The revised Atlanta criteria 2012 altered the classification,severity assessment and management of acute pancreatitis

BACKGROUND:The Atlanta criteria for acute pancreatitis(AP) has been revised recently.This study was to evaluate its practical value in classification of AP,the severity assessment and management.METHODS:The clinical features,severity classification,outcome and risk factors for mortality of 3212 AP patients who had been admitted in Ruijin Hospital from 2004 to 2011 were analyzed based on the revised Atlanta criteria(RAC) and the original Atlanta criteria(OAC).RESULTS:Compared to the OAC group,the incidence of severe acute pancreatitis(SAP) was decreased by approximately one half(13.9% vs 28.2%) in the RAC group.The RAC presented a lower sensitivity but higher specificity,and its predictive value for severity and poor outcome was higher than those of the OAC.The proportion of SAP diagnosis and ICU admission in the early phase in the RAC group was significantly lower than that in the OAC group(P<0.05).Based on the RAC,the risk factors for death among SAP patients were older age,high CT severity index(CTSI),renal failure,cardiovascular failure,acute necrotic collection and walled-off necrosis.Compared to the OAC,the acute physiology and chronic health evaluation II(APACHE II) score,Ranson score,idiopathic etiology,respiratory failure and laparotomy debridement were not risk factors of death in contrast to walled-off necrosis.Interestingly,hypertriglyceridemia-related SAP had good outcomes in both groups.CONCLUSIONS:The RAC showed a higher predictive value for severity and poorer outcome than the OAC.However,the RAC resulted in fewer ICU admissions in the early phase due to its lower sensitivity for diagnosis of SAP.Among SAP cases,older age,high CTSI,renal and cardiovascular failure,complications of acute necrotic collection and walled-off necrosis were independent risk factors for mortality.

Clinical features and outcomes of patients with severe acute pancreatitis complicated with gangrenous cholecystitis

BACKGROUND: The effects of gangrenous cholecystitis (GC) and consequent surgical interventions on the clinical outcomes and prognosis of patients with severe acute pancreatitis are not clear. The present study was to characterize the clinical outcomes of patients with severe acute pancreatitis complicated with GC. METHODS: We retrospectively analyzed 253 consecutive patients hospitalized for acute pancreatitis in intensive care unit. Among them, 68 were diagnosed as having severe acute pancreatitis; 10 out of the 68 patients had GC. We compared these 10 patients with GC and 58 patients without GC. The indices analyzed included sepsis/septic shock, pancreatic encephalopathy, acute respiratory distress syndrome, acute renal failure, multiple organ dysfunction syndrome, and death. RESULTS: Specific CT images of GC in patients with severe acute pancreatitis included enlarged and high-tensioned gallbladder, wall thickening, lumenal emphysema, discontinuous and/or irregular enhancement of mucosa, and pericholecystic effusion. The rates of severe sepsis/septic shock (70.0% vs 24.1%, P<0.01), pancreatic encephalopathy (50.0% vs 17.2%, P<0.05), acute respiratory distress syndrome (90.0% vs 41.4%, P<0.01), multiple organ dysfunction syndrome (70.0% vs 24.1%, P<0.01), acute renal failure (40.0% vs 27.6%, P<0.05), and death (40.0% vs 13.8%, P<0.05) were significantly higher in patients with GC than in those without GC.CONCLUSION: CT scans can help to identify early GC in patients with severe acute pancreatitis; early diagnosis and intervention for patients with GC can reduce morbidity and mortality.

Effects of fluid balance on prognosis of acute respiratory distress syndrome patients secondary to sepsis

BACKGROUND:Fluid management is crucial to acute respiratory distress syndrome(ARDS)secondary to sepsis.However,choices of fluid resuscitation strategies and fluid input volumes remain a thorny problem.Our study aimed to elucidate the relationship between fluid balance and prognosis of ARDS patients secondary to sepsis.METHODS:Our study included 322 sepsis patients from Ruijin Hospital between 2014 and 2018,and 84 patients were diagnosed as ARDS within 72 hours after onset of sepsis according to Berlin ARDS Defi nition.RESULTS:Among the 322 sepsis patients,84(26.1%)were complicated with ARDS within 72 hours.ARDS patients had a lower oxygenation index(PaO2/FiO2166.4±71.0 vs.255.0±91.2,P<0.05),longer duration of mechanical ventilation(11[6-24]days vs.0[0-0]days,P<0.05)than those without ARDS.Sepsis patients with ARDS showed daily positive net fl uid balance during seven days compared with those without ARDS who showed daily negative net fluid balance since the second day with signifi cant statistical differences.Among the 84 sepsis patients with ARDS,58(69.0%)died.Mean daily fl uid input volumes were much lower in survivors than in non-survivors(43.2±16.7 mL/kg vs.51.0±25.2 mL/kg,P<0.05)while output volumes were much higher in survivors(45.2±19.8 mL/kg vs.40.2±22.7 mL/kg,P<0.05).Using binary logistic regression analysis,we found that the mean daily fl uid balance was independently associated with mortality of sepsis patients complicating with ARDS(P<0.05).CONCLUSIONS:Early negative fluid balance is independently associated with a better prognosis of sepsis patients complicated with ARDS.

Biliary tract external drainage protects against intestinal barrier injury in hemorrhagic shock rats

AIM: To investigate the effects of biliary tract external drainage(BTED) on intestinal barrier injury in rats with hemorrhagic shock(HS). METHODS: BTED was performed via cannula insertion into the bile duct of rats. HS was induced by drawing blood from the femoral artery at a rate of 1 m L/min until a mean arterial pressure(MAP) of 40 ± 5 mm Hg was achieved. That MAP was maintained for 60 min. A total of 99 Sprague-Dawley rats were randomized into a sham group, an HS group and an HS + BTED group. Nine rats in the sham group were sacrificed 0.5 h after surgery. Nine rats in each of the HS and HS + BTED groups were sacrificed 0.5 h, 1 h, 2 h, 4 h and 6 h after resuscitation. Plasma tumor necrosis factor-α(TNF-α), interleukin-6(IL-6), and lipopolysaccharide(LPS) levels were analyzed using enzyme-linked immunosorbent assay. Plasma D-lactate levels were analyzed using colorimetry. The expression levels of occludin and claudin-1 in the ileum were analyzed using Western blot and immunohistochemistry. Histology of the ileumwas evaluated by hematoxylin and eosin staining. RESULTS: Plasma TNF-α levels in the HS + BTED group decreased significantly compared with the HS group at 1 h and 6 h after resuscitation(P < 0.05). Plasma IL-6 levels in the HS + BTED group decreased significantly compared with the HS group at 0.5 h, 1 h and 2 h after resuscitation(P < 0.05). Plasma D-lactate and LPS levels in the HS + BTED group decreased significantly compared with the HS group at 6 h after resuscitation(P < 0.05). The expression levels of occludin in the HS + BTED group increased significantly compared with the HS group at 4 h and 6 h after resuscitation(P < 0.05). The expression levels of claudin-1 in the HS + BTED group increased significantly compared with the HS group at 6 h after resuscitation(P < 0.05). Phenomena of putrescence and desquamation of epithelial cells in the ileal mucosa were attenuated in the HS + BTED group. Ileal histopathologic scores in the HS + BTED group decreased significantly compared with the HS group at 2 h, 4 h and 6 h after resuscitation(P < 0.05). CONCLUSION: BTED protects against intestinal barrier injury in HS rats.

Persistence and clearance of viral RNA in 2019 novel coronavirus disease rehabilitation patients

Background:A patient’s infectivity is determined by the presence of the virus in different body fluids,secretions,and excreta.The persistence and clearance of viral RNA from different specimens of patients with 2019 novel coronavirus disease(COVID-19)remain unclear.This study analyzed the clearance time and factors influencing 2019 novel coronavirus(2019-nCoV)RNA in different samples from patients with COVID-19,providing further evidence to improve the management of patients during convalescence.Methods:The clinical data and laboratory test results of convalescent patients with COVID-19 who were admitted to from January 20,2020 to February 10,2020 were collected retrospectively.The reverse transcription polymerase chain reaction(RT-PCR)results for patients’oropharyngeal swab,stool,urine,and serum samples were collected and analyzed.Convalescent patients refer to recovered non-febrile patients without respiratory symptoms who had two successive(minimum 24 h sampling interval)negative RT-PCR results for viral RNA from oropharyngeal swabs.The effects of cluster of differentiation 4(CD4)+T lymphocytes,inflammatory indicators,and glucocorticoid treatment on viral nucleic acid clearance were analyzed.Results:In the 292 confirmed cases,66 patients recovered after treatment and were included in our study.In total,28(42.4%)women and 38 men(57.6%)with a median age of 44.0(34.0-62.0)years were analyzed.After in-hospital treatment,patients’inflammatory indicators decreased with improved clinical condition.The median time from the onset of symptoms to first negative RT-PCR results for oropharyngeal swabs in convalescent patients was 9.5(6.0-11.0)days.By February 10,2020,11 convalescent patients(16.7%)still tested positive for viral RNA from stool specimens and the other 55 patients’stool specimens were negative for 2019-nCoV following a median duration of 11.0(9.0-16.0)days after symptom onset.Among these 55 patients,43 had a longer duration until stool specimens were negative for viral RNA than for throat swabs,with a median delay of 2.0(1.0-4.0)days.Results for only four(6.9%)urine samples were positive for viral nucleic acid out of 58 cases;viral RNA was still present in three patients’urine specimens after throat swabs were negative.Using a multiple linear regression model(F=2.669,P=0.044,and adjusted R2=0.122),the analysis showed that the CD4+T lymphocyte count may help predict the duration of viral RNA detection in patients’stools(t=-2.699,P=0.010).The duration of viral RNA detection from oropharyngeal swabs and fecal samples in the glucocorticoid treatment group was longer than that in the non-glucocorticoid treatment group(15 days vs.8.0 days,respectively;t=2.550,P=0.013)and the duration of viral RNA detection in fecal samples in the glucocorticoid treatment group was longer than that in the non-glucocorticoid treatment group(20 days vs.11 days,respectively;t=4.631,P<0.001).There was no statistically significant difference in inflammatory indicators between patients with positive fecal viral RNA test results and those with negative results(P>0.05).Conclusions:In brief,as the clearance of viral RNA in patients’stools was delayed compared to that in oropharyngeal swabs,it is important to identify viral RNA in feces during convalescence.Because of the delayed clearance of viral RNA in the glucocorticoid treatment group,glucocorticoids are not recommended in the treatment of COVID-19,especially for mild disease.The duration of RNA detection may relate to host cell immunity.

Clinical characteristics of 5375 cases of acute pancreatitis from a single Chinese center, 1996-2015

Acute pancreatitis (AP) remains a common and lifethreatening gastrointestinal emergency, which is usually induced by gallstones, hyperlipidaemia, alcohol abuse, pancreatic carcinoma, and trauma.[1] According to the 2012 Atlanta consensus, AP is divided into three general grades of severity: mild (MAP), moderate (MSAP), and severe (SAP).