[Clinical value of arterial stiffness assessment on risk prediction of vascular stiffness in the octogenarian elderly].

Objective: This study aimed to analyze clinical factors related to arterial stiffening and establish a risk prediction nomogram of arterial stiffening in the octogenarian(≥80 years). Methods: This study was a retrospective cross-sectional study, which enrolled the octogenarian elderly who underwent physical examination and secondary prevention intervention in the outpatient department of Chinese People's Liberation Army General Hospital from April 2022 to August 2022. Clinical data including demographics, biochemical indicators and medical history were collected. Brachial-ankle pulse wave velocity (baPWV) was detected during the clinical visit. Participants were divided into the control group (baPWV≤1 800 cm/s) and vascular sclerosis group (baPWV>1 800 cm/s). The risk factors of arterial stiffness were analyzed by univariate and logistic regression analysis, and the nomogram model was constructed by R programming language. The predictive effect of the nomogram model was evaluated by the receiver operating characteristic curve (ROC). Results: The median age of the 525 participants was 87.0 (82.0, 92.0) years, 504 (96.0%) were male, 82 in the control group, 443 in the vascular sclerosis group. The baPWV, age, systolic blood pressure, mean arterial pressure and diastolic blood pressure were significantly lower in the control group than those in the vascular sclerosis group (all P<0.05). Logistic regression analysis showed that high-density lipoprotein cholesterol, alanine aminotransferase and amylase were protective factors, and alkaline phosphatase and creatinine were risk factors of arterial stiffening (all P<0.05). The combined nomogram model scores including age, mean arterial pressure and the above five laboratory indicators indicated that mean arterial pressure and serum creatinine levels were strongly correlated with vascular sclerosis. The ROC curve suggested that the nomogram model had good prediction ability. Conclusions: Age, mean arterial pressure, high-density lipoprotein cholesterol, alanine aminotransferase, alkaline phosphatase, amylase and creatinine are independently determinants for increased vascular stiffness. The combined prediction model in this study can provide reference for individualized clinical risk prediction of vascular sclerosis in the octogenarian elderly.

Retrospective cohort study to examine the association between serum amylase and the incidence of type 2 diabetes mellitus, Toranomon Hospital Health Management Center Study 23 (TOPICS 23).

INTRODUCTION: Low serum amylase values are cross-sectionally associated with the prevalence of type 2 diabetes mellitus (T2DM) but have not been shown to be longitudinally associated with its incidence. This retrospective cohort (ie, historical cohort) study aimed to examine the association of previously lowered levels of serum amylase with incident T2DM. RESEARCH DESIGN AND METHODS: Examined were 8316 individuals who had annual health examinations for 6 years (ie, 7 times) at the Toranomon Hospital Health Management Center. The trajectory of serum amylase as the study exposure was classified into two elements: (1) serum amylase level at entry and (2) change in serum amylase, which was expressed as the annual change rate. The annual change rate was calculated by dividing the change in the amylase values according to follow-up periods. Regression analyses were performed to examine the association between low and decreased levels of serum amylase and the incidence of T2DM. RESULTS: Analyzed were 6917 individuals who had not developed T2DM within 1 year after cohort entry. T2DM thereafter occurred in 1021 patients. Cox regression indicated that the adjusted HR (95% CI) for incident T2DM for amylase ≤57 IU/L (quintile (Q) 1) was 0.97 (0.84 to 1.13) compared with amylase ≥58 IU/L (Q2-Q5). Logistic regression indicated that the adjusted OR (95% CI) for an annual change rate of amylase ≤-2.0% (Q1) vs ≥-1.9% (Q2-Q5) was 3.53 (3.00 to 4.16). The adjusted ORs were consistently significant throughout sensitivity analyses according to baseline amylase and the combination of age, body mass index, and hemoglobin A1c. CONCLUSIONS: Results showed that not low but previously decreased serum amylase was a risk factor for T2DM, suggesting the significance of periodic examinations of serum amylase values to detect individuals at high risk of T2DM.

Microscopic assessment of the degradation of millet starch granules by endogenous and exogenous enzymes during mashing.

The high gelatinization temperature (GT) of millet starch prevents the usage of infusion or step mashes as an effective means to generate fermentable sugars (FS) in brewing because the malt amylases lack thermostability at GT. Here, we investigate processing modifications to determine if millet starch can be efficiently degraded below GT. We determined that producing finer grists through milling did not introduce enough granule damage to markedly change gelatinization characteristics, though there was improved liberation of the endogenous enzymes. Alternatively, exogenous enzyme preparations were added to investigate their ability to degrade intact granules. At the recommended dosages (0.625 µL/g malt), significant FS concentrations were observed, although at lower concentrations and with a much-altered profile than possible with a typical wort. When exogenous enzymes were introduced at high (10×) addition rates, significant losses of granule birefringence and granule hollowing were observed well below GT, suggesting these exogenous enzymes can be utilized to digest millet malt starch below GT. The exogenous maltogenic α-amylase appears to drive the loss of birefringence, but more research is needed to understand the observed predominate glucose production.

Sustainable enzymatic treatment of organic waste in a framework of circular economy.

Enzymatic treatment of food and vegetable waste (FVW) is an eco-friendly approach for producing industrially relevant value-added products. This review describes the sources, activities and potential applications of crucial enzymes in FVW valorization. The specific roles of amylase, cellulase, xylanase, ligninase, protease, pectinase, tannase, lipase and zymase enzymes were explained. The exhaustive list of value-added products that could be produced from FVW is presented. FVW valorization through enzymatic and whole-cell enzymatic valorization was compared. The note on global firms specialized in enzyme production reiterates the economic importance of enzymatic treatment. This review provides information on choosing an efficient enzymatic FVW treatment strategy, such as nanoenzyme and cross-linked based enzyme immobilization, to make the process viable, sustainable and cheaper. Finally, the importance of life cycle assessment of enzymatic valorization of FVW was impressed to prove this approach is a better option to shift from a linear to a circular economy.

Assessment of probiotic and technological properties of Bacillus spp. isolated from Burkinabe Soumbala.

BACKGROUND: Soumbala is a highly loved alkaline traditional fermented food condiment in Burkina Faso. It harbors various microbiota dominated by fermentative Bacillus spp. as functional microorganism with little confirmed health-promoting properties. METHODS: The present study aimed to evaluate six Bacillus strains previously isolated and identified from soumbala. These strains were selected as presumptively safe bacteria for probiotic and technological characteristics. These strains were assessed for in vitro probiotic criteria (tolerance to acidic pH, gastric juice, 0.3% (m/v) bile salts, intestinal juice and 0.4% (w/v) phenol, cell surface hydrophobicity, auto-aggregation capacity, antimicrobial activity against foodborne pathogens, antibiotic susceptibility and biofilm production) and technological properties, including protease, amylase, lipase, and tannase activity, as well as poly-γ-glutamic acid (PGA) production and thermo-tolerance. RESULTS: All tested Bacillus strains (B54, F20, F24, F21, F26 and F44) presented variable relevant probiotic properties (good tolerance to pH 2 and pH 4, gastric juice, bile salts, intestinal juice and phenol), with marked differences in hydrophobicity and auto-aggregation capacity ranging from 73.62-94.71% and 49.35-92.30%, respectively. They exhibited a broad spectrum of activity against foodborne pathogens depending on target pathogen, with the highest activity exhibited by strain F20 (29.52 mm) against B. cereus 39 (p < 0.001). They also showed good biofilm production as well as variable hydrolytic enzyme activities, including protease (43.00-60.67 mm), amylase (22.59-49.55 mm), lipase (20.02-24.57 mm), and tannase (0-10.67 mm). All tested Bacillus strains tolerated temperature up to 50 °C, while only strains F26 and F44 showed the best PGA production. CONCLUSION: Overall, the tested cultures exhibiting potential probiotic and technological characteristics; particularly B. cereus F20, B. benzoevorans F21, B. cabrialessi F26, and B. tequilensis F44 could be a source of probiotic-starters of commercial interest in the production of high-quality soumbala.

Assessment of redox state and biochemical parameters of salivary glands in streptozotocin-induced diabetic male rats treated with mate tea (Ilex paraguariensis).

OBJECTIVE: The study aimed to assess the effects of mate tea [Ilex paraguariensis] on the redox state and biochemical parameters of salivary glands in diabetic male rats. DESIGN: Twenty-four male Wistar rats (3 months old) were randomly divided into groups (n = 8 per group): control rats that received water (C); diabetic rats that received water (D); diabetic rats treated with mate tea (DMT). The treated streptozotocin-induced diabetic rats were given mate tea powder by intragastric gavage at a dose of 20 mg/kg daily for 28 days. Content of total protein, amylase, oxidative lipid damage, measured as thiobarbituric acid reactive substances (TBARs), oxidative protein damage, measured as protein carbonyl, total antioxidant capacity, uric acid, reduced glutathione (GSH), superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx) were examined by the spectrophotometric method in the parotid and submandibular glands. RESULTS: The D group showed lower total protein, amylase, TBARs, protein carbonyl, total antioxidant capacity, GSH, uric acid, and GPx than the C group in both salivary glands, as well as higher SOD and CAT activities. The DMT group showed higher total protein, amylase, total antioxidant capacity, GSH, uric acid, and GPx than the D group in both salivary glands. Moreover, mate tea increased SOD in the parotid gland and CAT in the submandibular gland of diabetic rats but did not influence TBARs and protein carbonyl in either salivary gland compared to D group. CONCLUSION: Mate tea increased tissue protein synthesis and improved antioxidant defenses in the salivary glands of streptozotocin-induced diabetic male rats.

Reducing Phlebotomy, Length of Stay, Cost: Development of a Blunt Abdominal Trauma Pathway in a Level I, Pediatric Trauma Center.

OBJECTIVES: Blunt abdominal trauma (BAT) is a leading cause of morbidity in children with higher hemodynamic stabilities when compared with adults. Pediatric patients with BAT can often be managed without surgical interventions; however, laboratory testing is often recommended. Yet, laboratory testing can be costly, and current literature has not identified appropriate pathways or specific tests necessary to detect intra-abdominal injury after BAT. Therefore, the present study evaluated a proposed laboratory testing pathway to determine if it safely reduced draws of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase and lipase levels orders, emergency department (ED) length of stay, and cost in pediatric BAT patients. METHODS: A retrospective review of levels I, II, and III BAT pediatric patients (n = 329) was performed from 2015 to 2018 at our level I, pediatric trauma center. Patients were then grouped based on pre-post pathway, and differences were calculated using univariate analyses. RESULTS: After implementation of the pathway, there was a significant decrease in the number of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase, and lipase levels orders ( P < 0.05). Postpathway patients had lower average ED lengths of stay and testing costs compared with the pre pathway patients ( P < 0.05). There was no increase in rates of return to the ED within 30 days, missed injuries, or readmissions of patients to the ED. CONCLUSIONS: Results displayed that the adoption of a laboratory testing pathway for BAT patients reduced the number of laboratory tests, ED length of stay, and associated costs pediatric patients without impacting quality care.

Quality assessment of Portuguese monofloral honeys. Physicochemical parameters as tools in botanical source differentiation.

The quality evaluation and physicochemical parameters assessment of Portuguese monofloral honeys were performed. Fifty-one monofloral honeys were collected from several regions from mainland Portugal, and from the Azores islands, producer labelled as carob tree (n = 5), chestnut (n = 2), eucalyptus (n = 5), bell heather (n = 6), incense (n = 4), lavender (n = 8), orange (n = 9), rape (n = 2), raspberry (n = 2), rosemary (n = 1), sunflower (n = 3), and strawberry tree (n = 4). Pollen analysis and microbiological safety were evaluated, and the parameters such as colour index, moisture content, electrical conductivity, hydroxymethylfurfural, pH, free and total acidity, diastase activity, proline, and sugar profile were assessed for physicochemical characterization, in all 51 monofloral honeys. After melissopalynological examination, the honeys were either confirmed as monofloral, or classified as multifloral with predominance of a specific pollen type or multifloral. Microbiological analysis showed that honeys were safe for human consumption. Pairwise comparisons of physicochemical parameters, using only honey types with n ≥ 3, revealed significant differences between honey types. Despite some homogeneity in sugar profile among honeys, eucalyptus honey was significantly different in glucose, maltose and maltulose content compared to incense, orange and sunflower honeys, and also exhibited a higher isomaltose amount compared to all analyzed honeys. Electrical conductivity, colour index, free and total acidity, and diastase activity showed significant differences between the analyzed honeys, indicating that these parameters may provide an additional tool in monofloral honey identification.

Assessment of redox state and biochemical parameters of salivary glands in rats treated with anti-obesity drug sibutramine hydrochloride.

OBJECTIVES: To investigate the effects of anti-obesity drug sibutramine hydrochloride (SB) on redox state and biochemical parameters in the salivary glands. MATERIALS AND METHODS: Adult male Wistar rats were randomly divided into the following groups (n = 8 per group): control rats treated with vehicle (C) and rats treated with SB (10 mg/kg/day) by intragastric gavage for 28 days. The parotid (PG) and submandibular (SMG) glands were processed using histomorphometric analysis, and total protein, amylase, mucin, and oxidative damage to lipids were determined by measuring the formation of thiobarbituric acid reactive substances (TBARS), total antioxidant capacity (TAC), uric acid (UA), total glutathione (tGSH), superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx), and AKT phosphorylation. RESULTS: SB decreased the acinar area, and increased the stromal area in PG, while no effect on the morphometric parameters was observed in SMG. SB also increased oxidative damage to lipids (TBARs). The SB group showed lower total protein, amylase, TAC, UA, tGSH, SOD, CAT, and GPx than the C group in PG, while in SMG, SB decreased total protein, mucin, tGSH, SOD, CAT, and GPx. However, increased AKT phosphorylation observed in both salivary glands suggests that SB exerts low-intensity oxidative stress. CONCLUSIONS: SB impaired enzymatic and non-enzymatic antioxidant defenses in the salivary glands of rats. CLINICAL RELEVANCE: Chronic treatment with SB could mitigate salivary gland dysfunction due to disturbance of redox state.

Stat Laboratory Interventions to Improve Patient Management in the Emergency Department and Resource Expenditure: A 10-Year Study.

OBJECTIVE: To illustrate the changes in stat laboratory procedures over a 10 year period. MATERIALS AND METHODS: We implemented 5 different interventions: reporting total bilirubin through the icteric index, replacing total proteins for albumin, reporting albumin-adjusted calcium in hyper- or hypocalcemia, using lipase as a first marker and amylase-selected scenario, and measuring magnesium in hypocalcemia, hypokalemia, or high lipase values. RESULTS: Only 9.9% of total bilirubin that was requested was measured, which resulted in savings of $22,492.83. There were 30,036 albumin tests measured, and $15,625.18 was saved replacing total protein. There was $41,374.38 spent to measure lipase and amylase; the difference in costs from the lipase establishment was $16,929.62. Finally, $382.30 was spent for magnesium: 717 magnesium levels were measured given hypocalcemia or hypokalemia (42.8% hypomagnesemia), and 123 tests were added because of high lipase (35% hypomagnesemia). Overall, $53,374.15 was saved. CONCLUSION: Progressive changes in stat laboratory procedures resulted in more efficient resources expenditures.

A Comparative Quantitative Assessment of Salivary Iga and Alpha Amylase in Caries Free and Caries Active Children.

OBJECTIVES: The aim of the study was to assess the salivary IgA (immunoglobulin A) and alpha amylase levels in the unstimulated whole saliva samples of caries-free and caries-active children and correlate it with the caries status and age. STUDY DESIGN: The salivary IgA and amylase was investigated in 100 children in the range of 8-12 years divided in two groups, control group (DMFT and/or deft = 0) and study group (DMFT/deft score ≥5). The salivary IgA was measured using kit based on two-site sandwich enzyme immunoassay principle and amylase was estimated using the vitro amyl slides. RESULTS: The mean salivary IgA and amylase levels in the saliva of the children in the control group was found to be significantly increased (p=.001 and p=.014 respectively) whereas the relationship between salivary IgA and amylase levels in the saliva of the children was found to be insignificant with the age (p=.392 and p=.306 respectively). CONCLUSIONS: The results indicated that salivary IgA and amylase levels in saliva increased significantly in caries free children and the level of salivary IgA and alpha amylase has no significant relation with the age of the children.

Assessment of serum amylase, lipase and associated factors among patients with visceral leishmaniasis treated with sodium stibogluconate/paromomycin at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.

BACKGROUND: Visceral leishmaniasis (VL) is a life-threatening parasitic disease next to malaria, which is responsible for the death of 50,000 patients annually. It has three major clinical stages, including visceral, cutaneous, and mucocutaneous leishmaniasis. Ethiopia is one of the east African countries commonly affected with leishmanisis disease. There are many drugs for leishmaniasis, including sodium stibogluconate and paromomycin combined therapy. However, the adverse effect of those combined drugs is not well-defined. Therefore, the purpose of this study was to assess serum amylase, lipase, and associated factors among patients with VL treatment with those combined drugs. METHODS: Hospital-based cross-sectional study was conducted at the University of Gondar Comprehensive Specialized Hospital Leishmaniasis Research and Treatment Center from February to September 2020 G.C. Simple random sampling technique was utilized to select study participants. The study participants who fulfill the inclusion criteria were included in the study with written informed consent. 5 ml of blood was withdrawn by an experienced health professional to analyze serum amylase and lipase level. Descriptive data was presented by tables, charts and graphs. Data was cleared, entered by Epi-data version 3.1 then transfer to STATA 14.1 SE version and for analysis paired t-test was used, for factors correlation and regression was used. Those factor variable who have p-value <0.25 was filtered and goes to multivariate regression and p-value <0.05 was considered as significant variables. RESULTS: The result of this study showed that there was a significant mean difference between serum pancreatic amylase and lipase before and after treatment. The mean ± SD level of serum amylase after treatment showed a statistically significant elevation (P<0.001) as compared to its level before treatment. Similarly, the mean ± SD level of serum lipase after treatment showed a statistically significant elevation (P<0.001) as compared to its level before treatment. There was also significant association between age and baseline serum amylase as compared to serum amylase after treatment. Similarly, there was also significant relation of age and serum lipase with serum lipase after treatment. CONCLUSION: In this study, the level of serum amylase and lipase at treatment of cure was higher and there was an increase in mean serum amylase and lipase after a patient taking sodium stibogluconate and paromomycin combined drugs. Consequently, the elevated result of these biochemical profiles mainly associated with drug induced adverse effect and associated risk factors in VL patients.

A physicochemical assessment of the thermal stability of dextrin-colistin conjugates.

Attachment of polysaccharide carriers is increasingly being used to achieve precision delivery and improved effectiveness of protein and peptide drugs. Although it is clear that their clinical effectiveness relies on the purity and integrity of the conjugate in storage, as well as following administration, instability of polysaccharide-based conjugates can reduce the protective efficacy of the polymer, which may adversely affect the bioactive's potency. As a model, these studies used dextrin-colistin conjugates, with varying degrees of polymer modification (1, 2.5 and 7.5 mol% succinoylation) to assess the effect of storage temperature (- 20, 4, 21 and 37 °C) and duration (up to 12 months) on saccharide and colistin release and antimicrobial activity. Estimation of the proportion of saccharide release (by comparison of area under the curve from size exclusion chromatograms) was more pronounced at higher temperatures (up to 3 and 35% at - 20 °C and 37 °C, respectively after 12 months), however, repeated freeze-thaw did not produce any measurable release of saccharides, while addition of amylase (20, 100, 500 IU/L) caused rapid release of saccharides (> 70% total within 24 h). At all temperatures, conjugates containing the lowest degree of succinoylation released the highest proportion of free colistin, which increased with storage temperature, however no trend in saccharide release was observed. Despite the clear physical effects of prolonged storage, antimicrobial activity of all samples was only altered after storage at 37 °C for 12 months (> threefold decreased activity). These results demonstrate significant release of saccharides from dextrin-colistin conjugates during prolonged storage in buffered solution, especially at elevated temperature, which, in most cases, did not affect antimicrobial activity. These findings provide vital information about the structure-activity relationship of dextrin-colistin conjugates, prior to full-scale commercial development, which can subsequently be applied to other polysaccharide-protein and -peptide conjugates.

Clinical application of enhanced recovery after surgery in the treatment of choledocholithiasis by ERCP.

ABSTRACT: This study aims to investigate the effect of applying enhanced recovery after surgery methods (ERAS) in perioperative nursing of choledocholithiasis following endoscopic retrograde cholangiopancreatography (ERCP) for treatment of biliary calculus.Clinical data from 161 patients who underwent ERCP surgery in Wuhan Union Hospital from January 2017 to December 2019 were retrospectively analyzed. A total of 78 patients received perioperative nursing using the ERAS concept (experimental group) and 83 patients received conventional perioperative nursing (control group). Group differences were compared for the time to first postoperative ambulation, exhausting time, time to first defecation and eating, intraoperative blood loss, postoperative complication incidence (pancreatitis, cholangitis, hemorrhage), white blood cell (WBC), and serum amylase (AMS) values at 24 hours, duration of nasobiliary duct indwelling, length of hospital stay, and hospitalization expenses.No significant between-group differences were noted for demographic characteristics (age, sex, BMI, ASA score, and comorbidity) (P > .05). Time to first ambulation, exhausting time, time to defecation and eating, and nasobiliary drainage time were shorter in the experimental group than the control group, and the differences were statistically significant (P < .05). There was no significant between-group difference in postoperative WBC values at 24 hours (P > .05), but the experimental group's AMS values at 24 hours postoperation were significantly lower than those of the controls (154.93 ±â€Š190.01 vs 241.97 ±â€Š482.64, P = .031). Postoperative complications incidence was 9.1% in the experimental group, which was significantly lower than the 20.4% in the control group, and this difference was statistically significant (P = .039). Compared with the control group, nasobiliary drainage time (26.53 ±â€Š7.43 hours vs 37.56 ±â€Š9.91 hours, P < .001), hospital stay (8.32 ±â€Š1.55 days vs 4.56 ±â€Š1.38 days, P < .001), and hospitalization expenses (36800 ±â€Š11900 Yuan vs 28900 ±â€Š6500 Yuan, P = .016) were significantly lower in the experimental group.ERAS is a safe and effective perioperative nursing application in ERCP for treating choledocholithiasis. It can effectively accelerate patients' recovery and reduce the incidence of complications; therefore, it is worthy of being applied and promoted in clinical nursing.

Development and validation of the bile leakage grading criterion in patients following Roux-en-Y hepaticojejunostomy.

OBJECTIVE: The present research aimed to propose a severity grading criterion for bile leakage in pediatric patients after Roux-en-Y hepaticojejunostomy for choledochal cysts. SUMMARY BACKGROUND DATA: Despite a bile leakage classification system from the International Study Group of Liver Surgery (ISGLS) has been developed, a commonly used grading system for pediatric patients after Roux-en-Y hepaticojejunostomy has not yet been established. METHODS: A review of clinical, laboratory, and ultrasonographic parameters were used to develop a grading system for classifying the severity of bile leakage. A total of 267 patients with bile leakage were retrospectively assessed to review the system. RESULTS: We developed a grading system for bile leakage severity for use in pediatric patients following Roux-en-Y hepaticojejunostomy. By applying the criteria to 267 patients, grade I, II, or III bile leakage was determined in 103 patients (8.7%), 115 patients (9.8%), and 49 patients (4.2%) patients, respectively. The most severe bile leakage grade (grade III), was associated with significantly higher γ-glutamyl transpeptidase and amylase levels, greater drain fluid output, more intensive care unit (ICU) admissions, and longer postoperative hospital stay. Interestingly, patients with grade II leakage who underwent reoperation had significantly more ICU admissions, longer postoperative hospital stays (p < 0.05), and higher overall hospitalization cost (p < 0.05) compared with those who underwent conservation management. Of the patients with bile duct stricture and common bile duct (CBD) stones, there were no differences among the different grades of postoperative bile leakage. CONCLUSIONS: The proposed bile leakage criteria may optimize objective diagnosis and therapeutic modalities.

Cost of Unnecessary Amylase and Lipase Testing at Multiple Academic Health Systems.

OBJECTIVES: To determine adherence to Choosing Wisely recommendations for using serum lipase to diagnose acute pancreatitis rather than amylase, avoiding concurrent amylase/lipase testing and avoiding serial measurements after the first elevated test as both are ineffective for tracking disease course. METHODS: Deidentified laboratory data from four large health systems were analyzed to determine concurrent testing rates, serial testing rates, and provider-ordering patterns. RESULTS: While most providers adhered to recommendations with 58,693 lipase-only tests ordered and performed, 86% of amylase tests were performed concurrently with lipase. Ambulatory, inpatient, and emergency department settings revealed concurrent rates of 51%, 41%, and 8%, respectively. Services with order sets containing both amylase and lipase were associated with higher rates of concurrent testing. CONCLUSIONS: Concurrent amylase/lipase testing is an area of opportunity to improve compliance, especially in ambulatory settings. Revision of order sets and provider education could be interventions to reduce unnecessary testing and save costs.

Assessing abdominal pain in adults: a rational, cost-effective, and evidence-based strategy.

The management of abdominal pain has changed significantly in the past 20 years, with increasing emphasis on identifying patients who are at high risk for occult pathology and worse outcomes. Emphasizing safe disposition over diagnosis, this issue identifies the important aspects of the history and physical examination, explores strengths and weaknesses of laboratory evaluations, and summarizes the pros and cons of the many types of imaging now available. With abdominal pain still the most common chief complaint seen in the emergency department, a new look at the evolution of assessment strategies is in order, such as new recommendations on the use of oral contrast, managing HIV patients on highly active antiretroviral therapy, maximizing use of bedside ultrasound, when and how to offer pain relief, and the value of serial examinations and observation to reduce costs and improve care.

Risk of Immune-Related Pancreatitis in Patients with Solid Tumors Treated with Immune Checkpoint Inhibitors: Systematic Assessment with Meta-Analysis.

We performed a systematic review and meta-analysis to determine the risk of immune-related pancreatitis associated with the treatment by immune checkpoint inhibitors (ICIs) for solid tumors. Eligible studies were selected from multiple databases including phase II/III randomized controlled trials (RCTs) with ICIs in solid tumor patients. The data were analyzed with Stata version 12.0 software. After excluding ineligible studies, a total of 15 clinical trials were considered eligible for the meta-analysis, which included 9099 patients. Compared with chemotherapy or placebo, the risk ratio (RR) for all-grade lipase elevation after CTLA-4 inhibitor treatment was 1.05 (95% confidence interval (CI): 1.01-2.24, p = 0.047). However, the risk for pancreatitis after ICI treatment in any subgroup was not significantly higher than that after control therapy. In addition, compared with ipilimumab/nivolumab alone, the RR for all-grade and high-grade lipase elevation under combination treatment of nivolumab and ipilimumab was 6.43 (95% CI: 1.43-28.99, p = 0.015) and 6.44 (95% CI: 1.39-29.79, p = 0.017), respectively, and the RR for all-grade amylase elevation under combination treatment was 6.08 (95% CI: 1.51-24.44, p = 0.011). Our meta-analysis has demonstrated that both CTLA-4 inhibitors alone and combination treatment of nivolumab and ipilimumab could increase the risk of amylase or lipase elevation, but not significantly increase the risk of pancreatitis when compared with controls.

Decision analysis supports the use of drain amylase-based enhanced recovery method after esophagectomy.

Postesophagectomy anastomotic leak is a common postsurgical complication. The current standard method of detecting leak is esophagram usually late in the postoperative period. Perianastomotic drain amylase level had shown promising results in early detection anastomosis leak. Previous studies have shown that postoperative day 4 amylase level is more specific and sensitive than esophagram. The purpose of this study is to determine if implementing a drain amylase-based screening method for anastomotic leak can reduce length of stay and hospital cost relative to a traditional esophagram-based pathway. The drain amylase protocol we propose uses postoperative day 4 drain amylase level to direct the initiation of PO intake and discharge. We designed a decision analysis tree using TreeAge Pro software to compare the drain amylase-based screening method to the standard of care, the esophagram. We performed a retrospective review of postesophagectomy patients from a tertiary academic medical center (University hospital Cleveland medical center) where amylase level was measured routinely postoperatively. The patients were separated into amylase-based pathway group and the standard of care group based on their postop management. The length of stay, costs, complications, and leak rate of these two groups were used to inform the decision analysis tree. In the base-case analysis, the decision analysis demonstrated that an amylase-based screening method can reduce the hospital stay by one day and reduced costs by ∼$3,000 compared to esophagram group. To take the variability of the data into consideration, we performed a Monte Carlo simulation. The result showed again a median saving of 0.71 days and ∼$2,500 per patient in hospital cost. A ballistic sensitivity analysis was performed to show that the sensitivity of postoperative day 4 amylase level in detecting a leak was the most important factor in the model. We conclude that implementing an amylase-based screening method for anastomotic leak in postesophagectomy patient can significantly reduce hospital cost and length of stay. This study demonstrates a novel protocol to improve postesophagectomy care. Based on this result, we believe a prospective multicenter study is appropriate.

Evaluation of Drain Amylase Level after Pancreaticoduodenectomy with Special Reference to Delayed Pancreatic Fistula.

Postoperative pancreatic fistula (PF) is a relatively frequent and occasionally fatal complication of pancreatoduodenectomy (PD). Several risk factors for PF have been reported, including high drain amylase level (D-AMY). Among the 140 consecutive patients who underwent PD, we analyzed 110 cases with D-AMY measurements over time after PD. According to the D-AMY change, we divided patients into five patterns and defined delayed PF cases. We analyzed clinical characteristics, including serum amylase and D-AMY, and examined the correlation between the period of drain insertion and PF grade. In 15 delayed PF cases, 12 cases were grade B or C, pancreatic cancer was less frequent, pancreatic ducts were smaller, and soft pancreas texture was more commonly observed. The D-AMY on postoperative day (POD) 1 was higher in cases of delayed PF compared with non-PF cases (P < 0.0001). In 28 cases with drain removal before POD 7, grade B or C PF was not observed afterward. The average D-AMY on POD 1 in cases with drain removal before POD 1 was significantly lower than in delayed PF cases. Although further studies are required to determine the most appropriate timing of drain removal, it is thought that intra-abdominal drains should be removed within seven days of PD in cases without signs of PF. On the other hand, delayed PF should be considered in cases of soft pancreas texture and/or high D-AMY on POD 1, even if D-AMY levels are low on POD 3 or decreasing on POD 5.