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      Therapeutics and Clinical Risk Management (submit here)

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      Predictors of acute pancreatitis with low elevation of serum amylase


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          Background and aims

          Serum amylase is a traditional measure used to establish the diagnosis of acute pancreatitis (AP). The current study aimed to assess the predictors and clinical outcome of AP with low serum amylase.


          All patients were divided into two groups, based on their serum amylase level within the first 2 days after hospital admission: group 1 (amylase ≥300 U/L) and group 2 (amylase <300 U/L). Clinical outcomes were compared between the two groups before and after 1:1 propensity score matching. Clinical and biochemical parameters were collected and evaluated as potential predictors of AP with low serum amylase.


          A total of 464 patients were enrolled. After propensity score matching according to age, gender, time interval before admission, hematocrit, blood urea nitrogen and creatinine, 108 matched pairs of patients were selected. There was no significant statistical difference between group 2 and group 1 with respect to severity of AP, median days of stay in hospital and death. Multivariate analysis indicated that biliary etiology (odds ratio [OR]: 0.499; 95% confidence interval [CI]: 0.265–0.942; P=0.003), low-density lipoprotein cholesterol (LDL-C) (OR: 1.009; 95% CI: 1.002–1.017; P=0.017) and triglyceride levels (OR: 1.001; 95% CI: 1.0001–1.001; P=0.015) were independently associated with development of AP along with low serum amylase.


          Serum amylase level was not related to the severity of AP, median hospital stay (days) and death. Biliary etiology, LDL-C and triglyceride levels were independently associated with the development of AP with lower elevation of serum amylase.

          Most cited references28

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          Evaluation of the Propensity score methods for estimating marginal odds ratios in case of small sample size

          Background Propensity score (PS) methods are increasingly used, even when sample sizes are small or treatments are seldom used. However, the relative performance of the two mainly recommended PS methods, namely PS-matching or inverse probability of treatment weighting (IPTW), have not been studied in the context of small sample sizes. Methods We conducted a series of Monte Carlo simulations to evaluate the influence of sample size, prevalence of treatment exposure, and strength of the association between the variables and the outcome and/or the treatment exposure, on the performance of these two methods. Results Decreasing the sample size from 1,000 to 40 subjects did not substantially alter the Type I error rate, and led to relative biases below 10%. The IPTW method performed better than the PS-matching down to 60 subjects. When N was set at 40, the PS matching estimators were either similarly or even less biased than the IPTW estimators. Including variables unrelated to the exposure but related to the outcome in the PS model decreased the bias and the variance as compared to models omitting such variables. Excluding the true confounder from the PS model resulted, whatever the method used, in a significantly biased estimation of treatment effect. These results were illustrated in a real dataset. Conclusion Even in case of small study samples or low prevalence of treatment, PS-matching and IPTW can yield correct estimations of treatment effect unless the true confounders and the variables related only to the outcome are not included in the PS model.
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            A critical evaluation of laboratory tests in acute pancreatitis.

            An ideal laboratory test in the evaluation of a patient with acute pancreatitis (AP) should, in addition to accurately establishing the diagnosis of AP, provide early assessment of its severity and identify the etiology. None of the tests available today meet all these criteria, and presently there is no biochemical test that can be considered the "gold standard" for the diagnosis and assessment of severity of AP. In the diagnosis of AP, serum amylase and lipase remain important tests. Advantages of amylase estimation are its technical simplicity, easy availability, and high sensitivity. However, its greatest disadvantage is its low specificity. A normal amylase would usually exclude the diagnosis of AP, with the exception of AP secondary to hyperlipidemia, acute exacerbation of chronic pancreatitis, and when the estimation of amylase is delayed in the course of the disease. The major advantage of lipase is an increased sensitivity in acute alcoholic pancreatitis and in patients who initially present to the emergency room days after the onset of the disease, as lipase remains elevated longer than amylase. Although once considered to be specific for AP, nonspecific elevations of lipase have been reported in almost as many disorders as amylase, thus decreasing its specificity. Simultaneous estimation of amylase and lipase does not improve the accuracy. Other enzymes for the diagnosis of AP--pancreatic isoamylase, immunoreactive trypsin, and elastase--are more cumbersome and expensive and have no clear role in the diagnosis of AP. No enzyme assay has a predictive role in determining the severity or etiology of AP. Once the diagnosis of AP is established, daily measurements of enzymes have no value in assessing the clinical progress of the patient or ultimate prognosis and should be discouraged. A host of new serological and urinary markers have been investigated in the last few years. Their main use is in predicting the severity of AP. At present, serum C-reactive protein at 48 h is the best available laboratory marker of severity. Urinary trypsinogen activation peptides within 12-24 h of onset of AP are able to predict the severity but are not widely available. Serum interleukins 6 and 8 seem promising but remain experimental.
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              The Interplay between Inflammation, Coagulation and Endothelial Injury in the Early Phase of Acute Pancreatitis: Clinical Implications

              Acute pancreatitis (AP) is an inflammatory disease with varied severity, ranging from mild local inflammation to severe systemic involvement resulting in substantial mortality. Early pathologic events in AP, both local and systemic, are associated with vascular derangements, including endothelial activation and injury, dysregulation of vasomotor tone, increased vascular permeability, increased leukocyte migration to tissues, and activation of coagulation. The purpose of the review was to summarize current evidence regarding the interplay between inflammation, coagulation and endothelial dysfunction in the early phase of AP. Practical aspects were emphasized: (1) we summarized available data on diagnostic usefulness of the markers of endothelial dysfunction and activated coagulation in early prediction of severe AP; (2) we reviewed in detail the results of experimental studies and clinical trials targeting coagulation-inflammation interactions in severe AP. Among laboratory tests, d-dimer and angiopoietin-2 measurements seem the most useful in early prediction of severe AP. Although most clinical trials evaluating anticoagulants in treatment of severe AP did not show benefits, they also did not show significantly increased bleeding risk. Promising results of human trials were published for low molecular weight heparin treatment. Several anticoagulants that proved beneficial in animal experiments are thus worth testing in patients.

                Author and article information

                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                14 December 2017
                : 13
                : 1577-1584
                [1 ]Department of Gastroenterology and Hepatology
                [2 ]Department of Anesthesiology
                [3 ]Department of Surgery, Zhejiang Provincial Top Key Discipline in Surgery, Wenzhou Key Laboratory of Surgery
                [4 ]Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
                [5 ]Microbiology & Biotechnology Research Lab, Department of Environmental Sciences, Fatima Jinnah Women University, Rawalpindi, Pakistan
                [6 ]Department of Medical Records, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
                [7 ]Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg
                [8 ]Department of Medicine, Marienhausklinik St Josef Kohlhof, Neunkirchen, Germany
                Author notes
                Correspondence: Mengtao Zhou, Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, 325000, Nanbaixiang, Wenzhou, Zhejiang, People’s Republic of China, Tel +86 138 0669 7558, Fax +86 577 5557 9122, Email studyzhoumengtao@ 123456sina.com

                These authors contributed equally to this work

                © 2017 Hong et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Original Research

                severity,acute pancreatitis,risk factor,lipids,etiology,prediction
                severity, acute pancreatitis, risk factor, lipids, etiology, prediction


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