Soluble B7-H5 Is a Novel Diagnostic, Severity, and Prognosis Marker in Acute Pancreatitis

As an important ligand in T lymphocyte costimulatory pathways, B7-H5 is involved deeply in the immune response in various diseases. However, its clinical usefulness as an early indicator in acute pancreatitis (AP) remains unclear. In this study, the levels of sB7-H5 and cytokines in plasma samples of 75 AP patients, 20 abdominal pain patients without AP, and 20 healthy volunteers were determined. Then, the correlation of sB7-H5 and clinical features, cytokines, the Ranson score, APACHE II score, Marshall score, and BISAP score was analysed, and the value of sB7-H5 for diagnostic, severity, and prognosis of AP was evaluated. We found that the levels of sB7-H5 were specifically upregulated in AP patients. Receiver operating characteristic (ROC) analysis revealed that sB7-H5 can identify AP patients from healthy or abdominal pain patients with 78.9% or 86.4% sensitivity and 93.3% or 90.0% specificity. Further analysis showed that the levels of sB7-H5 were significantly correlated with WBC ( p = 0.004 ), GLU ( p = 0.008 ), LDH ( p < 0.001 ), Ca2+ ( p = 0.006 ), AST ( p = 0.009 ), PLT ( p = 0.041 ), IL-6 ( p < 0.001 ), IL-10 ( p < 0.001 ), and TNF-α ( p < 0.001 ). And levels of sB7-H5 were gradually increased among patients with mildly acute pancreatitis (MAP), moderately severe acute pancreatitis (MSAP), and severe acute pancreatitis (SAP). It can distinguish the severity of AP with good sensitivity and specificity. Moreover, when dividing the patients into two groups according to the median level of sB7-H5, the local complication and length of stay of low levels of the sB7-H5 group were significantly less than those in high levels of the sB7-H5 group. And the levels of sB7-H5 in AP patients were significantly correlated with the Ranson score ( p < 0.001 ), APACHE II score ( p < 0.001 ), Marshall score ( p < 0.001 ), and BISAP score ( p < 0.001 ). The AUCs of assessing local complications of sB7-H5 at day 1 and day 3 were 0.704 ( p = 0.0024 ) and 0.727 ( p = 0.0373 ). These results showed the potential value of sB7-H5 as a diagnostic, severity, and prognosis marker of AP.

Predictive Value of Rotterdam Score and Marshall Score in Traumatic Brain Injury: A Contemporary Review

This article conducts a contemporary comparative review of the medical literature to update and establish evidence as to which framework among Rotterdam and Marshall computed tomography (CT)-based scoring systems predicts traumatic brain injury (TBI) outcomes better. The scheme followed was following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines for literature search. The search started on August 15, 2020 and ended on December 31, 2020. The combination terms used were Medical Subject Headings terms, combination keywords, and specific words used for describing various pathologies of TBI to identify the most relevant article in each database. PICO question to guide the search strategy was: “what is the use of Marshall (I) versus Rotterdam score (C) in TBI patients (P) for mortality risk stratification (O).” The review is based on 46 references which included a full review of 14 articles for adult TBI patients and 6 articles for pediatric TBI articles comparing Rotterdam and Marshall CT scores. The review includes 8,243 patients, of which 2,365 were pediatric and 5,878 were adult TBI patients. Marshall CT classification is not ordinal, is more descriptive, has better inter-rater reliability, and poor performance in a specific group of TBI patients requiring decompressive craniectomy. Rotterdam CT classification is ordinal, has better discriminatory power, and a better description of the dynamics of intracranial changes. The two scoring systems are complimentary. A combination of clinical parameters, severity, ischemic and hemodynamic parameters, and CT scoring system could predict the prognosis of TBI patients with significant accuracy. None of the classifications has good evidence for use in pediatric patients.

Clinical Profile and Outcome of Patients with Severe Acute Pancreatitis

Background: Acute pancreatitis (AP) is an acute inflammatory condition of the pancreas leading to pancreatic autodigestion. The present study was conducted to study the clinical profile and outcome of patients with severe acute pancreatitis. Subjects & Methods: The study was conducted on 40 patients of acute pancreatitis. Clinical profile including history, examination findings, etiology of pancreatitis, clinical severity (according to Modified Marshall Score, BISAP score, APACHE II, HAPS score, SOFA score) was recorded. Results: Severe Acute Pancreatitis (SAP) among patients. Majority of the patients i.e. 22 (55%) had alcohol consumption as etiological factor causing SAP followed by biliary 10 (25%) & idiopathic 5 (12.5%). Hypertriglyceridemia and drug-induced (herbal medication) pancreatitis was present in 1 (2.5%) patient each. Out of all 1 (2.5%), patients had a history of both alcohol consumption and the presence of gallstone as an etiological factor. 22 patients (55%) out of 40 patients only conservative management was used while 18(45%) patients underwent USG guided percutaneous drainage was done. Out of these 18 patients, 3(7.5%) patients required Laparoscopic Necrosectomy & 2(5%) patients required open necrosectomy in addition to ultrasound-guided PCD. Patients who improved had a mean BISAP SCORE of 2.15 0.54, Modified Marshall score of 3.65 1.44, APACHE II score of 9.77 4.45, SOFA score 5.54 2.49, RANSON’s score 3.85 1.80 and HAP score of 0.65 0.63. Conclusion: Most common etiology of severe acute pancreatitis is alcohol followed by biliary etiology. Out of severity scores (BISAP, APACHE-II, SOFA, HAPS), only BISAP score ≥3 is predictive of poor outcome in patients with severe acute pancreatitis.

Evaluation of Prognostic Factors of Severity in Acute Biliary Pancreatitis

Acute pancreatitis (AP) is an inflammatory disorder of the pancreas that, when classified as severe, is associated with high morbidity and mortality. Promptly identifying the severity of AP is of extreme importance for improving clinical outcomes. The aim of this study was to compare the prognostic value of serological biomarkers, ratios, and multifactorial scores in patients with acute biliary pancreatitis and to identify the best predictors. In this observational and prospective study, the biomarkers, ratios and multifactorial scores were evaluated on admission and at 48 h of the symptom onset. On admission, regarding the AP severity, the white blood count (WBC) and neutrophil–lymphocyte ratio (NLR), and regarding the mortality, the WBC and the modified Marshall score (MMS) showed the best predictive values. At 48 h, regarding the AP severity, the hepcidin, NLR, systemic inflammatory response index (SIRI) and MMS and regarding the mortality, the NLR, hepcidin and the bedside index for severity in AP (BISAP) score, showed the best predictive values. The present study enabled the identification, for the first time, of SIRI as a new prognostic tool for AP severity, and validated hepcidin and the NLR as better prognostic markers than C-reactive protein (CRP) at 48 h of symptom onset.

Impacto socioeconómico del manejo actual de la pancreatitis aguda de origen biliar severa: estudio comparativo

Objetivo La pancreatitis aguda de origen biliar es una patología gastrointestinal común, en donde el tratamiento oportuno es el pilar más importante a pesar de sus discrepancias. El objetivo del estudio es establecer el impacto socioeconómico en el manejo actual de esta patología, comparando dos hospitales de tercer nivel de estrato socioeconómico alto y bajo de la ciudad de Bogotá, Colombia.Materiales y Métodos Se realizó un estudio retrospectivo, comparativo de corte transversal entre enero de 2012 y diciembre de 2017, en dos hospitales de Bogotá D. C. Se evaluaron sus características socioeconómicas, género, tiempo de evolución al momento de la consulta, Marshall score, estancia en UCI, estancia hospitalaria, complicaciones, manejo quirúrgico y mortalidad.Resultados Se analizaron 101 pacientes de dos estratos socioeconómicos diferentes (alto y bajo). Se encontró que los pacientes de estrato bajo tienen un riesgo diez veces mayor de requerir un procedimiento quirúrgico. Asimismo, registraron una mayor mortalidad en comparación con pacientes de estrato alto (11,3% vs. 4,2%). También se evidenciaron más complicaciones en el grupo de nivel socioeconómico bajo con respecto al alto, como en la falla exocrina (81,1% vs. 31,3%) y el síndrome compartimental (35,8% vs. 4,2%).Conclusión Se encuentra mayor morbimortalidad en los pacientes de bajo nivel socioeconómico en el contexto de esta patología. Este estudio puede guiar a nuevas investigaciones acerca del impacto socioeconómico en los desenlaces de pancreatitis aguda severa.

A noninvasive method for the estimation of increased intracranial pressure in patients with severe traumatic brain injury using optic nerve sheath diameter measured on computed tomography head

Background: Measurement of optic nerve sheath diameter (ONSD) using ocular ultrasonography has shown a promise in predicting increased intracranial pressure (ICP). However, this method is dependent on operator technique and equipment availability. We propose an alternative method of measuring ONSD and Marshall score grading by utilizing initial computed tomography (CT) head obtained on admission. We believe that such a technique could help predict patients requiring an invasive ICP monitor on admission. Methods: Patients were retrospectively selected from the neurosurgery database of a level II trauma center. Control patients originated from a database of nontraumatic brain injury (TBI) patients with a negative CT head and no intracranial pathology. Study subjects included patients aged 18–90 years, who sustained a severe TBI requiring placement of an ICP monitor on admission. All patients had a non-contrast CT head before the placement of an ICP monitor. Patients receiving any intervention for decreasing suspected elevated ICPs and those with any documented orbital fractures before ICP monitor placement were excluded from the study. All measurements were performed by at least of two independent assessors. Results: A total of 242 patients were reviewed, of which 204 (100 control and 104 intervention) met inclusion criteria for this study. T he average age in the control group was 49.1 ± 22.9 years old while the average age of the intervention group was 36.9 ± 15.1 years (P < 0.0001). The average Glasgow Coma Scale was 7 in the intervention group. The average ONSD of the control group was 5.73 ± 0.58 mm compared to 6.76 ± 0.83 mm in the intervention group (P < 0.0001). Linear regression analysis demonstrated a statistically significant correlation between ONSD and opening ICP (r = 0.40, P < 0.001) and peak ICP (r = 0.31, P < 0.0001). An ONSD 6.0 mm + Marshall score 3 on initial CT head demonstrated a 92.5% sensitivity, 92.6% specificity, and 96.1% positive predictive value for developing an ICP 20 mmHg during hospitalization. Conclusion: Utilizing ONSD in combination with Marshall score grading on initial CT head is a strong predictor of elevated ICP. These criteria can be used in future studies to develop more objective criteria to guide ICP monitor placement.

P11 Which factors influence the decision to transfer patients with traumatic brain injury to a neurosurgery unit in a major trauma network?

ObjectivesTo identify factors that influence the decision to transfer patients with traumatic brain injury (TBI) to a neurosurgical centre.DesignRetrospective data collected as part of TrIBAL study.SubjectsAll patients with TBI referred to our neurosurgery unit from regional acute hospitals over a 4 month period.MethodsOur primary outcome was transfer to a neurosurgical centre. We identified the following factors that may predict decision to transfer: patient demographics, transfer distance, anticoagulation therapy and severity of TBI (initial GCS and Marshall score). A multivariable logistic regression analysis was performed.ResultsA total of 347 patients were referred from regional hospitals with TBI and of these, 53 (15%) were transferred. The mean age of patients referred was 69.6 years, 62.5% were men and 43% on antiplatelets or anticoagulated. Similar number of patients were referred from hospitals within 30 miles (54%) and those more than 30miles away (46%). Eighty-four percent of patients had mild TBI (GCS 13–15) on initial assessment and 67% had a Marshall CT score of 2. After regression analysis, younger age, male gender and higher Marshall score predicted transfer to our neurosurgical centre (p<0.05).ConclusionsMany patients with TBI have relatively ‘minor’ injuries and remain at their local hospital. In our cohort higher Marshall score, younger age and male gender predicted transfer to a neurosurgicial centre. Transfer distance, anticoagulation therapy and initial GCS did not influence decision to transfer.

Neutrophil to lymphocyte ratio (NLR) in acute pancreatitis as an early predictor of severity and outcome

Background: The management of Acute Pancreatitis (AP) is determined by an accurate assessment of severity of the disease. Numerous severity indicators have been described till date, most of which require reassessment after admission and resuscitation. We propose a novel indicator, the Neutrophil to Lymphocyte ratio (NLR), as a predictor of severity of acute pancreatitis at the initial time of diagnosis. NLR may have a role in predicting the length of hospital stay and ICU admission and also to predict adverse manifestations of Severe Acute Pancreatitis (SAP) including organ failure.Methods: A retrospective analysis was performed of 107 patients diagnosed with acute pancreatitis based on Atlanta 2012 definitions, who were admitted and treated between August 2017 and November 2017. The patients were grouped according to severity of acute pancreatitis and organ failure occurrence and a comparative analysis was performed to compare the NLR between groups. NLR was also compared with the modified Marshall score as a standard predictor of organ failure in acute pancreatitis.Results: Median NLR among the severe group is significantly higher compared to mild and moderate group (P <0.001). NLR significantly correlated with length of hospital stay (p 0.004) and also had a statistically significant correlation with ICU stay (p < 0.001). We found in our study that NLR at admission correlated significantly with the modified Marshall score in predicting the organ failure (p <0.001) in patients with acute pancreatitis. The receiver operator characteristic (ROC) curve analysis showed a cut-off values of NLR >8.5 at admission correlated with adverse outcomes in patients with acute pancreatitis.Conclusions: Neutrophil to Lymphocyte ratio (NLR) can be used as a predictor of severity of acute pancreatitis, right at the time of initial diagnosis. Further it may predict adverse outcomes, need for ICU care as well as length of hospital stay. NLR can be used as a tool to refer at risk patients to tertiary center needing ICU admission.