Acute pancreatitis precedes chronic pancreatitis in the majority of patients: Results from the NAPS2 consortium

INTRODUCTION

The mechanistic definition of chronic pancreatitis (CP) identifies acute pancreatitis (AP) as a precursor stage. We hypothesized that clinical AP frequently precedes the diagnosis of CP and is associated with patient- and disease-related factors. We describe the prevalence, temporal relationship and associations of AP in a well-defined North American cohort.

METHODS

We evaluated data from 883 patients with CP prospectively enrolled in the North American Pancreatitis Studies across 27 US centers between 2000 and 2014. We determined how often patients had one or more episodes of AP and its occurrence in relationship to the diagnosis of CP. We used multivariable logistic regression to determine associations for prior AP.

RESULTS

There were 624/883 (70.7%) patients with prior AP, among whom 161 (25.8%) had AP within 2 years, 115 (18.4%) within 3-5 years, and 348 (55.8%) >5 years prior to CP diagnosis. Among 504 AP patients with available information, 436 (86.5%) had >1 episode. On multivariable analyses, factors associated with increased odds of having prior AP were a younger age at CP diagnosis, white race, abdominal pain, pseudocyst(s) and pancreatic duct dilatation/stricture, while factors associated with a lower odds of having prior AP were exocrine insufficiency and pancreatic atrophy. When compared with patients with 1 episode, those with >1 AP episode were diagnosed with CP an average of 5 years earlier.

CONCLUSIONS

Nearly three-quarters of patients were diagnosed with AP prior to CP diagnosis. Identifying which AP patients are at-risk for future progression to CP may provide opportunities for primary and secondary prevention.

Enhanced Human-Induced Pluripotent Stem Cell Derived Cardiomyocyte Maturation Using a Dual Microgradient Substrate

Human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CM) raise many possibilities for cardiac research but they exhibit an immature phenotype, which influences experimental outcomes. The aim of our research is to investigate the effects of a topographical gradient substrate on the morphology and function of commercially available hiPSC-CM. The lateral dimensions the microgrooves on the substrate varied from 8 to 100 μm space between the 8 μm grooves on one axis and from ∼5 nm to ∼1 μm in depth on the other axis. Cells were seeded homogeneously across the substrate and according to the manufacturers protocols. At days 4 and 10, measures of eccentricity, elongation, orientation, sarcomere length (SL), and contractility of the hiPSC-CM were taken. Only the deepest and widest region (8-30 μm wide and 0.85-1 μm deep) showed a significantly higher percentage of hiPSC-CM with an increased eccentricity (31.3 ± 6.4%), elongation (10.4 ± 4.3%), and orientation (<10°) (32.1 ± 2.7%) when compared with the control (flat substrate) (15.8 ± 5.0%, 3.4 ± 2.7%, and 10.6 ± 1.1%, respectively). Additionally, during stimulus-induced contraction, the relaxation phase of the twitch was prolonged (400 ms) compared to nonelongated cells (200 ms). These findings support the potential use of dual microgradient substrates to investigate substrate topographies that stimulate migration and/or maturation of hiPSC-CM.

Ethical issues arising from the INTERGROWTH-21st Fetal Growth Longitudinal Study

The INTERGROWTH-21st Project presented a complex set of ethical challenges given the involvement of health institutions in geographically and culturally diverse areas of the world, with differing attitudes to pregnancy. This paper addresses how the research team dealt with some of those issues.

Use and perceived effectiveness of non-analgesic medical therapies for chronic pancreatitis in the United States

BACKGROUND

Effectiveness of medical therapies in chronic pancreatitis has been described in small studies of selected patients.

AIM

To describe frequency and perceived effectiveness of non-analgesic medical therapies in chronic pancreatitis patients evaluated at US referral centres.

METHODS

Using data on 516 chronic pancreatitis patients enrolled prospectively in the NAPS2 Study, we evaluated how often medical therapies [pancreatic enzyme replacement therapy (PERT), vitamins/antioxidants (AO), octreotide, coeliac plexus block (CPB)] were utilized and considered useful by physicians.

RESULTS

Oral PERT was commonly used (70%), more frequently in the presence of exocrine insufficiency (EI) (88% vs. 61%, P < 0.001) and pain (74% vs. 59%, P < 0.002). On multivariable analyses, predictors of PERT usage were EI (OR 5.14, 95% CI 2.87-9.18), constant (OR 3.42, 95% CI 1.93-6.04) or intermittent pain (OR 1.98, 95% CI 1.14-3.45). Efficacy of PERT was predicted only by EI (OR 2.16, 95% CI 1.36-3.42). AO were tried less often (14%) and were more effective in idiopathic and obstructive vs. alcoholic chronic pancreatitis (25% vs. 4%, P = 0.03). Other therapies were infrequently used (CPB - 5%, octreotide - 7%) with efficacy generally <50%.

CONCLUSIONS

Pancreatic enzyme replacement therapy is commonly utilized, but is considered useful in only subsets of chronic pancreatitis patients. Other medical therapies are used infrequently and have limited efficacy.

MRI and S-MRCP findings in patients with suspected chronic pancreatitis: correlation with endoscopic pancreatic function testing (ePFT)

PURPOSE

To review magnetic resonance imaging (MRI) and secretin stimulated magnetic resonance cholangiopancreatography (S-MRCP) findings of patients with suspected chronic pancreatitis and compare them with endoscopic pancreatic function testing (ePFT).

MATERIALS AND METHODS

MRI and S-MRCP findings of 36 patients with clinically suspected chronic pancreatitis were reviewed. Baseline ductal changes, duodenal filling grades, and pancreatic duct caliber change (PDC) on S-MRCP, mean values of pancreatic anteroposterior (AP) diameter, signal intensity ratio (SIR) between pancreas and the spleen on T1-weighted fat saturated images, and arterial to venous (A/V) enhancement ratios were compared between groups of normal and abnormal pancreatic exocrine function determined by ePFT.

RESULTS

All patients (n = 24) with normal ePFT (HCO(3) >80 mEq/L) had grade 3 normal duodenal filling. Patients with abnormal ePFT (HCO(3) <80 mEq/L) (n = 12) had grade 1 (n = 1) and grade 2 (n = 11) diminished duodenal filling (P < 0.0001). PDC was 1.51 in the normal ePFT group versus 1.27 in the abnormal ePFT group (P = 0.01). No significant differences were found in terms of mean pancreatic AP diameter (21.8 vs. 19.8 cm), SIR (1.59 vs. 1.44), and A/V (1.08 vs. 1.01) between groups of normal/abnormal pancreatic exocrine function.

CONCLUSION

Despite discrepancies between pancreatic exocrine function and the findings on standard MRI/MRCP, the S-MRCP findings are comparable to ePFT in the evaluation of chronic pancreatitis.

The effect of prior sphincterotomy on the secretin-stimulated magnetic resonance cholangiopancreatography (s-MRCP)

RATIONALE AND OBJECTIVES

A lack of pancreatic duct compliance and decreased duodenal filling on secretin-stimulated magnetic resonance cholangiopancreatography (s-MRCP) has been noted in patients with chronic pancreatitis. Whether endoscopic sphincterotomy can affect pancreatic duct compliance and duodenal filling on diagnostic s-MRCP is unknown.

MATERIALS AND METHODS

A retrospective review of patients referred to the authors' clinic from December 2006 to December 2007 was performed. Those patients with no evidence of chronic pancreatitis who underwent s-MRCP were studied. Findings on s-MRCP were analyzed, specifically noting change in pancreatic duct diameter size from baseline to maximum dilation and duodenal filling after secretin administration (0.2 microg/kg intravenous dose of human secretin).

RESULTS

Of the 34 patients studied, 12 underwent endoscopic sphincterotomy, and 22 had intact sphincters of Oddi. In the sphincterotomy group, there was a mean change of 0.2 cm (range, 0.0-0.4 cm), while in the nonsphincterotomy group, the mean change was 0.9 cm (range, 0.3-2.0 cm) after secretin administration. The difference was significant (P < .005).

CONCLUSION

Endoscopic sphincterotomy significantly decreases pancreatic duct dilation in response to secretin on s-MRCP. However, further studies are required to determine the effect sphincterotomy has on the amount of duodenal filling and the rate at which duodenal filling occurs.

The effects of oral pancreatic enzymes (Creon 10 capsule) on steatorrhea: a multicenter, placebo-controlled, parallel group trial in subjects with chronic pancreatitis

OBJECTIVES

Creon 10 Minimicrospheres is an enteric-coated, delayed-release pancrelipase preparation designed to deliver active pancreatic enzymes to the small intestine. The primary objective of this study was to compare the effect of Creon 10 with placebo in the control of steatorrhea in chronic pancreatitis patients. Secondary objectives included evaluation of stool parameters and global improvement of symptoms scales.

METHODS

The study was a randomized, double-blind, placebo-controlled, 2-week trial. After a placebo run-in ("washout") phase, the effect on coefficient of fat absorption (%), daily fat excretion before and after treatment, and stool frequency and consistency were assessed.

RESULTS

In Creon 10-treated subjects, the change in mean coefficient of fat absorption (%) from run-in to double-blind phase was significantly higher compared with placebo-treated subjects (+36.7 vs. +12.1, P = 0.0185). Stool consistency improved significantly more with Creon 10 than with placebo (P = 0.0102) resulting in more subjects with formed stool; stool frequency decreased significantly more with Creon 10 than with placebo (P = 0.0015) from 10.8 during placebo run-in to 5.2 stools per day during double-blind treatment; and daily mean fat excretion in stool decreased significantly more (-56.5 vs. -11.4 g/d, P = 0.0181) in Creon 10-treated subjects compared with placebo-treated subjects. Global disease symptom scores showed greater improvement for both physicians and subjects in the Creon 10 group relative to those receiving placebo. Between treatment difference reached statistical significance for Creon 10 (P = 0.0435) for physician score and showed a trend (P = 0.0634) favoring Creon for subject score.

CONCLUSIONS

This randomized, placebo-controlled trial found that Creon 10 treatment controlled steatorrhea, as reflected in reduced fat excretion, decreased stool frequency and improved stool consistency. Creon 10 treatment was safe and well tolerated.

Cholecystectomy is an effective treatment for biliary dyskinesia

BACKGROUND

An increasing number of reports indicate symptomatic relief of biliary colic symptoms after cholecystectomy for biliary dyskinesia. Despite this, cholecystectomy as a treatment for biliary dyskinesia remains controversial. Our aim was to determine efficacy of cholecystectomy in alleviating biliary dyskinesia symptoms and the correlation with histologic findings.

METHODS

Records of patients with gallbladder ejection fraction <35% between January 1994 and February 1999 were reviewed. Gallbladder pathology and degree of symptomatic improvement were determined on follow-up.

RESULTS

Of the 27 cholecystectomy patients, 24 (89%) had significant improvement, 2 (7%) had partial improvement, and 1 (4%) had minimal improvement. Ten patients (43%) had normal gall-bladder, and 9 (90%) of them had significant improvement after cholecystectomy. Of the 6 nonsurgical patients, none had significant improvement, 4 (67%) had partial improvement, and 2 (33%) had minimal improvement.

CONCLUSIONS

Biliary dyskinesia patients who underwent cholecystectomy had significantly greater symptom improvement compared with nonsurgical patients. Pathologic correlation suggests chronic inflammation may not be the only cause of gallbladder dysfunction. Cholecystectomy should be a first-line therapy for biliary dyskinesia patients.

Expression of a brain-type cannabinoid receptor (CB1) in alveolar Type II cells in the lung: regulation by hydrocortisone

Using the polymerase chain reaction with degenerate primers to identify novel G-protein-coupled receptors of the rat alveolar Type II cell, we identified sequences expressed by the Type II cell identical to the sequence of the rat brain cannabinoid receptor (CB1). The use of Northern blot analysis to examine expression of CB1 mRNA in rat tissues revealed differences between the brain and lung. While rat brain expressed a 6.0 kb mRNA as previously described, rat lung expressed mRNA of 4.5 and 6.0 kb. Isolated lung alveolar Type II cells also expressed mRNA of 4.5 and 6.0 kb as determined by Northern analysis. However, only freshly isolated Type II cells contained cannabinoid receptor mRNA. Reverse transcriptase-polymerase chain reaction (RT-PCR) failed to detect CB1 mRNA in Type II cells maintained in culture for 1 or 2 days. We next determined developmental changes in lung CB1 mRNA expression using semi-quantitative RT-PCR. CB1 expression was detected as early as gestational day 16 in rat lung and mRNA levels increased to fetal day 20 before birth, before declining to adult levels. Fetal rat lung explants were utilized to further examine the ontogeny and hormonal effects on CB1 mRNA expression. Hydrocortisone induced a dose-dependent expression in 15-day and 18-day explants, similar to previous results for surfactant-associated proteins. Our results demonstrate expression of CB1 mRNA in rat alveolar Type II cells and rat lung. This expression is ontogenically and hormonally regulated, with maximal expression noted just prior to birth in rat lung. Since CB1 mRNA is only expressed in freshly isolated Type II cells, CB1 may be useful as a Type II cell marker.

Effect of octreotide on pancreatic endocrine function in partial pancreatectomy

Octreotide acetate (Sandostatin), a long-acting somatostatin analogue, has been demonstrated to inhibit pancreatic exocrine secretion. The effect of octreotide acetate on pancreatic endocrine function in patients undergoing pancreas surgery or pancreas transplantation has not been as well described, nor have the clinical implications been studied as systematically. This study was designed to investigate the effects of octreotide acetate on glucose metabolism and endocrine function in a partial pancreatectomized canine model, simulating reduced islet cell reserve. Serum levels of glucose, insulin, and glucagon were determined at intervals over 2 hr following an intravenous glucose tolerance test (0.5 g/kg intravenous bolus of 50% glucose) in: normal animals (Group A, n = 5), normal animals pretreated with an intravenous bolus of 400 micrograms of octreotide acetate (Group B, n = 5), partial pancreatectomized animals (Group C, n = 5), and partial pancreatectomized animals pretreated with an intravenous bolus of 400 micrograms of octreotide acetate (Group D, n = 5). Peak glucose concentration was significantly increased in Group D when compared to Group C (Group C = 304.2 +/- 13.5 mg/dl vs Group D = 353.2 +/- 12.9 mg/dl, P < 0.05), indicating an impairment of glucose metabolism by octreotide. In addition, octreotide significantly decreased peak insulin release in the partial pancreatectomy groups (Group C = 129 +/- 12.9 micro U/ml vs Group D = 47.5 +/- 6.8 micro U/ml, P < 0.05). There were no significant differences in the rate of glucose utilization or glucagon concentrations among the groups. These results demonstrate that octreotide does result in insulin suppression, with a resultant increase in stimulated glucose concentrations, in a canine model of reduced islet cell mass. Further studies are required to determine the mechanism of action of octreotide on endocrine function in the setting of pancreas transplant.

Functional effects of transgenic expression of cholera toxin in pancreatic beta-cells

Investigation of intracellular pathways of stimulus-secretion signaling in vivo is possible by transgenic expression of agents known to influence specific biochemical interactions in the cells. The objective of the present study was to establish an experimental model for analyzing signal transduction mechanisms in pancreatic beta-cells in vivo, by expressing the cholera toxin A1 subunit under control of the insulin promoter, intending a constant activation of the Gs-protein, and thereby constant generation of cAMP. Surprisingly, the transgenic mice demonstrated mild hyperglycemia and hypoinsulinemia in vivo, and diminished glucose-induced insulin release from the in vitro perfused pancreas, whereas the pancreatic insulin content was normal. These observations suggest a deficiency in either the insulin release mechanisms or glucose recognition. Although the translated cholera toxin A1 subunit was biologically active, there was no increase in the islet content of cAMP. We conclude that the observed phenotype in the cholera toxin transgenic mice may be caused by a deleterious effect of the transgene itself on beta-cell function, or that counter regulatory mechanisms may compensate for the transgene-induced changes in intracellular enzymatic pathways.

Indications for open cervical node biopsy in HIV-positive patients

Open node biopsy was the method of choice for diagnosing human immunodeficiency virus (HIV) infection before serologic testing became available. Currently, the otolaryngologist is often called on to assist in the management of HIV-positive patients with troublesome cervical adenopathy. Today's questions are: what is the place of fine-needle aspiration (FNA), and when is open cervical node biopsy indicated. A retrospective review was undertaken of 93 consecutive cervical node biopsies performed by our department during the 5-year period from 1985 to 1989. Twenty of the patients who underwent biopsy were HIV-positive. Of these twenty, ten carried an established diagnosis of acquired immune deficiency syndrome (AIDS). Seventeen of these patients underwent FNA before biopsy. In the eight patients with persistent generalized lymph-adenopathy (PGL) and nontender, nonenlarging nodes, pathologic analysis revealed lymphoid hyperplasia. Five of these patients had antecedent FNA, none demonstrating any pathologic changes. Of the twelve patients with enlarging or tendon nodes, the diagnosis of mycobacterial adenitis was made in eight, Nocardial infection in two, Burkitt's lymphoma in one, and metastatic Kaposi's sarcoma in one. In four of the patients diagnosed with mycobacterial infections, FNA yielded cytologic evidence of acid-fast bacilli and open lymph node biopsy added nothing. In contrast, FNA failed to reveal the diagnosis in both patients with Nocardial infection, and in the two patients with neoplastic disease. We conclude that cervical node biopsy is not indicated in the HIV or AIDS patient with nontender or nonenlarging nodes.(ABSTRACT TRUNCATED AT 250 WORDS)

Closure of a controlled biliary fistula complicating partial cholecystectomy with endoscopic biliary stenting

An elderly woman presented 2 months after partial cholecystectomy performed for gangrenous cholecystitis with choledocholithiasis and a controlled biliary fistula. Despite ductal clearance of stones via endoscopic retrograde sphincterotomy and stone extraction, bilious drainage via the fistulous tract persisted. Endoscopic insertion of a 10F Amsterdam endoprosthesis resulted in complete closure of the fistula within 6 wk. This case represents the first example of closure of a biliary fistula after partial cholecystectomy.

Peptic ulcer disease following renal transplantation in the cyclosporine era

Peptic ulcer disease (PUD) remains a well-known sequela of renal transplantation, and, when complications occur, morbidity and mortality can be significant. For this reason, all patients at our center undergo a pretransplant upper gastrointestinal series (UGI). Patients with evidence of active ulcer disease on UGI and/or a history of PUD undergo upper gastrointestinal endoscopy and do not undergo transplantation until healing is demonstrated. Following transplantation, antiulcer prophylaxis is utilized for 6 weeks (in patients without pretransplant PUD) or 3 months (in patients with pretransplant PUD). To help define the incidence and significance of PUD in the cyclosporine era, as well as the value of pretransplant screening and posttransplant ulcer prophylaxis, a retrospective chart analysis of 254 patients who underwent renal or renal/pancreas allograft transplanted between January 1984 and December 1989 was accomplished. Twenty-six patients (10%) presented with symptomatic PUD at a mean of 7.8 months posttransplant. The incidence of PUD was 10% in patients with a negative pretransplant history and UGI, 15% in patients with a positive pretransplant history and negative UGI and endoscopy, and 0% in patients with a positive pretransplant history and UGI. Age, sex, primary disease, donor source, and number of rejection episodes were not significantly different in recipients with or without PUD. At the time of presentation, 23 patients (88%) had completed their antiulcer prophylaxis. Four patients (15%) died secondary to ulcer disease including two of three (66%) following surgical treatment and two of 23 (9%) during medical treatment. Posttransplant PUD continues to result in significant morbidity and mortality in the cyclosporine era. Pretransplant screening, including UGI and endoscopy, is not a reliable predictor of posttransplant, symptomatic PUD. Based on this study, it is concluded that all patients should receive longer periods of antiulcer prophylaxis, independent of previously defined pre- and posttransplant risk factors.

The effect of dimethyl PGE2 on canine pancreatic autograft exocrine secretion

This study was designed to evaluate the effect of 16,16-dimethyl prostaglandin E2 (dimethyl PGE2) on exocrine secretion in autografted animals with pancreaticocystostomies. The rates of secretion of urinary (autograft) amylase (units/min) and bicarbonate (mmole/min), over a 5-hr interval, were determined in the basal state (Group A, N = 5), after a bolus injection of 1 microgram/kg of dimethyl PGE2 (Group B, N = 5), during an OP-CCK infusion at 125 ng/kg/hr (Group C, N = 5), and during an OP-CCK infusion plus a bolus injection of 1 microgram/kg (Group D, N = 5) or 18 micrograms/kg (Group E, N = 5) of dimethyl PGE2 at the end of the second hour. Basal secretion of amylase and bicarbonate were decreased 1 hr after 1 microgram/kg of dimethyl PGE2, with the bicarbonate inhibition being statistically significant (Group A = 0.073 +/- 0.04 vs Group B = 0.001 +/- 0.00; P less than 0.05). When compared to Group C (128.3 +/- 28.0), an immediate and significant inhibition of OP-CCK-stimulated amylase release was demonstrated in both Group D (36.3 +/- 11.1; P less than 0.02) and Group E (57.3 +/- 13.4; P less than 0.05). One and two hours post-dimethyl PGE2, amylase releases were 37.7 +/- 8.6 and 64.7 +/- 6.8 in Group D and 0.92 +/- 0.3 and 8.28 +/- 2.6 in Group E, compared to 140.3 +/- 23.3 and 104.9 +/- 31.8 in Group C, indicating a dose-related, prolonged inhibition of autograft amylase secretion.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of terbutaline on exocrine function in the denervated canine pancreas

This study was designed to evaluate the effects of the beta adrenergic agonist, terbutaline, on pancreatic exocrine secretion in the denervated canine pancreas. In vitro assessment was performed by evaluating the effect of terbutaline on 10(-8) OP-CCK stimulated amylase release of pancreatic tissue slices incubated at 37 degrees C in Krebs-bicarbonate media. In vivo assessment was accomplished in animals with pancreatic autografts and functioning pancreaticocystostomies, by evaluating the effect of intravenous terbutaline (0.075 mg/kg over 15 min) on the basal, and OP-CCK (125 ng/kg/hr)--stimulated, rate of secretion of urinary (autograft) amylase and bicarbonate. Incubation of tissue slices with terbutaline had no significant effect on OP-CCK-stimulated amylase release. The intravenous terbutaline infusion resulted in a decrease in the basal rate of amylase (U/min) and bicarbonate (mmol/min) secretion, with the bicarbonate inhibition being significantly decreased, when compared with controls (0.073 +/- .04 vs. 000 +/- .00; P less than 0.05). Following the terbutaline infusion, there was also a significant decrease in OP-CCK-stimulated amylase (140.3 +/- 23.3 vs. 24.6 +/- 11.9; P less than 0.005) and bicarbonate release (.069 +/- .03 vs. .003 +/- .001; P less than 0.05). This inhibition persisted until the study was terminated 3 hr after the terbutaline infusion. These studies demonstrate that terbutaline causes a significant and prolonged decrease in autograft exocrine secretion--and, as a result, may have a therapeutic role in reducing the exocrine complications associated with pancreatic transplantation. The mechanism of action of this agent in the denervated pancreas requires further elucidation.

Single-channel activity in sarcolemmal vesicles from human and other mammalian muscles

Segments of mammalian, including human, skeletal muscle 1-2 cm long can be induced to shed vesicles by treatment with collagenase in a high-KCl solution containing no added calcium. The vesicles are encompassed by clean sarcolemma so that the gigaseal necessary for patch-clamping is readily formed. The properties of inwardly rectifying potassium channels and of calcium-activated potassium channels in patches detached from such vesicles are shown to be consistent with expectations based on earlier studies on intact muscle fibers and with patch clamp results on the same type of channels in other tissues. A chloride channel which rectifies outwardly with a conductance ranging from 15 to 50 pS is also described. The utility of sarcolemmal vesicles for the study of ion channels in human biopsy material is discussed.