BACKGROUND Acute respiratory distress syndrome (ARDS) is a major cause of death in patients with severe acute pancreatitis (SAP). Although a series of prediction models have been developed for early identification of such patients, the majority are complicated or lack validation. A simpler and more credible model is required for clinical practice. AIM To develop and validate a predictive model for SAP related ARDS. METHODS Patients diagnosed with AP from four hospitals located at different regions of China were retrospectively grouped into derivation and validation cohorts. Statistically significant variables were identified using the least absolute shrinkage and selection operator regression method. Predictive models with nomograms were further built using multiple logistic regression analysis with these picked predictors. The discriminatory power of new models was compared with some common models. The performance of calibration ability and clinical utility of the predictive models were evaluated. RESULTS Out of 597 patients with AP, 139 were diagnosed with SAP (80 in derivation cohort and 59 in validation cohort) and 99 with ARDS (62 in derivation cohort and 37 in validation cohort). Four identical variables were identified as independent risk factors for both SAP and ARDS: heart rate [odds ratio (OR) = 1.05; 95%CI: 1.04-1.07; P < 0.001; OR = 1.05, 95%CI: 1.03-1.07, P < 0.001], respiratory rate (OR = 1.08, 95%CI: 1.0-1.17, P = 0.047; OR = 1.10, 95%CI: 1.02-1.19, P = 0.014), serum calcium concentration (OR = 0.26, 95%CI: 0.09-0.73, P = 0.011; OR = 0.17, 95%CI: 0.06-0.48, P = 0.001) and blood urea nitrogen (OR = 1.15, 95%CI: 1.09-1.23, P < 0.001; OR = 1.12, 95%CI: 1.05-1.19, P < 0.001). The area under receiver operating characteristic curve was 0.879 (95%CI: 0.830-0.928) and 0.898 (95%CI: 0.848-0.949) for SAP prediction in derivation and validation cohorts, respectively. This value was 0.892 (95%CI: 0.843-0.941) and 0.833 (95%CI: 0.754-0.912) for ARDS prediction, respectively. The discriminatory power of our models was improved compared with that of other widely used models and the calibration ability and clinical utility of the prediction models performed adequately. CONCLUSION The present study constructed and validated a simple and accurate predictive model for SAP-related ARDS in patients with AP.

BackgroundAcute pancreatitis (AP) damages the intestinal barrier, which aggravates AP. Butyrate exhibits anti-inflammatory effects in AP, but it is unknown if such a protective effect is associated with the regulation of gut microorganisms. We aim to investigate the effects of sodium butyrate (SB) on pancreatic inflammation, colonic barrier, and gut microorganisms.MethodsC57BL/6 mice were divided into groups of sham operation (Sham), AP, 200 mg/kg SB intervention (SB-200), and 500 mg/kg SB intervention group (SB-500). Samples were harvested 24 h after the model was established. The gut microbiota was analyzed using 16S rRNA gene sequencing.ResultsPancreatic infiltration of neutrophils, macrophages, and M2-type macrophages was significantly reduced in the SB-500 intervention group. Supplementation of SB-500 improved colon mucosal histology and the expression of ZO-1 and occluding. The relative abundance of Alloprevotella and Muribaculaceae was increased and that of Akkermansia was decreased in the SB-500 group compared with the AP group. Ruminococcaceae was the most significantly increased species and Prevotellaceae was the most significantly decreased species in the SB-500 group compared with the AP group.ConclusionHigh dose of SB inhibits pancreatic inflammation probably by maintaining the intestinal barrier and regulating gut microbiota in mice with AP.

急性呼吸窘迫综合征(ARDS)是重症急性胰腺炎(SAP)常见的并发症,也是导致SAP患者早期死亡的首要原因,目前发病机制尚不清楚.近年来肠道菌群及其代谢产物参与调控SAP相关ARDS日益受到关注,深入探究"肠-肺轴"的发病机制有助于为SAP-ARDS的药物研发提供新的思路.总结了近年来肠道菌群及其代谢产物在SAP-ARDS领域的研究进展.

Objective:To explore the clinical characteristics and predictors of severe acute pancreatitis complicated with acute respiratory distress syndrome (SAP-ARDS).Methods:Clinical data of consecutive 313 SAP patients hospitalized from January 2000 to January 2020 in Peking Union Medical College Hospital, were retrospectively analyzed, including 258 cases with ARDS (ARDS group) and 55 cases without ARDS (non-ARDS group). According to the severity of ARDS, ARDS group were further divided into mild ARDS group (165 cases) and moderate to severe ARDS group (93 cases). Clinical symptoms, laboratory examination and imaging results, ICU admission time and clinical outcome, as well as the local and systemic complications, acute physiology and chronic health evaluation (APACHEⅡ) within 24 h after admission, bedside index for severity in acute pancreatitis (BISAP), CT severity index (CTSI), sequential organ failure assessment (SOFA) and quick sequenctial organ failure assessment(qSOFA) score were recorded. Univariate and multivariate logistic regression were performed to analyze independent risk factors of SAP complicated with moderate to severe ARDS. Receiver operating characteristics curves (ROC) was drawn to calculate area under the ROC curve (area under curve, AUC) and evaluate the performance of WBC and hsCRP in predicting SAP complicated with moderate to severe ARDS, and assess the performance of APACHEⅡ, BISAP, CTSI, SOFA and qSOFA scores in predicting SAP-ARDS endotracheal intubation.Results:The ICU length of stay and mortality rate of SAP-ARDS patients were significantly higher than those without ARDS [(8.3±11.6 day vs 5.7±7.7 day, 12.4% vs 3.6%, all P value <0.05)]. Univariate analysis showed that elevated WBC ( OR 4.52, 95% CI 1.64-12.4) and hsCRP ( OR 3.69, 95% CI 1.29-10.48) on admission were independent risk factors for moderate to severe ARDS with SAP. The AUC of WBC and hsCRP for predicting SAP with moderate to severe ARDS at admission were 0.651(95% CI 0.532-0.770) and 0.615 (95% CI 0.500-0.730), respectively. The predicted cut-off values (Cut-off values) were 17.5×10 9/L and 159 mg/L, respectively, and the sensitivity was 53.1% and 78.1%, the specificity was 78.1% and 48.4% respectively. The area under the ROC curve for APACHEⅡ, BISAP, CTSI, SOFA, and qSOFA score 24 h after admission in the early prediction of endotracheal intubation were 0.739 (95% CI 0.626-0.840), 0.705 (95% CI 0.602-0.809), 0.753 (95% CI 0.650-0.849 ), 0.737 (95% CI 0.615-0.836) and 0.663 (95% CI 0.570-0.794), and the optimum Cut-off values were 14 points, 3 points, 5 points, 7 points, 2 points, and the sensitivity and specificity for these predictors were 58.8% and 81.4%, 79.4% and 60.0%, 73.5% and 67.1%, 38.2% and 98.6%, 45.5% and 83.3%, respectively. Conclusions::Elevated blood WBC and hsCRP on admission were independent risk factors for moderate to severe ARDS in SAP. APACHEⅡ≥14, BISAP≥3, CTSI≥5, SOFA≥7, or qSOFA≥2 within the 24 h admission indictaed that the risk of SAP patients to receive endotracheal intubation was high.

目的 基于单中心临床治疗成本数据,对英夫利西单抗(Infliximab,IFX)纳入医保前后和沙利度胺(Thalidomide,THA)、甲氨蝶呤(Methotrexate,MTX)在复发克罗恩病(Crohn's disease,CD)治疗中的成本-效用进行比较分析.方法 纳入2009年10月1日至2018年9月30日采用THA、MTX和IFX治疗的复发CD患者,收集其直接医疗成本和CD疾病活动度评分(Crohn's disease activity index,CDAI).IFX纳入医保后的相应成本由IFX医保前后费用差价算得.质量调整寿命年(quality adjusted life year,QALY)由CDAI换算得来,QALY原始算法基于EQ-5D量表换算得来.以THA治疗方案为参照进行成本-效用分析,2018年人均GDP为成本-效用评估阈值标准.结果 在IFX纳入医保前后,对复发CD患者而言,THA方案人均直接医疗成本最低(0.80万元).而相对于THA治疗方案,增加单位QALY的不同治疗方案费用:MTX治疗方案花费100万元,IFX纳入医保前需花费133.67万元,但在IFX纳入医保后仅需消耗1.87万元,远低于2018年人均GDP.结论 IFX纳入医保后成为复发CD患者极具成本-效用优势的药物治疗方案.

Background: Acute pancreatitis (AP) has a broad spectrum of severity and is associated with considerable morbidity and mortality. Dysbiosis of gut microbiota may be associated with AP severity. Aims: We aimed to evaluate the composition and functional effects of gut microbiota in different grades of AP severity. Methods: We carried out shotgun metagenomic sequencing on rectal swab samples from three patients with mild acute pancreatitis (MAP), three with moderately severe acute pancreatitis (MSAP), three with severe acute pancreatitis (SAP) and three normal control persons (NOR). Differences analysis in gut microbiota composition and functional enrichment was performed. Results: Gut microbiota in AP patients was characterized by decreased species richness. The most representative gut microbiota in mild acute pancreatitis (MAP), moderately severe acute pancreatitis (MSAP), and severe acute pancreatitis (SAP) was Streptococcus, Escherichia-coli, and Enterococcus, respectively. Each of the three APassociated genera could differentiate AP from healthy control population. Representative pathways associated with the glutathione metabolism, lipopolysaccharide biosynthesis, and amino acid metabolism (valine, leucine and isoleucine degradation) were enriched in MAP, MSAP, and SAP, respectively. Conclusions: The study shows a potential association of gut microbiome composition and function to the progression of AP severity.

Background: What features should alert clinicians to suspect underlying tumors in patients with acute pancreatitis (AP) was largely unknown. This study aimed to assess the clinical characteristics and outcome in patients with tumor-associated AP. Methods: Patients who presented with AP and were diagnosed with tumor after admission were included according to the inclusion and exclusion criteria and followed up by hospital notes, telephone, WeChat and/or e-mail. The clinical characteristics and outcome were analyzed with multivariable logistic regression and were compared with AP patients without tumor. Results: Out of a cohort of 1,792 AP patients we identified 103 who had a neoplastic etiology. The 103 patients had a median age of 57 (range, 13-81) and 65 were males. AP was mild in 92 patients, moderately severe in 7 and severe in 4. The three most common tumors included pancreatic cancer (PC) (40), periampullary carcinoma (PAC) (25), and neoplastic pancreatic cysts (NPC) (22). The following ranked features were predictive of a tumor etiology: dilation of main pancreatic duct (MPD) (OR 417.83, 95% CI: 80.40-2,171.42), vascular invasion (OR 82.04, 95% CI: 6.05-1,113.14), mild AP (8.29, 95% CI: 1.98-34.73), and anemia (OR 5.73, 95% CI: 2.02-16.26). The median survival period of AP patients with PC, PAC, and NPC was 10.0 (7.0-23.5), 21.0 (5.0-37.0), and 35.0 (30.0-96.0) months, respectively. Conclusions: Mild AP patients with dilation of MPD, vascular invasion, and anemia were more frequently suggested a tumor etiology. Thus, clinical vigilance is needed for timely detection of tumor-associated pancreatitis with these characteristics.

AP是临床常见的急症，可引起严重的局部和全身并发症，病死率高，目前尚缺乏高质量循证医学证据支持的有效药物。近年来非编码RNAs在AP发病机制中的作用日益受到关注，有望成为AP潜在的生物标志物和治疗靶点。

Acute pancreatitis (AP) has a wide spectrum of severity and can be associated with considerable morbidity and mortality. Whether gut microbiota dysbiosis is associated with AP severity remains obscure. We aim to investigate the differences in the alterations of gut microbiota in different grades of AP severity. We collected clinical information and rectal swab samples from 80 individuals. The gut microbiota was tested by 16S rRNA gene sequencing, gut microbiota species composition analysis, difference analysis, random forest model prediction analysis, and gut microbiota species correlation network analysis. There was a different microbiota profile in different severity grades. Bacteroides, Escherichis-Shigella, and Enterococcus were dominant species in mild, moderately severe, and severe AP, respectively. Finegoldia was the most significantly increased and Blautia the most decreased species in mild AP. Anaerococcus was the most significantly increased and Eubacterium hallii the most decreased species in moderately severe AP. Enterococcus was the most significantly increased and Eubacterium hallii the most decreased species in severe AP. Finegoldia, Eubacterium_hallii, and Lachnospiraceae were potential diagnostic biomarkers for mild AP and Eubacterium_hallii and Anaerococcus for moderately severe AP. There was a positive interaction between Firmicutes and Bacteroidetes in mild AP. The disturbed gut microbiota is different among grades of AP, suggesting their potential role in the progression of disease severity. There was a different microbiota profile in different severity grades. Bacteroides, Escherichis-Shigella, and Enterococcus were dominant gut microbiota species in MAP, MSAP, and SAP, respectively. Finegoldia was the most significantly increased and Blautia the most decreased gut microbiota species in MAP. Anaerococcus was the most significantly increased and Eubacterium hallii the most decreased species in MSAP. Enterococcus was the most significantly increased and Eubacterium hallii the most decreased species in SAP. Finegoldia, Eubacterium_hallii, and Lachnospiraceae were potential diagnostic biomarkers for MAP and Eubacterium_hallii and Anaerococcus for MSAP. There was a positive interaction between Firmicutes and Bacteroidetes in MAP.

探讨住院医师在消化科培训期间训练内科临床思维的重要性.通过探讨消化系统疾病的诊疗要求和内科临床思维特征,辩证分析二者相关性.消化系统疾病与其他器官有密切的关联,临床表现复杂多样.一方面,消化系统疾病可导致其他器官异常,出现胃肠道之外的临床表现;另一方面,其他系统的疾病也可能引起胃肠道症状从而模拟消化系统疾病.在消化科轮转的住院医师必须以贯通式的内科思维分析病情,才能更好地实现培训目的.

IgG4相关性疾病（IgG4-related disease,IgG4-RD）是一种多系统受累的自身免疫性疾病,以血清IgG4水平升高、受累病灶浆细胞浸润伴IgG4高表达和纤维化等为特征。IgG 4-RD的泌尿系统损害常见于肾脏、输尿管,累及膀胱者罕见,通过检索PubMed、Embase、SinoMed、万方数据库及中国学术期刊网络出版总库等数据库,发现国外仅3例

>患者男,15岁,因"鼻塞、脓血涕1年,间断咯血5个月"于2017年10月就诊于北京协和医院风湿免疫科。患者2016年9月无明显诱因出现双侧鼻塞、脓血涕,间断鼻腔少量出血,当地医院多次查鼻窦CT提示鼻窦炎,予抗炎治疗效果不佳,症状反复。患者为青少年男性,无明显诱因出现双侧鼻塞伴脓血涕,有明确的影像学证据,但抗炎治疗效果不佳,考虑:①慢

腹腔脓肿是克罗恩病( Crohn's disease,CD)常见并发症,西方国家发生率为10%~30%,日本发生率约为9.9%,我国尚缺乏相关报道[1]. 传统上克罗恩病合并腹腔脓肿是手术的绝对适应证,因此,早期手术治疗占很大比例,包括手术引流、病变肠管切除、造瘘等. 由于手术创伤大、术后并发症多,目前开展的早期药物治疗和(或)经皮穿刺引流等微创手术同样取得了良好的治疗效果,可使部分患者延迟手术甚至避免手术. 美国一项基于全国住院患者资料的调查发现,自1998至2007年,克罗恩病合并腹腔脓肿患者接受手术治疗的比例由59%下降至32%,药物联合经皮穿刺引流的比例由7%增加至29%,单纯药物治疗的比例维持在 34% ~38%[2]. 2016 年欧洲克罗恩病和结肠炎组织( ECCO )循证共识也推荐对克罗恩病合并腹腔脓肿的患者首先抗感染、经皮穿刺或手术引流治疗,如有必要可延迟手术切除[3]. 但由于缺乏实践证据,目前药物治疗尚无统一方案,因此,现就文献总结分享克罗恩病腹腔脓肿的药物治疗经验.

痛风石是慢性期痛风的特征性表现,药物治疗起效缓慢,长期存在影响患者的心身健康.中性粒细胞胞外网状陷阱(NETs)可能参与了痛风石的形成,并且可通过降低炎症因子和趋化因子水平从而限制痛风急性期炎性反应.早期诊断水平的提高、新药的出现和手术方法的改进有助于预防痛风石的进一步损害.