Discharge protocol in acute pancreatitis: an international survey and cohort analysis

Discharge protocol; Acute pancreatitisProtocol d'alta; Pancreatitis agudaProtocolo de alta; Pancreatitis agudaThere are several overlapping clinical practice guidelines in acute pancreatitis (AP), however, none of them contains suggestions on patient discharge. The Hungarian Pancreatic Study Group (HPSG) has recently developed a laboratory data and symptom-based discharge protocol which needs to be validated. (1) A survey was conducted involving all members of the International Association of Pancreatology (IAP) to understand the characteristics of international discharge protocols. (2) We investigated the safety and effectiveness of the HPSG-discharge protocol. According to our international survey, 87.5% (49/56) of the centres had no discharge protocol. Patients discharged based on protocols have a significantly shorter median length of hospitalization (LOH) (7 (5;10) days vs. 8 (5;12) days) p < 0.001), and a lower rate of readmission due to recurrent AP episodes (p = 0.005). There was no difference in median discharge CRP level among the international cohorts (p = 0.586). HPSG-protocol resulted in the shortest LOH (6 (5;9) days) and highest median CRP (35.40 (13.78; 68.40) mg/l). Safety was confirmed by the low rate of readmittance (n = 35; 5%). Discharge protocol is necessary in AP. The discharge protocol used in this study is the first clinically proven protocol. Developing and testifying further protocols are needed to better standardize patients’ care.The study was supported by a project grant (TKP2021-EGA-23) of the Ministry of Innovation and Technology of Hungary to PH, by an NKFIH OTKA grant (K131996) to PH, by the János Bolyai Research Scholarship of the Hungarian Academy of Sciences (to AM), by the Project Grants (KA–2019–14, FK131864 to AM) and by the ÚNKP–22–5 New National Excellence Program of the Ministry for Innovation and Technology from the source of the National Research, Development and Innovation Fund (to AM). The project has received funding from the EU’s Horizon 2020 research and innovation program under grant agreement No. 739593. (to BCN). BCN has received funding from János Bolyai Research Grant (BO/00648/21/5) and the New National Excellence Program (UNKP-22-5-SZTE-585) and it was supported by the ÚNKP-22-4-II New national Excellence Program of the Ministry for Culture and Innovation from the Source of the National Research, Development and Innovation Fund (to KM)

EASY-APP: An artificial intelligence model and application for early and easy prediction of severity in acute pancreatitis

Acute pancreatitis; Artificial intelligence; Severity predictionPancreatitis aguda; Inteligencia artificial; Predicción de gravedadPancreatitis aguda; Intel·ligència artificial; Predicció de la gravetatBackground Acute pancreatitis (AP) is a potentially severe or even fatal inflammation of the pancreas. Early identification of patients at high risk for developing a severe course of the disease is crucial for preventing organ failure and death. Most of the former predictive scores require many parameters or at least 24 h to predict the severity; therefore, the early therapeutic window is often missed. Methods The early achievable severity index (EASY) is a multicentre, multinational, prospective and observational study (ISRCTN10525246). The predictions were made using machine learning models. We used the scikit-learn, xgboost and catboost Python packages for modelling. We evaluated our models using fourfold cross-validation, and the receiver operating characteristic (ROC) curve, the area under the ROC curve (AUC), and accuracy metrics were calculated on the union of the test sets of the cross-validation. The most critical factors and their contribution to the prediction were identified using a modern tool of explainable artificial intelligence called SHapley Additive exPlanations (SHAP). Results The prediction model was based on an international cohort of 1184 patients and a validation cohort of 3543 patients. The best performing model was an XGBoost classifier with an average AUC score of 0.81 ± 0.033 and an accuracy of 89.1%, and the model improved with experience. The six most influential features were the respiratory rate, body temperature, abdominal muscular reflex, gender, age and glucose level. Using the XGBoost machine learning algorithm for prediction, the SHAP values for the explanation and the bootstrapping method to estimate confidence, we developed a free and easy-to-use web application in the Streamlit Python-based framework (http://easy-app.org/). Conclusions The EASY prediction score is a practical tool for identifying patients at high risk for severe AP within hours of hospital admission. The web application is available for clinicians and contributes to the improvement of the model.University of Pécs Medical School Research Fund. Grant Number: 300909. National Research, Development and Innovation Office Research Fund. Grant Numbers: K131996, FK131864, K128222, FK12463

Assessment of the level III of Inoue by preoperative endoscopic ultrasound and elastography: a novel approach to predict a periarterial divestment technique in borderline resectable (BR) or locally advanced (LA) pancreatic adenocarcinoma—How I do it

Pancreatic cancer; Periarterial divestment; Triangle operationCáncer de páncreas; Desinversión periarterial; Operación triangularCàncer de pàncrees; Desinversió periarterial; Operació triangularBackground Periarterial divestment is a surgical technique to approach borderline resectable (BR) or locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC) with arterial involvement. There are no reports in the literature regarding the role of endoscopic ultrasound and elastography (EUS-EG) in exploring the integrity of Inoue’s level III and its correlation with the periarterial divestment technique feasibility. Our research is aimed at exploring the role of EUS-EG in this scenario. Methods We describe our approach to Inoue’s level II by EUS-EG in patients with BR and LA pancreatic cancer patients after neoadjuvant chemotherapy. Results Between June 2019 and December 2020, four patients out of 25 were eligible to perform a preoperative EUS-EG. In all cases, Inoue’s level III integrity was corroborated by EUS-EG and confirmed posteriorly in the surgical scenario where a periarterial divestment technique was feasible. Vein resections were necessary in all cases, with no need for arterial resection. An R0 (> 1 mm) margin was achieved in all patients, and the histopathological assessment showed the presence of neurovascular tissue at the peripheral arterial margin. Conclusion Preoperatively, EUS-EG is a novel approach to explore the integrity of Inoue’s level III and could be helpful to preclude a periarterial divestment technique in borderline resectable or locally advanced pancreatic adenocarcinoma with arterial involvement.Open Access Funding provided by Universitat Autonoma de Barcelona

The role of high serum triglyceride levels on pancreatic necrosis development and related complications

Acute pancreatitis; Pancreatic necrosis; TriglyceridePancreatitis aguda; Necrosi pancreàtica; TriglicèridsPancreatitis aguda; Necrosis pancreática; TriglicéridosBackground The relevance of elevated serum triglyceride (TG) levels in the early stages of acute pancreatitis (AP) not induced by hypertriglyceridemia (HTG) remains unclear. Our study aims to determine the role of elevated serum TG levels at admission in developing pancreatic necrosis. Methods We analyzed the clinical data collected prospectively from patients with AP. According to TG levels measured in the first 24 h after admission, we stratified patients into four groups: Normal TG (< 150 mg/dL), Borderline-high TG (150–199 mg/dL), High TG (200–499 mg/dL) and Very high TG (≥ 500 mg/dL). We analyzed the association of TG levels and other risk factors with the development of pancreatic necrosis. Results A total of 211 patients were included. In the Normal TG group: 122, in Borderline-high TG group: 38, in High TG group: 44, and in Very high TG group: 7. Pancreatic necrosis developed in 29.5% of the patients in the Normal TG group, 26.3% in the Borderline-high TG group, 52.3% in the High TG group, and 85.7% in the Very high TG group. The trend analysis observed a significant association between higher TG levels and pancreatic necrosis (p = 0.001). A multivariable analysis using logistic regression showed that elevated TG levels ≥ 200 mg/dL (High TG and Very high TG groups) were independently associated with pancreatic necrosis (OR: 3.27, 95% CI − 6.27, p < 0.001). Conclusions An elevated TG level at admission ≥ 200 mg/dl is independently associated with the development of pancreatic necrosis. The incidence of pancreatic necrosis increases proportionally with the severity of HTG

Elevated Serum Triglyceride Levels in Acute Pancreatitis: A Parameter to be Measured and Considered Early

Triglicéridos séricos; Pancreatitis agudaTriglicèrids sèrics; Pancreatitis agudaAcute pancreatitis; Serum triglycerideBackground The value of serum triglycerides (TGs) related to complications and the severity of acute pancreatitis (AP) has not been clearly defined. Our study aimed to analyze the association of elevated levels of TG with complications and the severity of AP. Methods The demographic and clinical data of patients with AP were prospectively analyzed. TG levels were measured in the first 24 h of admission. Patients were divided into two groups: one with TG values of<200 mg/dL and another with TG≥200 mg/dL. Data on the outcomes of AP were collected. Results From January 2016 to December 2019, 247 cases were included: 200 with TG<200 mg/dL and 47 with TG≥200 mg/dL. Triglyceride levels≥200 mg/dL were associated with respiratory failure (21.3 vs. 10%, p=0.033), renal failure (23.4 vs. 12%, p=0.044), cardiovascular failure (19.1 vs. 7.5%, p=0.025), organ failure (34 vs. 18.5%, p=0.02), persistent organ failure (27.7 vs. 9.5%, p=0.001), multiple organ failure (19.1 vs. 8%, p=0.031), moderately severe and severe AP (68.1 vs. 40.5%, p=0.001), pancreatic necrosis (63.8 vs. 34%, p<0.001), and admission to the intensive care unit (27.7 vs. 9.5%, p=0.003). In the multivariable analysis, a TG level of≥200 mg/dL was independently associated with respiratory, renal, and cardiovascular failure, organ failure, persistent organ failure, multiple organ failure, pancreatic necrosis, severe pancreatitis, and admission to the intensive care unit (p<0.05). Conclusions In our cohort, TG≥200 mg/dL was related to local and systemic complications. Early determinations of TG levels in AP could help identify patients at risk of complications.Open Access Funding provided by Universitat Autonoma de Barcelona

Sensibilidad y especificidad del signo de palidez palmar y escala de color de hemoglobina de la OMS, en comparación con la hemoglobina sanguínea, como método diagnóstico de anemia en niños de 2 meses a 5 años, en el Hospital Nacional A. Loayza

OBJETIVOEvaluar dos instrumentos: Escala de Color de Hemoglobina de la OMS (HbCs) y signo de palidez palmar, como instrumentos diagnósticos de anemia en menores de 5 años durante Agosto 2011, en el Hospital Nacional A. LoayzaMATERIAL Y MÉTODODiseño no experimental, analítico, transversal, correlacional. Se incluyeron 112 pacientes, entre 2 a 60 meses de edad..RESULTADOSLa media de hemoglobina sérica fue 11.16gr/dl (±1.42 DS). La anemia afectó en mayor proporción a las niñas. Según la escala de Clasificación Nutricional de Waterlow, el 39.3% de la población estuvo dentro el rango de normalidad. La prevalencia de anemia encontrada fue de 45.5%. Para anemia leve, el colorímetro obtuvo una sensibilidad del 66%, especificidad del 71%, valor predictivo positivo de 58% y valor predictivo negativo 78% (valor p&lt;0.0001); el signo de palidez palmar obtuvo una sensibilidad de 74%, especificidad de 47%, valor predictivo positivo de 46% y valor predictivo negativo de 75% (valor p&lt;0.028). Para anemia moderada, el colorímetro obtuvo sensibilidad del 66%, especificidad del 96%, VPP del 60% y VPN del 97% (valor p&lt;0.00001), la palidez palmar no obtuvo significancia estadística (valor p=0.71).CONCLUSIONESLa escala de color de hemoglobina de la OMS y el signo de palidez palmar, obtuvieron porcentajes de sensibilidad, especificidad, VPP y VPN similares a los reportados en la literatura. Ambas herramientas diagnósticas parecen tener el potencial necesario para ser usadas en establecimientos de salud de primer nivel. (Rev Horiz Med 2012;12(1):30-36