature in Celsius degree on the day of admission for each AP case from the publically available website: weather. com. We constructed multivariable logistic regression models. Results: We analyzed 460 patients. Mean age was 48 years (range 17 to 89 years), 54% were males. In Univariate and Multivariate analysis, having an AP episode during winter was found to be protective against Acute Kidney Injury (AKI) (aOR: 0.4, P<0.005, CI 0.2-0.9). After adjusting for admission SIRS, age and gender; Weather seasons were found to impact AP etiology nor be independent risk factors for Persistent Systemic Inflammatory Response Syndrome (SIRS), AKI, ARDS, pancreatic necrosis, mortality, ICU, Length of Stay (LOS), in-hospital infections, BISAP score, nor recurrent AP. In addition, the mean temperature (T) of Chicago (15°C) was compare to lower temperatures as well as higher temperature variations; Higher temperatures than the average Chicago T was found to be protective against Persistent SIRS at 48h (aOR 0.6, P<0.05, CI 0.3-0.9). No other significant impact on these temperatures variations was found. Conclusion: Weather Seasonal effect was not found to impact the etiology of acute pancreatitis. All etiologies were equally distributed among all seasons. However, AKI during winter was found to have a significantly lower incidence and Persistent SIRS had lower incidence during higher or warmer temperatures. This is the largest study to date to examining weather seasonal effect in AP.

Stratified analysis and clinical significance of elevated serum triglyceride levels in early acute pancreatitis: a retrospective study

BackgroundHypertriglyceridemia is one of the three most common causes of AP, which is associated with the AP prognosis that has not been clearly defined.MethodsIn this retrospective study, 1539 AP patients, who had serum triglyceride (TG) levels measured within the first 72 h, were assessed. The study groups consisted of patients with normal, mild, moderate, and severe/very severe HTG levels based on the Endocrine Society Clinical Practice Guidelines. We collected baseline demographic information, laboratory values, complications, and clinical outcome data in different HTG severity groups to analyze the clinical significance of elevated TG levels in AP.ResultsOur study included 1539 AP patients; of these, 1078 (70%) had a normal TG levels, and 461 (30%) had elevated TG levels. The rates of severe AP increased in HTG groups of increasing severity (4% vs. 8% vs. 12%; Ptrend < 0.001). acute necrotic collection (ANC) and pancreatic necrosis developed in 32 and 39 of 112 patients (29% and 35%) (Ptrend = 0.001; Ptrend = 0.001) in the severe/very severe HTG group, respectively. The proportion of persistent organ failure (POF), multiple organ failure (MOF), and persistent Systemic Inflammatory Response Syndrome (SIRS) increased with higher grades of HTG (Ptrend < 0.001; Ptrend < 0.001; Ptrend < 0.001). The ICU admission rate was higher in the severe/very severe HTG group (57/112 patients; 51%; Ptrend < 0.001). A logistic multivariate regression analysis showed a positive correlation between HTG and certain AP complications.ConclusionIn addition to other factors, an elevated TG level could be associated with the severity and prognosis of AP, including pancreatic necrosis, POF, MOF, persistent SIRS, ICU admission, and mortality.

Mesenchymal stromal cell treatment prevents H9N2 avian influenza virus-induced acute lung injury in mice.

BackgroundThe avian influenza virus (AIV) can cross species barriers and expand its host range from birds to mammals, even humans. Avian influenza is characterized by pronounced activation of the proinflammatory cytokine cascade, which perpetuates the inflammatory response, leading to persistent systemic inflammatory response syndrome and pulmonary infection in animals and humans. There are currently no specific treatment strategies for avian influenza.MethodsWe hypothesized that mesenchymal stromal cells (MSCs) would have beneficial effects in the treatment of H9N2 AIV-induced acute lung injury in mice. Six- to 8-week-old C57BL/6 mice were infected intranasally with 1 × 104 MID50 of A/HONG KONG/2108/2003 [H9N2 (HK)] H9N2 virus to induce acute lung injury. After 30 min, syngeneic MSCs were delivered through the caudal vein. Three days after infection, we measured the survival rate, lung weight, arterial blood gas, and cytokines in both bronchoalveolar lavage fluid (BALF) and serum, and assessed pathological changes to the lungs.ResultsMSC administration significantly palliated H9N2 AIV-induced pulmonary inflammation by reducing chemokines and proinflammatory cytokines levels, as well as reducing inflammatory cell recruit into the lungs. Thus, H9N2 AIV-induced lung injury was markedly alleviated in mice treated with MSCs. Lung histopathology and arterial blood gas analysis were improved in mice with H9N2 AIV-induced lung injury following MSC treatment.ConclusionsMSC treatment significantly reduces H9N2 AIV-induced acute lung injury in mice and is associated with reduced pulmonary inflammation. These results indicate a potential role for MSC therapy in the treatment of clinical avian influenza.

Early Predictors of Fluid Sequestration in Acute Pancreatitis: A Validation Study.

The primary aim of this retrospective study was to externally validate predictors of increased fluid sequestration at 48 hours (FS⁴⁸) in acute pancreatitis (AP). Patients admitted between January 10 and February 13 with a diagnosis of AP were evaluated. The FS⁴⁸ was calculated as difference between total fluid input and output in the first 48 hours. Predictors of FS⁴⁸, such as young age, alcoholic etiology, hemoconcentration, hyperglycemia, and systemic inflammatory response syndrome (SIRS), and outcomes in AP, such as increased length of stay, acute fluid collection(s), necrosis, and persistent organ failure (POF), were defined in accordance with the previous study. Linear regression analysis was performed to evaluate the association between predictors and outcome. Two hundred twenty-seven AP patients (mean age, 48 years; 54% men) with a median FS⁴⁸ of 4.2 L were evaluated. Age younger than 40 years, alcoholic etiology, hemoconcentration, and SIRS independently predicted increased FS⁴⁸ (P < 0.05). Increased FS⁴⁸ was associated with persistent SIRS and POF (P < 0.01). There was a significant trend between number of predictors and FS (P < 0.001). The presence of 4 predictors or more was associated with higher rates of persistent SIRS and POF (P < 0.01). Our study validated 4 of 5 predictors of increased FS⁴⁸ from the previous study. Presence of 4 predictors or more and increased FS⁴⁸ are both associated with persistent SIRS and POF.

Clinical outcomes of combined necrotizing pancreatitis versus extrapancreatic necrosis alone.

Extrapancreatic necrosis (EPN) alone, i.e., in the absence of pancreatic parenchyma necrosis has gradually come to be regarded as a separate entity of acute necrotizing pancreatitis (ANP). However, data regarding the prognostic significance of EPN are quite limited, and the outcomes of interventions for patients with EPN alone are not well elucidated. The aim of this study was to explore the differences in the outcomes of patients with EPN alone and patients with both the pancreatic parenchyma and extrapancreatic necrosis (combined necrosis). From January 2009 to December 2013, a total of 334 patients with ANP who had received interventions in the West China Hospital in China were included. Based on the extent of necrosis as assessed with contrast-enhanced CT, the patients were divided into Group 1 (n = 285) in which the necrosis involved both the pancreatic parenchyma and extrapancreatic tissues (combined necrosis) and Group 2 (n = 49) in which the necrosis involved only the extrapancreatic tissues. Additionally, Group 3 included 443 patients with interstitial pancreatitis who were also included in the analyses. The demographic characteristics, support treatment information, organ failure information, infection necrosis, persistent systemic inflammatory response syndrome (SIRS) in the first week of onset, CT severity index, and intervention types, as well as the postoperative stay lengths, ICU utility, and complications were collected and compared. Compared with the patients in Group 1, the patients in Group 2 suffered less persistent SIRS in the first week of onset (12/24.5% vs. 145/50.9%; P < 0.05), less persistent organ failure (6/12.2% vs. 95/33.3%; P < 0.05), less persistent multiple organ failure (3/6.1% vs. 67/23.5%; P < 0.05), and less bacteremia (5/10.2% vs. 107/37.5%; P < 0.001). The intervention types were significantly different between the two groups (P < 0.001); initial open necrosectomy was performed in 174/61.6% and 8/16.3% of the patients in Groups 1 and 2, respectively, and initial percutaneous catheter drainage (PCD) was performed in 73/25.6% and 29/59.2% of the patients in the two respective groups. Second open necrosectomies following PCD were required in 61/83.5% and 9/31.0% of the patients in Groups 1 and 2, respectively (P < 0.001). A greater number of patients in Group 1 were diagnosed with infected necrosis (204/71.6% vs. 10/20.4%; P < 0.001) and had to be sent to the ICU for further postoperative care (221/77.5% vs. 23/46.9%; P < 0.001). The postoperative stay was longer for Group 1 (median: 43.0 vs. 26.5 days; P < 0.001). Residual necrotic tissue or abscess was the most common postoperative complication in both groups. The mortality was higher in Group 1 (52/18.2% vs. 1/2.1%; P < 0.05). Compared with the patients in Group 2, the patients with interstitial pancreatitis exhibited milder courses and better outcomes. Subgroup comparisons with Group 1 indicated that early multiple organ failure was significantly associated with higher mortality. The patients with EPN alone exhibited significantly better prognoses than those with combined necrosis, and EPN alone should be regarded as a separate group of acute necrotizing pancreatitis. Open necrosectomy can be avoided in the majority of patients with EPN alone, who receive PCD as the initial first intervention.

Hypertriglyceridemia-Induced Pancreatitis and Risk of Persistent Systemic Inflammatory Response Syndrome

BackgroundThe mechanisms responsible for the development of acute pancreatitis (AP) and its complications are not fully understood. AimTo assess the role of clinical and host molecular factors for the development and outcome of persistent systemic inflammatory response syndrome (SIRS) in patients with AP. MethodsWe included 191 patients with AP in the study. The considered variables were demographic characteristics, prognosis and outcome, etiology, laboratory findings and complications. Interleukin (IL) 10 (-1082 G/A, -592 C/A), TNFA-308 (G/A) and ILB-31 (C/T) polymorphisms were determined by pyrosequencing. An amplification refractory mutation system-polymerase chain reaction method was used to genotype the IL8-251 (A/T) polymorphism. ResultsDemographic characteristics were not statistically significant risk factors for the acquisition of persistent SIRS in patients with AP. Patients with hypertriglyceridemia were more likely to develop persistent SIRS (P < 0.05). No association with the TNFA, ILB, IL8-251 (A/T) and IL10 single-nucleotide polymorphisms was detected from the allele, genotype or haplotype frequencies. ConclusionsPatients with hypertriglyceridemia-induced AP were more likely to develop persistent SIRS.