Glucose challenge test screening for prediabetes and undiagnosed diabetes

Aims/hypothesis  Diabetes prevention and care are limited by lack of screening. We hypothesised that screening could be done with a strategy similar to that used near-universally for gestational diabetes, i.e. a 50 g oral glucose challenge test (GCT) performed at any time of day, regardless of meal status, with one 1 h sample. Methods  At a first visit, participants had random plasma and capillary glucose measured, followed by the GCT with plasma and capillary glucose (GCTplasma and GCTcap, respectively). At a second visit, participants had HbA_1c measured and a diagnostic 75 g OGTT. Results  The 1,573 participants had mean age of 48 years, BMI 30.3 kg/m² and 58% were women and 58% were black. Diabetes (defined by WHO) was present in 4.6% and prediabetes (defined as impaired glucose tolerance [2 h glucose 7.8–11.1 (140–199 mg/dl) with fasting glucose ≤6.9 (125 mg/dl)] and/or impaired fasting glucose with plasma glucose 6.1–6.9 mmol/l [110–125 mg/dl]) in 18.7%. The GCTplasma provided areas under the receiver-operating-characteristic curves of 0.90, 0.82 and 0.79 for detection of diabetes, diabetes or prediabetes, and prediabetes, respectively, all of which were higher than GCTcap, random and capillary glucose, and HbA_1c (p < 0.02 for all). The performance of GCTplasma was unaffected by time after meals or time of day, and was better in blacks than whites, but otherwise comparable in men and women, and in groups with differing prevalence of glucose intolerance. GCTplasma screening would cost approximately US$84 to identify one person with previously unrecognised diabetes or prediabetes. Conclusions/interpretation  GCT screening for prediabetes and previously unrecognised diabetes would be accurate, convenient and inexpensive. Widespread use of GCT screening could help improve disease management by permitting early initiation of therapy aimed at preventing or delaying the development of diabetes and its complications. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorised users.     

Relationship between the exocrine and endocrine pancreas after acute pancreatitis

AIM:To determine the prevalence and time course of pancreatic exocrine insufficiency in individuals with newly diagnosed prediabetes or diabetes mellitus after acute pancreatitis.METHODS:Relevant literature cited in three major biomedical journal databases(EMBASE,MEDLINE,and Scopus)was reviewed independently by two authors.There were no language constraints but the search was limited to human studies.Studies included were cohort studies of adult patients who were discharged after an attack of acute pancreatitis.Patients were excluded if they were under 18 years of age or had a previous diagnosis of prediabetes or diabetes mellitus,pancreatic exocrine insufficiency,or chronic pancreatitis.The main outcome measure was the prevalence of concomitant pancreatic exocrine insufficiency in patients who were diagnosed with prediabetes and diabetes mellitus after an attack of acute pancreatitis.Subgroup analysis was conducted for patients who were diagnosed with prediabetes only and those who were diagnosed withdiabetes mellitus only.Subgroup analysis looking at the time course of concomitant pancreatic exocrine and endocrine insufficiency was also conducted.Pooled prevalence and corresponding 95%confidence intervals were calculated for all outcome measures and P-values<0.05 were deemed statistically significant.RESULTS:Eight clinical studies comprising of 234patients met all eligibility criteria.The pooled prevalence of newly diagnosed prediabetes or diabetes in individuals after acute pancreatitis was 43%(95%CI:30%-56%).The pooled prevalence of pancreatic exocrine insufficiency in individuals after acute pancreatitis was 29%(95%CI:19%-39%).The prevalence of concomitant pancreatic exocrine insufficiency in individuals with newly diagnosed prediabetes or diabetes was 40%(95%CI:25%-55%).The prevalence of concomitant pancreatic exocrine insufficiency among individuals with prediabetes alone and diabetes mellitus alone was 41%(95%CI:12%-75%)and 39%(95%CI:28%-51%),respectively.Further analysis showed that the prevalence of concomitant pancreatic exocrine insufficiency in individuals with prediabetes or diabetes decreases over time after an attack of acute pancreatitis.CONCLUSION:Pancreatic exocrine insufficiency occurs in 40%of individuals with newly diagnosed prediabetes or diabetes mellitus after acute pancreatitis.Further studies are needed to investigate the pathogenesis of diabetes in this setting.     

Analysis of factors influencing survival in patients with severe acute pancreatitis

Objective: Acute pancreatitis (AP) ranges from a mild and self-limiting disease to a fulminant illness with significant morbidity and mortality. Severe acute pancreatitis (SAP) is defined as persistent organ failure lasting for 48?h. We aimed to determine the factors that predict survival and mortality in patients with SAP.

Methods: We reviewed a consecutive series of patients who were admitted with acute pancreatitis between January 2003 and January 2013. A total of 1213 cases involving 660 patients were evaluated, and 68 cases with SAP were selected for the study. Patients were graded based on the Computer Tomography Severity Index (CTSI), the bedside index for severity (BISAP), and Ranson’s criteria.

Results: The frequency of SAP was 5.6% (68/1213 cases). Among these patients, 17 died due to pancreatitis-induced causes. We compared several factors between the survivor (n?=?51) and non-survivor (n?=?17) groups. On multivariate analysis, there were significant differences in the incidence of diabetes mellitus (p?=?.04), Ranson score (p?=?.03), bacteremia (p?=?.05) and body mass index (BMI) (p?=?.02) between the survivor and non-survivor groups.

Conclusions: Bacteremia, high Ranson score, DM, and lower BMI were closely associated with mortality in patients with SAP. When patients with SAP show evidence of bacteremia or diabetes, aggressive treatment is necessary. For the prediction of disease mortality, the Ranson score might be a useful tool in SAP.     

一种理想的急性坏死性胰腺炎大鼠模型

目的 建立一种理想的急性坏死性胰腺炎(ANP)大鼠模型。方法 用3．5％的牛磺胆酸钠0．1ml／100g逆行注入SD大鼠胰胆管内诱导ANP模型，于造模后15小时采集血和多脏器组织标本，测定血清淀粉酶含量，在光镜下观察多脏器的组织学改变。结果模型组大鼠血清淀粉酶含量比对照组明显升高，并且多脏器出现了病理改变。结论 此大鼠模型可靠、简便、存活时间较长，伴有多脏器损害，是一种理想的ANP的动物模型。     

Pancreatic exocrine insufficiency,diabetes mellitus and serum nutritional markers after acute pancreatitis

AIM: To investigate impairment and clinical significance of exocrine and endocrine pancreatic function in patients after acute pancreatitis (AP).METHODS: Patients with AP were invited to participate in the study. Severity of AP was determined by the Atlanta classification and definitions revised in 2012. Pancreatic exocrine insufficiency (PEI) was diagnosed by the concentration of fecal elastase-1. An additional work-up, including laboratory testing of serum nutritional markers for determination of malnutrition, was offered to all patients with low levels of fecal elastase-1 FE. Hemoglobin A1c or oral glucose tolerance tests were also performed in patients without prior diabetes mellitus, and type 3c diabetes mellitus (T3cDM) was diagnosed according to American Diabetes Association criteria.RESULTS: One hundred patients were included in the study: 75% (75/100) of patients had one attack of AP and 25% (25/100) had two or more attacks. The most common etiology was alcohol. Mild, moderately severe and severe AP were present in 67, 15 and 18% of patients, respectively. The mean time from attack of AP to inclusion in the study was 2.7 years. PEI was diagnosed in 21% (21/100) of patients and T3cDM in 14% (14/100) of patients. In all patients with PEI, at least one serologic nutritional marker was below the lower limit of normal. T3cDM was more frequently present in patients with severe AP (P = 0.031), but was also present in some patients with mild and moderately severe AP. PEI was present in all degrees of severity of AP. There were no statistically significantly differences according to gender, etiology and number of AP attacks.CONCLUSION: As exocrine and endocrine pancreatic insufficiency can develop after AP, routine follow-up of patients is necessary, for which serum nutritional panel measurements can be useful.     

Long-term outcome of severe acute pancreatitis

Background/Purpose

This study was undertaken to evaluate the post-discharge outcome of severe acute pancreatitis (SAP) and to clarify the prognostic factors for poor outcome.

Methods

In 45 patients, recurrence of acute pancreatitis (AP), transition to chronic pancreatitis (CP), and development of diabetes mellitus (DM) were evaluated. Relationships of the outcome with the findings on admission and the presence/absence of alcohol intake were analyzed.

Results

The mean follow-up period was 56 ± 6 months. Recurrence of AP was noted in 19% of the patients. The recurrence rate was higher in patients with necrotizing pancreatitis than in those without this feature. C-reactive protein and white blood cell (WBC) count were higher in patients with recurrence of AP. Transition to CP was noted in 22% of patients. The transition rate was higher in those with alcoholic SAP than in those with biliary SAP. In patients with transition to CP, the WBC count, hematocrit, Ranson score, and Japanese severity score were higher, and base excess (BE) was lower, compared with these features in patients without this transition. Development of DM was noted in 39% of patients. Blood glucose and BE were higher in patients who developed DM than in those who did not.

Conclusions

The degree of inflammation and pancreatic necrosis found on admission for SAP may be related to the recurrence of AP. Alcoholic SAP in which the disease is very severe may contribute to the transition to CP. Patients with impaired glucose tolerance readily develop DM after SAP.

     

Development and validation of a multivariate prediction model for patients with acute pancreatitis in Intensive Care Medicine

Background/objectives

Development and validation of a multivariate prediction model for patients with acute pancreatitis (AP) admitted in Intensive Care Units (ICU).

Risk factors of recurrent pancreatitis after first acute pancreatitis attack: a retrospective cohort study

Abstract

Background and aims: Few studies have been conducted in Asia on the recurrence of acute pancreatitis (AP). This study was designed to investigate characteristics of the disease to predict recurrence.

Methods: We retrospectively analyzed 617 patients that experienced a first AP attack between January 2009 and December 2014. Based on reviews of clinical and follow-up data, we attempted to identify risk factors of recurrence using Cox regression analysis.

Results: During a median follow-up of 3.2?years (range 3–72?months), 100(16.2%) of the 617 study subjects experienced one or more episodes of recurrent acute pancreatitis (RAP). Of these 100 patients, 75(75%) experienced one relapse, 12(12%) two relapses, and 13(13%) three or more relapses. The etiologies of RAP were an alcohol (48%), gallstone (31%), idiopathic (14%), and others (7%). Univariate analysis showed that an age of <60?years, male gender, smoking, an alcohol-associated etiology, and a local complication at index admission were significant risk factors of RAP. Cox regression analysis showed that an age of <60?years (HR = 1.602, 95% CI: 1.029–2.493), male gender (HR = 1.927, 95% CI: 1.127–3.295), and the presence of a local complication (HR = 3.334, 95% CI: 2.211–5.026) were significant risk factors of RAP development.

Conclusion: A local complication at index admission was found to be the strongest risk factor of RAP, and a male gender and an age of <60?years were significantly associated with RAP. Special attention and close follow-up should be afforded to patients with a local complication at index admission or male patients <60?years old.     

急性胰腺炎后胰腺外分泌功能研究概况

近年来,急性胰腺炎发病率日益增高,而对于急性期后胰腺外分泌功能的恢复情况研究甚少。本文回顾分析相关国内外文献,对急性胰腺炎后胰腺外分泌功能的情况做一综述。     

A prospective study of the Bedside Index for Severity in Acute Pancreatitis (BISAP) score in acute pancreatitis: An Indian perspective

IntroductionA simple and easily applicable system for stratifying patients with acute pancreatitis is lacking. The aim of our study was to evaluate the ability of BISAP score to predict mortality in acute pancreatitis patients from our institution and to predict which patients are at risk for development of organ failure, persistent organ failure and pancreatic necrosis.MethodsAll patients with acute pancreatitis were included in the study. BISAP score was calculated within 24 h of admission. A Contrast CT was used to differentiate interstitial from necrotizing pancreatitis within seven days of hospitalization whereas Marshall Scoring System was used to characterize organ failure.ResultsAmong 246 patients M:F = 153:93, most common aetiology among men was alcoholism and among women was gallstone disease. 207 patients had no organ failure and remaining 39 developed organ failure. 17 patients had persistent organ failure, 16 of those with BISAP score ≥3. 13 patients in our study died, out of which 12 patients had BISAP score ≥3. We also found that a BISAP score of ≥3 had a sensitivity of 92%, specificity of 76%, a positive predictive value of 17%, and a negative predictive value of 99% for mortality.DiscussionThe BISAP score is a simple and accurate method for the early identification of patients at increased risk for in hospital mortality and morbidity.     

Recovery of the pancreas after acute pancreatitis is not necessarily complete

Summary In 38 patients, exocrine pancreatic function was tested by means of the secretin-pancreozymin test (SPT) and pancreatic duct system with endoscopic retrograde cholangiopancreatography (ERCP) 34±36 mo (mean±SD, range 1–156 mo) following acute pancreatitis. SPT and ERCP results were both normal in 19 (50%). They were both abnormal in four (11%) patients (group 1). Fourteen (37%) patients with normal SPT had abnormal ERCP test results (group 2), and one (3%) patient with normal ERCP had abnormal SPT (group 3). All patients except one of group 2 could be followed up within a mean observation time of 105±46 mo (range 24–168 mo): Chronic pancreatitis developed in all four patients of group 1, in one patients of group 2, and in the single patient of group 3, and suspected chronic pancreatitis in another patient of group 2. Elevens of the remaining 12 patients with abnormal ERCP results, but normal exocrine pancreatic function (group 2), showed no signs or symptoms of acute or chronic pancreatitis. It is concluded that (1) recovery to normal does not necessarily occur after acute pancreatitis, (2) progression to chronic pancreatitis is possible at a considerable percentage, and (3) duct changes demonstrated by ERCP may persist without any later signs and symptoms of acute or chronic pancreatitis.     

Guidelines for the diagnosis and treatment of acute pancreatitis in China (2021)

Acute pancreatitis (AP) is a common acute abdominal condition of the digestive system. In recent years, treatment concepts, methods, and strategies for the diag...     

胰腺腺泡细胞凋亡与急性胰腺炎及其治疗策略

细胞凋亡是由基因控制的细胞自主的有序的死亡,包含了复杂的调控机制,与细胞坏死有着本质区别,不引起炎症刺激.在实验性及临床急性胰腺炎中均观察到胰腺腺泡细胞的凋亡,研究表明其可能是机体有利的保护性反应,与病情严重程度呈负相关关系.本文总结了近年来对急性胰腺炎胰腺腺泡细胞凋亡机制的研究进展,并对治疗方面的相关研究和探索进行了归纳和阐述.     

Triglyceride levels and apolipoprotein E polymorphism in patients with acute pancreatitis

BACKGROUND:?Hypertriglyceridemia is an unusual cause of acute pancreatitis and sometimes considered to be an epiphenomenon. This study aimed to investigate the clinical and analytical features and the APOE genotypes in patients with acute pancreatitis and severe hypertriglyceridemia.
METHODS:?We undertook a one-year, prospective study of patients with acute pancreatitis whose first laboratory analysis on admission to the emergency department included measurement of serum triglycerides. The APOE genotype was determined and the patients answered an established questionnaire within the first 24 hours concerning their alcohol consumption, the presence of co-morbidities and any medications being taken. The patients' progression, etiological diagnosis, hospital stay and clinical and radiological severity were all recorded.
RESULTS:?Hypertriglyceridemia was responsible for 7 of 133 cases of pancreatitis (5%); the remaining cases were of biliary (53%), idiopathic (26%), alcoholic (11%) or other (5%) origin. Compared with these remaining cases, the patients with hypertriglyceridemia were significantly younger, had more relapses, and more often had diabetes mellitus. They usually consumed alcohol or consumed it excessively on the days before admission. Also, the ε4 allele of the APOE gene was more common in this group (P<0.05).
CONCLUSION:?One of 20 episodes of acute pancreatitis is caused by hypertriglyceridemia and it is linked to genetic (ε4 allele) and comorbid factors such as diabetes and, especially, alcohol consumption.     

Utility of the new Japanese severity score and indications for special therapies in acute pancreatitis

Background  The Japanese severity score (JSS) for acute pancreatitis was revised in 2008. As special therapies for severe acute pancreatitis (SAP), continuous regional arterial infusion of protease inhibitor and antibiotics (CRAI) and enteral nutrition (EN) are now utilized in Japan. We investigated the usefulness of the new JSS and the indications for CRAI and EN based on the new JSS. Methods  We assessed the new JSS in 138 patients with SAP according to the previous Japanese criteria. Usefulness of the new JSS for the prediction of mortality rates was compared with conventional scoring systems by receiver-operator characteristic curve analysis. We analyzed the relationship between the new JSS and prognosis in patients with and without CRAI and EN, respectively. Results  Forty-five patients (33%) were assessed as having mild acute pancreatitis, and 93 patients (67%) were assessed as having SAP. Their mortality rates were 7 and 40%, respectively. The area under the curve for the prediction of mortality rates with the new JSS was 0.822 and was the highest among conventional scoring systems. In patients with new JSS ≥ 6, the mortality rate was lower in patients with CRAI than in patients without CRAI (P = 0.129). In patients with new JSS ≥ 4, the mortality rate was lower in patients with EN than in patients without EN (P = 0.016). Conclusions  The new JSS is useful and easier to use for the prediction of prognosis compared to the conventional scoring systems. EN was effective in reducing the mortality rate in patients with a new JSS ≥ 4.     

Clinical and pathological features of acute interstitial pancreatitis in the aged

Histological examination of the pancreas disclosed acute diffuse interstitial pancreatitis in nine cases (0.62%) out of 1457 autopsies performed in 3 yr at two general hospitals in Tokyo. In this series, there were 11 cases of necrotizing or hemorrhagic pancreatitis. In addition to diffuse phlegmonous inflammation, acute interstitial pancreatitis was characterized by rupture of the ducts and ductules associated with profuse intraluminal exudation of polymorphonuclear leukocytes and protein plugs formation. There was scarce parenchymal or fat necrosis. The interstitial type may represent characteristics of acute pancreatitis in the aged. In all nine cases, there were few clinical signs suggestive of acute pancreatitis, except for shock, that developed rapidly. Duration of the disease was rather short. Diagnosis of acute pancreatitis was not made before death. In five patients, acute pancreatitis was terminally superimposed on other serious ailments. But in the other four cases, acute pancreatitis was disclosed as the primary disease at autopsy. Although there was only one case that had a possibility of being secondary to biliary tract infection, ascending bacterial infection and impaired secretion by atrophic parenchyma seemed to be involved in its pathogenesis.     

簇素在急性胰腺炎发病机制中的研究进展

簇素是一种普遍存在的异源二聚体硫酸化糖蛋白,目前研究推测簇素参与调节急性胰腺炎发病中胰腺细胞的凋亡、拮抗细胞坏死及抑制补体对细胞膜的攻击,进而减轻炎症反应,同时参与损伤胰腺细胞的再生和修复,最终保护胰腺组织。现认为,簇素在急性胰腺炎中是一种保护细胞的蛋白质。     

Urinary trypsinogen activation peptide (TAP) predicts severity in patients with acute pancreatitis

Summary Conclusions Urinary TAP obtained within the first 48 h of the onset of symptoms can distinguish patients with severe acute pancreatitis. Background Urinary trypsinogen activation peptide (TAP) has recently been described as an early marker of severity in acute pancreatitis. Methods In a multicenter study, urine samples were collected for TAP concentration at 6–12, 24, and 48 h after admission from 139 patients with acute pancreatitis (99 with mild disease, 40 with severe disease) and from 50 control patients. Severity of acute pancreatitis was defined by the presence of organ failure and/or pancreatic necrosis on dynamic contrast-enhanced computed tomography. Results Median urinary TAP in the 139 patients with acute pancreatitis compared to the 50 control patients was significantly higher at admission, 4.6 vs 0.8 ng/mL (p<0.001), and 6–12 h, 1.9 vs 0.55 ng/mL (p=0.04). Among patients who presented within 48h of the onset of symptoms, the median urinary TAP for severe pancreatitis (9 patients) compared to mild pancreatitis (40 patients) was significantly higher at admission, 29.6 vs. 3.6 ng/mL (p=0.001). Also, when obtained within 48h of the onset of symptoms, all patients with severe pancreatitis had an admission urinary TAP level>10 ng/mL. The sensitivity and specificity of an admission urinary TAP≥10 for severe pancreatitis was 100 and 85%, respectively. Given a cutoff of 10 ng/mL for an admission urinary TAP obtained within 48h of the onset of symptoms, the negative predictive value was 100% for mild pancreatitis.     

尿胰蛋白酶原-2的测定对急性胰腺炎的诊断价值

目的探讨尿胰蛋白酶原2(Trypsinogen2Try2)的测定对急性胰腺炎(AcutepancreatitisAP)的诊断价值。方法对280例急腹症患者同时测定尿Try2及血、尿淀粉酶,其中尿Try2测定采用免疫层析法,血、尿淀粉酶采用酶学方法检测。结果55例急性胰腺炎患者中有53例尿Try2阳性,敏感性为96.4%,225例非AP的急腹症患者尿Try2有12例假阳性,特异性为94.7%;而血淀粉酶的敏感性和特异性分别为81.8%(45/55)和88.9%(25/225),尿淀粉酶的敏感性和特异性分别为80.0%(44/55)和88.4%(26/225),差异有显著性(P<0.05);7例重症急性胰腺炎患者尿Try2均为阳性。结论尿Try2是急腹症患者筛选AP快速而简便的方法,具有较高的特异性和敏感性。     

尿胰蛋白酶原-2检测对急性胰腺炎的诊断价值

目的评价免疫层析法检测尿胰蛋白酶原-2在急性胰腺炎（acute pancreatitis,AP）中的应用价值。方法对134例急性腹痛病例进行尿胰蛋白酶原-2及血、尿淀粉酶的检测,并比较其敏感性、特异性、阴性预测值、阳性预测值及准确度。结果30例AP患者中28例尿胰蛋白酶原-2阳性,敏感性为93．3％,血清淀粉酶检测的敏感性为86．7％（26／30）,尿淀粉酶检测的敏感性为83．3％（25／30）;104例其他急腹症中,8例尿胰蛋白酶原-2阳性,特异性为92．3％。血清淀粉酶检测的特异性为87．5％（91／104）;尿淀粉酶检测的特异性为85．6％（89／104）。尿胰蛋白酶原-2检测敏感性、特异性、阴性预测值、阳性预测值及准确度均最高,但三者之间差异无显著性（P〉0．05）。结论尿胰蛋白酶原-2是急腹症患者筛选AP快速而简便的方法,具有较高的特异性和敏感性。