Outcome and quality of life of patients with acute pancreatitis requiring intensive care

Quality of life after severe acute pancreatitis: systematic review

BACKGROUND

Severe acute pancreatitis, the most severe form of acute pancreatitis, can alter pancreatic morphology, physiology, and function resulting in long-term morbidity, even after a single episode. This review assesses long-term outcomes and quality of life of severe acute pancreatitis.

METHODS

A comprehensive literature review was conducted across MEDLINE, Embase, Scopus, and PubMed electronic databases on 18 January 2021 and updated on 26 April 2022 to ensure no new literature had been omitted. All studies were prospective or retrospective, included adult patients (>18 years) presenting with acute pancreatitis for whom data on long-term outcomes specifically after severe acute pancreatitis were reported. Quantitative and qualitative data extraction and synthesis were carried out and no meta-analysis was performed. Outcome measures included aetiology and mortality of severe acute pancreatitis, length of stay, endocrine and exocrine pancreatic insufficiency, chronic symptoms, and quality of life compared with healthy controls as assessed by validated questionnaires.

RESULTS

Fourteen retrospective cohort studies were included, for a total of 779 patients, using quality of life questionnaires. The most common aetiology of severe acute pancreatitis was biliary (36 per cent) followed by alcoholic (29 per cent). Mortality rate ranged from 5 to 35 per cent and length of stay ranged from 2 to 367 days. Quality of life was somewhat lower in patients with exocrine insufficiency, but unaffected by endocrine insufficiency or chronic symptoms. Quality of life was more likely to be reduced in the first 4 years but normalize thereafter and was more likely to be negatively affected where alcohol was the aetiology. In four studies, the relationship between disease severity and lower quality of life was investigated, and a significant correlation was found.

CONCLUSION

The review shows how a single episode of severe acute pancreatitis can have a variable effect on long-term quality of life, which is different to previous studies showing a strong reduction in quality of life. This could indicate that in current times treatment modalities are more effective.

Mortality and costs related to severe acute pancreatitis in the intensive care units of Australia and New Zealand (ANZ), 2003-2020

BACKGROUND AND OBJECTIVE

Comprehensive data on the burden of severe acute pancreatitis (SAP) in global intensive care units (ICUs) and trends over time are lacking. Our objective was to compare trends in hospital and ICU mortality, in-hospital and ICU length of stay, and costs related to ICU admission in Australia and New Zealand (ANZ) for SAP.

METHODS

We performed a retrospective, observational, cohort study of ICU admissions reported to the ANZ Intensive Care Society Adult Patient Database over three consecutive six-year time periods from 2003 to 2020.

RESULTS

12,635 patients with SAP from 189 ICUs in ANZ were analysed. No difference in adjusted hospital mortality (11.4% vs 11.5% vs 11.0%, p = 0.85) and ICU mortality rates (7.5% vs 8.0% vs 8.1%, p = 0.73) were noted over the study period. Median length of hospital admission reduced over time (13.9 days in 2003-08, 13.1 days in 2009-14 and 12.5 days in 2015-20; p < 0.01). No difference in length of ICU stay was noted over the study period (p = 0.13). The cost of managing SAP in ANZ ICUs remained constant over the three time periods.

CONCLUSIONS

In critically-ill SAP patients in ANZ, no change in mortality has been noted over nearly two decades. There was a slight reduction in hospital stay (1 day), while the length of ICU stay remained unchanged. Given the significant costs related to care of patients with SAP in ICU, these findings highlight the need to prioritise resource allocation for healthcare delivery and targeted clinical research to identify treatments aimed at reducing mortality.

Quality of life after surgical and endoscopic management of severe acute pancreatitis: A systematic review

BACKGROUND

Treatment for severe acute severe pancreatitis (SAP) can significantly affect Health-related quality of life (HR-QoL). The effects of different treatment strategies such as endoscopic and surgical necrosectomy on HR-QoL in patients with SAP remain poorly investigated.

AIM

To critically appraise the available evidence on HR-QoL following surgical or endoscopic necrosectomy in patient with SAP.

METHODS

A literature search was performed on PubMed, Google™ Scholar, the Cochrane Library, MEDLINE and Reference Citation Analysis databases for studies that investigated HR-QoL following surgical or endoscopic necrosectomy in patients with SAP. Data collected included patient characteristics, outcomes of interventions and HR-QoL-related details.

RESULTS

Eleven studies were found to have evaluated HR-QoL following treatment for severe acute pancreatitis including 756 patients. Three studies were randomized trials, four were prospective cohort studies and four were retrospective cohort studies with prospective follow-up. Four studies compared HR-QoL following surgical and endoscopic necrosectomy. Several metrics of HR-QoL were used including Short Form (SF)-36 and EuroQol. One randomized trial and one cohort study demonstrated significantly improved physical scores at three months in patients who underwent endoscopic necrosectomy compared to surgical necrosectomy. One prospective study that examined HR-QoL following surgical necrosectomy reported some deterioration in the functional status of the patients. On the other hand, a cohort study that assessed the long-term HR-QoL following sequential surgical necrosectomy stated that all patients had SF-36 > 60%. In the only study that examined patients following endoscopic necrosectomy, the HR-QoL was also very good. Three studies investigated the quality adjusted life years suggesting that endoscopic and surgical approaches to management of pancreatic necrosis were comparable in cost effectiveness. Finally, regarding HR-QoL between open necrosectomy and minimally invasive approaches, patients who underwent the later had a significantly better overall quality of life, vitality and mental health.

CONCLUSION

This review would suggest that the endoscopic approach might offer better HR-QoL compared to surgical necrosectomy. However, the available comparative literature was very limited. More randomized trials powered to detect differences in HR-QoL are required.

Analysis of Patients with Alcohol Dependence Treated in Silesian Intensive Care Units

Analysis of patients with alcohol dependence (AD) treated in intensive care units has never been performed in Poland. Data from 25,416 adult patients identified in a Silesian Registry of Intensive Care Units were analysed. Patients with AD were identified, and their data were compared with the remaining population. Preadmission and admission variables that independently influenced ICU death in these patients were identified. Among 25,416 analysed patients, 2285 subjects (9.0%) were indicated to have AD among their comorbidities. Patients with AD were significantly younger (mean age: 53.3 ± 11.9 vs. 62.2 ± 15.5 years, p < 0.001) but had a higher mean APACHE II score at admission and were more frequently admitted to the ICU due to trauma, poisonings, acute pancreatitis, and severe metabolic abnormalities. ICU death and unfavourable outcomes were more frequent in these patients (47.8% vs. 43.0%, p < 0.001 and 54.1% vs. 47.0%, p < 0.001, respectively). Multiorgan failure as the primary cause of ICU admission was among the most prominent independent risk factors for ICU death in these patients (OR: 3.30, p < 0.001). Despite the younger age, ICU treatment of patients with AD was associated with higher mortality and a higher percentage of unfavourable outcomes.

Patient-reported outcomes after minimally invasive retroperitoneal pancreatic necrosectomy to treat acute pancreatitis: An exploratory study

OBJECTIVE

The aim of this study (abbreviated as QUANTUM) was to assess the quality of life (QoL) of patients who underwent minimally invasive retroperitoneal pancreatic necrosectomy (MIRPN) for acute pancreatic necrosis with or without infection of necrotic tissue collections after discharge and to compare the patient-reported outcomes (PRO) in these patients with published data in normative population.

METHODS

Patients with acute pancreatitis who underwent MIRPN between January 2010 and December 2016 were identified and invited to complete the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and EORTC PAN28(CP) questionnaires. PRO were compared using Pearson correlation coefficient and ANOVA (significance P < 0.01) with an age- and sex-matched normative population of western Europe, stratified by age, and also the time duration after MIRPN (<3 y and >3 y). A change >15 points in the PRO score was taken as clinically important.

RESULTS

Among 52 eligible patients identified, 46 (88%) agreed to participate, 74% returned questionnaires. After the MIRPN all patients had worse physical and social functioning scores with a clinically important (>15 points) reduction in those ≤50 years; while fatigue, pain and insomnia symptom scales had the highest scores (42, 26 and 30 points, respectively). Patients <3 years after MIRPN had similar scores for all functional scales and global health-related quality of life (HRQoL) compared to the normative population. However, over time their global HRQoL deteriorated and after 3 years their scores for functioning and symptoms were statistically (P < 0.0001) and clinically (>15 points) worse than those in age-matched controls.

CONCLUSIONS

During the first 3 years after the MIRPN patients have a relatively high QoL but report worse fatigue than the normative population. However, patients should be informed that their HRQoL deteriorates with time, often due to chronic pancreatitis and pancreatic insufficiency. This study supports the use of MIRPN and prospective studies of HRQoL in this setting are indicated.

The Short- and Long-Term Burden of Acute Pancreatitis in the United States: A Retrospective Cohort Study

OBJECTIVES

This retrospective cohort study assessed short- and long-term economic, clinical burden, and productivity impacts of acute pancreatitis (AP) in the United States.

METHODS

United States claims data from patients hospitalized for AP (January 1, 2011-September-30, 2016) were sourced from MarketScan databases. Patients were categorized by index AP severity: severe intensive care unit (ICU), severe non-ICU, and other hospitalized patients.

RESULTS

During index, 41,946 patients were hospitalized or visited an emergency department for AP. For inpatients, median (interquartile range) AP-related total cost was $13,187 ($12,822) and increased with AP severity (P < 0.0001). During the postindex year, median AP-related costs were higher (P < 0.0001) for severe ICU versus severe non-ICU and other hospitalized patients. Hours lost and costs due to absence and short-term disability were similar between categories. Long-term disability costs were higher (P = 0.005) for severe ICU versus other hospitalized patients. Factors associated with higher total all-cause costs in the year after discharge included AP severity, length of hospitalization, readmission, AP reoccurrence, progression to chronic pancreatitis, or new-onset diabetes (P < 0.0001).

CONCLUSIONS

An AP event exerts substantial burden during hospitalization and involves long-term clinical and economic consequences, including loss of productivity, which increase with index AP event severity.

Variation in outcome of invasive mechanical ventilation between different countries for patients with severe COVID-19: A systematic review and meta-analysis

BACKGROUND

COVID 19 is the most recent cause of Adult respiratory distress syndrome ARDS. Invasive mechanical ventilation IMV can support gas exchange in patients failing non-invasive ventilation, but its reported outcome is highly variable between countries. We conducted a systematic review and meta-analysis on IMV for COVID-associated ARDS to study its outcome among different countries.

METHODS

CENTRAL, MEDLINE/PubMed, Cochrane Library, and Scopus were systematically searched up to August 8, 2020. Studies reporting five or more patients with end point outcome for severe COVID 19 infection treated with IMV were included. The main outcome assessed was mortality. Baseline, procedural, outcome, and validity data were systematically appraised and pooled with random-effect methods. Subgroup analysis for different countries was performed. Meta-regression for the effect of study timing and patient age and were tested. Publication bias was examined. This trial was registered with PROSPERO under registration number CRD42020190365.

FINDINGS

Our electronic search retrieved 4770 citations, 103 of which were selected for full-text review. Twenty-one studies with a combined population of 37359 patients with COVID-19 fulfilled the inclusion criteria. From this population, 5800 patients were treated by invasive mechanical ventilation. Out of those, 3301 patients reached an endpoint of ICU discharge or death after invasive mechanical ventilation while the rest were still in the ICU. Mortality from IMV was highly variable among the included studies ranging between 21% and 100%. Random-effect pooled estimates suggested an overall in-hospital mortality risk ratio of 0.70 (95% confidence interval 0.608 to 0.797; I2 = 98%). Subgroup analysis according to country of origin showed homogeneity in the 8 Chinese studies with high pooled mortality risk ratio of 0.97 (I2 = 24%, p = 0.23) (95% CI = 0.94-1.00), similar to Italy with a low pooled mortality risk ratio of 0.26 (95% CI 0.08-0.43) with homogeneity (p = 0.86) while the later larger studies coming from the USA showed pooled estimate mortality risk ratio of 0.60 (95% CI 0.43-0.76) with persistent heterogeneity (I2 = 98%, p<0.001). Meta-regression showed that outcome from IMV improved with time (p<0.001). Age had no statistically significant effect on mortality (p = 0.102). Publication bias was excluded by visualizing the funnel plot of standard error, Egger's test with p = 0.714 and Begg&Mazumdar test with p = 0.334.

INTERPRETATION

The study included the largest number of patients with outcome findings of IMV in this current pandemic. Our findings showed that the use of IMV for selected COVID 19 patients with severe ARDS carries a high mortality, but outcome has improved over the last few months and in more recent studies. The results should encourage physicians to use this facility when indicated for severely ill COVID-19 patients.

Patients' Perceptions of Experiences of Recovering From Acute Pancreatitis: An Interview Study

The incidence of registered admissions in inpatient care with a diagnosis of acute pancreatitis was 58 per 100,000 capita in Sweden during the year 2013. Although acute pancreatitis is a well-explored area, there is a demand for research from the patients' perceptions. The aim of this study was to describe patients' perceptions of recovering from acute pancreatitis. Data collection for this phenomenographical study included 16 individual semistructured interviews. Analysis was done according to the 7 steps suggested by . Recovery after acute pancreatitis was perceived within 5 categories; a time of physical suffering, an emotional journey, challenges to the usual life and its good qualities, barriers and need for social support, and healthcare as an important factor. Physical and emotional symptoms influence recovery after acute pancreatitis by challenging the good things and things that are taken for granted in everyday life. Promoting factors toward good recovery was a proper support from the social network as well as healthcare providers.

Serum soluble fibrinogen-like protein 2 concentration predicts delirium after acute pancreatitis

OBJECTIVE

Inflammation can cause delirium. Soluble fibrinogen-like protein 2 (sFGL2) is a modulator of the immune response and more recently found to be a biomarker for brain injury. This study was designed to discover the predictive capability of serum sFGL2 concentrations for delirium after acute pancreatitis (AP).

MATERIALS AND METHODS

In this prospective, observational study, serum sFGL2 concentrations were quantified in 184 healthy controls and in 184 AP patients. Disease severity was assessed by Acute Physiology and Chronic Health Care Evaluation II score, Ranson score, multiple organ dysfunction score, and sequential organ failure assessment score. Delirium was recorded during hospital stay. Predictors of delirium were identified using multivariate analysis.

RESULTS

Serum sFGL2 concentrations were substantially higher in AP patients than in controls. Serum sFGL2 concentrations were intimately correlated with the preceding severity parameters. Serum sFGL2 and the aforementioned severity parameters were independent predictors for delirium. Under receiver operating characteristic curve, the discriminatory ability of serum sFGL2 was equivalent to those of the above-mentioned severity parameters. Moreover, serum sFGL2 dramatically improved the predictive value of the aforementioned severity parameters.

CONCLUSIONS

Elevation of serum sFGL2 concentrations is strongly associated with the AP severity and has the potential to distinguish delirium after AP.

Moderately severe and severe acute pancreatitis : a systematic review of the outcomes in the USA and European Union-5

Background and objectives

The global incidence of hospitalisation due to acute pancreatitis (AP) has been rising in the recent decades. In the USA alone, there was a 13.2% increase between 2009 and 2012 compared with 2002–2005. There remains a lack of approved treatments to prevent disease progression, leaving many liable to developing complications that include multisystem organ failure (OF) and death. This therapeutic deficit raises questions about the scale of the current burden of illness (BOI) associated with severe forms of AP. The aim of the systematic literature review (SLR) was to assess clinical, humanistic, and economic outcomes associated with moderately severe AP (MSAP) and severe AP (SAP) in the USA and the European Union-5 (EU-5).

Methods

Systematic searches were conducted in MEDLINE and Embase to identify studies published in English (between 2007 and 2017) that reported on the BOI of MSAP and/or SAP. Manual searches of ‘grey’ literature sources were also conducted.

Results

The SLR identified 19 studies which indicated that 15%–20% of patients with AP progress to more severe forms of the disease, up to 10.5% of those with SAP require surgery for complications, and up to 40% die during hospitalisation. By contrast, there appears to be a lack of data on the extent to which SAP affects patients’ quality of life.

Conclusion

The available evidence clearly demonstrates that the current management for MSAP and SAP in the USA and EU-5 does not adequately meet patients’ needs. Early identification and intervention for AP is crucial, given the evidence of high rates of morbidity and an associated economic burden that is considerable. Since many patients with the condition present to hospitals at a point when multisystem OF or death is highly likely, there is a particularly urgent need for effective treatment options to prevent disease progression.

Predictive value of serum cyclophilin A concentrations after acute pancreatitis

BACKGROUND

Cyclophilin A is identified as a biomarker for inflammation. We elucidated prognostic significance of serum cyclophilin A (CypA) concentrations in acute pancreatitis (AP).

METHODS

In this prospective and observational study, serum CypA concentrations were quantified in 210 AP patients and 100 healthy controls. We recorded local complication, in-hospital mortality and organ failure. Disease severity was assessed using the traditional predictors, namely Acute Physiology and Chronic Health Care Evaluation II score, Ranson score, multiple organ dysfunction score and sequential organ failure assessment score.

RESULTS

Serum CypA concentrations were significantly lower in controls than in AP group. CypA concentrations after AP were highly correlated with the traditional predictors and other inflammatory mediators, including blood erythrocyte sedimentation rate, procalcitonin levels, white blood cell count and C-reactive protein levels. Serum CypA emerged as an independent predictor for in-hospital local complication, organ failure and mortality. Under receiver operating characteristic curve, serum CypA possessed similar prognostic ability, as compared to the traditional predictors. Its predictive ability was almost similar to that of procalcitonin levels and significantly exceeded those of the other inflammatory mediators. Also, it significantly improved prognostic performance of the traditional predictors.

CONCLUSIONS

Increased serum CypA concentrations have close relation to the severity, inflammation and prognosis, substantializing CypA as a potential prognostic biomarker of AP.

Recurrent Acute Pancreatitis Significantly Reduces Quality of Life Even in the Absence of Overt Chronic Pancreatitis

OBJECTIVES

The impact of recurrent acute pancreatitis (RAP) on quality of life (QOL) is unknown. We hypothesized that RAP would reduce QOL even in the absence of chronic pancreatitis (CP).

METHODS

Data were pooled from three prospective, cross-sectional studies conducted across 27 U.S. centers (the North American Pancreatitis Studies); these included subjects with chronic pancreatitis (n = 1086), RAP alone (n = 508), and non-disease controls (n = 1025). QOL was measured using the Short Form 12 (SF-12), generating a Physical Component Summary (PCS) and the Mental Component Summary score (MCS). Multivariable regression models were developed to measure the effect of RAP on QOL, the predictors of lower QOL in those with RAP, and the differential effect QOL predictors between CP and RAP.

RESULTS

Compared to controls (51.0 ± 9.4), subjects with RAP (41.1 ± 11.4) and CP (37.2 ± 11.8) had lower PCS (p < 0.01). Subjects with CP had lower PCS compared to those with RAP (p < 0.01). Similarly, MCS was lower among RAP (44.6 ± 11.5) and CP (42.8 ± 12.2) subjects compared to controls (51.7 ± 9.1, p < 0.01). Subjects with CP had lower MCS compared to those with RAP (p < 0.01). After controlling for independent predictors of PCS, RAP was associated with lower PCS (estimate -8.46, p < 0.01) and MCS (estimate -6.45, p < 0.0001) compared to controls. The effect of endocrine insufficiency on PCS was differentially greater among RAP subjects (-1.28 for CP vs. -4.9 for RAP, p = 0.0184).

CONCLUSIONS

Even in the absence of CP, subjects with RAP have lower physical and mental QOL. This underscores the importance of identifying interventions to attenuate RAP before the development of overt CP.

Acute Pancreatitis Has a Long-term Deleterious Effect on Physical Health Related Quality of Life

BACKGROUND & AIMS

It is not clear how acute pancreatitis (AP) affects health related quality of life (HRQOL). We aimed to determine the long-term independent effect of AP on physical and mental HRQOL.

METHODS

We analyzed data from 91 patients (mean 52 years of age, 54% women) admitted with AP to the University of Pittsburgh Medical Center from 2011 to 2015 who responded to telephone surveys at a median of 14 months after hospital discharge (interquartile range, 12-16 months). Individuals who did not answer the telephone survey were sent a questionnaire by regular mail. Patients answered questions from the 12-Item Short-Form Survey, and answers were used to calculate mental component summary (MCS) and physical component summary (PCS) scores with norm-based scoring (normal ≥50). HRQOL for these subjects was compared with that of age- and sex-matched individuals without pancreatitis (1:2) identified from the North American Pancreatitis Study. We controlled for other covariates using multivariable regression analysis.

RESULTS

At follow-up, individuals with AP had a significantly lower PCS score (46.2 ± 11.8) than did control subjects (51.1 ± 9.5; P < .01), but a similar MCS score. A 4-point reduction of the PCS was attributed to AP after controlling for sociodemographic factors and medical comorbidities. The only pancreatitis-related factor associated with low PCS score was multisystem organ failure. Presence of abdominal pain, analgesic use, disability, and current smoking at the time of follow-up were also associated with lower PCS scores. Etiology of AP, disease severity (by Revised Atlanta classification), use of nutritional support, and performance of pancreatic interventions did not affect HRQOL at follow-up.

CONCLUSIONS

In a 14-month follow-up of patients hospitalized with AP, we found a meaningful, independent, and deleterious effect of AP in the physical HRQOL of these patients, compared to individuals without AP. Further research is needed to determine the duration of this impairment and to evaluate the effects of modifying risk factors.

Predictors and outcomes of acute pancreatitis in critically ill patients presenting to the emergency department of a tertiary referral centre in Australia

OBJECTIVE

To provide a current review of the clinical characteristics, predictors and outcomes in critically ill patients presenting to the ED with acute pancreatitis and subsequently admitted to an intensive care unit (ICU) of a tertiary referral centre in Australia.

METHODS

A retrospective single-centre study of adult patients admitted with pancreatitis. Severe acute pancreatitis defined by Bedside Index of Severity in Acute Pancreatitis (BISAP) score ≥2.

RESULTS

Eighty-seven patients fulfilled criteria for inclusion during the study period, representing 0.9% of all ICU admissions. The median age of patients was 54. Survival was independent of patients' age, sex, aetiology and comorbidities. Mortality was 30.8% for both inpatient referrals to the ICU and for direct referrals via the ED. Higher mortality was identified among patients requiring mechanical ventilation (74.2 vs 24.6% in survivors; P < 0.0001), vasopressor support (85.7 vs 33.8% in survivors; P < 0.0001) or renal replacement therapy (60 vs 16.9% in survivors; P < 0.002). BISAP score surpasses Ranson's and Acute Physiological and Chronic Health Examination (APACHE) II scores in discriminating between survivors and non-survivors among unselected patients with acute pancreatitis admitted to ICU, whereas APACHE II discriminates better in the cohort admitted from ED.

CONCLUSION

Severe acute pancreatitis is associated with high mortality. Aetiology and comorbidity did not predict adverse outcomes in this population. BISAP score is non-inferior to APACHE II score as a prognostic tool in critically ill patients with acute pancreatitis and could be used to triage admission. Evidence of persistent organ dysfunction and requirements for organ support reliably identify patients at high-risk of death.

Studying the Power of the Integrative Weaning Index in Predicting the Success Rate of the Spontaneous Breathing Trial in Patients under Mechanical Ventilation

BACKGROUND AND AIMS

The use of weaning predictive indicators can avoid early extubation and wrongful prolonged mechanical ventilation. This study aimed to determine the power of the integrative weaning index (IWI) in predicting the success rate of the spontaneous breathing trial (SBT) in patients under mechanical ventilation.

MATERIALS AND METHODS

In this prospective study, 105 patients undergoing mechanical ventilation for over 48 h were enrolled. Before weaning initiation, the IWI was calculated and based on the defined cutoff point (≥25), the success rate of the SBT was predicted. In case of weaning from the device, 2-h SBT was performed and the physiologic and respiratory indices were continuously studied while being intubated. If they were in the normal range besides the patient's tolerance, the test was considered as a success. The result was then compared with the IWI and further analyzed.

RESULTS

The SBT was successful in 90 (85.7%) and unsuccessful in 15 (14.3%) cases. The difference between the true patient outcome after SBT, and the IWI prediction was 0.143 according to the Kappa agreement coefficient (P < 0.001). Moreover, regarding the predictive power, IWI had high sensitivity (95.6%), specificity (40%), positive and negative predictive values (90.5% and 60), positive and negative likelihood ratios (1.59 and 0.11), and accuracy (86.7%).

CONCLUSION

The IWI as a more objective indicator has acceptable accuracy and power for predicting the 2-h SBT result. Therefore, in addition to the reliable prediction of the final weaning outcome, it has favorable power to predict if the patient is ready to breathe spontaneously as the first step to weaning.

Contemporary review of drug-induced pancreatitis: A different perspective

Although gallstone and alcohol use have been considered the most common causes of acute pancreatitis, hundreds of frequently prescribed medications are associated with this disease state. The true incidence is unknown since there are few population based studies available. The knowledge of drug induced acute pancreatitis is limited by the availability and the quality of the evidence as the majority of data is extrapolated from case reports. Establishing a definitive causal relationship between a drug and acute pancreatitis poses a challenge to clinicians. Several causative agent classification systems are often used to identify the suspected agents. They require regular updates since new drug induced acute pancreatitis cases are reported continuously. In addition, infrequently prescribed medications and herbal medications are often omitted. Furthermore, identification of drug induced acute pancreatitis with new medications often requires accumulation of post market case reports. The unrealistic expectation for a comprehensive list of medications and the multifactorial nature of acute pancreatitis call for a different approach. In this article, we review the potential mechanisms of drug induced acute pancreatitis and provide the perspective of deductive reasoning in order to allow clinicians to identify potential drug induced acute pancreatitis with limited data.

Quality of life after acute pancreatitis: a systematic review and meta-analysis

Patient-centered outcomes, including quality of life (QoL), after acute pancreatitis (AP) remain largely unknown. Our aim was to systematically review the best available evidence on QoL after AP. English-language articles on the effect of AP on QoL were identified in MEDLINE, EMBASE, and Scopus. Results were statistically aggregated to obtain a pooled mean difference (MD) and corresponding 95% confidence interval (CI) for individual QoL domains and component summaries, where appropriate. A total of 16 prospective observational studies encompassing 687 AP patients were included. Four studies comprising 267 AP patients, as measured by SF-36 and SF-12 questionnaires, were suitable for meta-analysis. The general health and vitality domains were significantly worse in the patients compared with healthy controls (MD, -10.90; 95% CI, -15.63 to -6.17; P < 0.00001 and MD, -4.64; 95% CI, -7.32 to -1.95; P = 0.0007, respectively). The remaining individual domains and physical and mental component summary scores did not differ between patients and controls. The QoL seems to be significantly impaired in patients after AP with a need to standardize reporting on QoL. Future studies should investigate the effect of different interventions on patients' QoL.

Acute pancreatitis--costs for healthcare and loss of production

OBJECTIVE. Severity of acute pancreatitis (AP) can vary from a mild to a fulminant disease with high morbidity and mortality. Cost analysis has, however, hitherto been sparse. The aim of this study was to calculate the cost of acute pancreatitis, both including hospital costs and costs due to loss of production. MATERIAL AND METHODS. All adult patients treated at Skane University Hospital, Lund, during 2009-2010, were included. A severity grading was conducted and cost analysis was performed on an individual basis. RESULTS. Two hundred and fifty-two patients with altogether 307 admissions were identified. Mean age was 60 ± 19 years, and 121 patients (48%) were men. Severe AP (SAP) was diagnosed in 38 patients (12%). Thirteen patients (5%) died. Acute biliary pancreatitis was more costly than alcohol induced AP (p < 0.001). Total costs for treating mild AP (MAP) in patients ≤65 years old was lower (p = 0.001) and costs for SAP was higher (p = 0.024), as compared to older patients. The overall hospital cost and cost for loss of production was per person in mean €5,100 ± 2,400 for MAP and €28,200 ± 38,100 for SAP (p < 0.001). The costs for treating AP during the two-year-long study period were in mean €9,762 ± 19,778 per patient. Extrapolated to a national perspective, the annual financial burden for AP in Sweden would be €38,500,000; corresponding to €4,100,000 per million inhabitants. CONCLUSIONS. The costs of treating AP are high, especially in severe cases with a long ICU stay. These results highlight the need to optimize care and continue the identification and focus on SAP, in order to try to limit organ failure and infectious complications.

Quality of life before admission to the intensive care unit

Objective

To examine the reliability of the SF-36 general health questionnaire when used to evaluate the health status of critically ill patients before admission to intensive care and to measure their health-related quality of life prior to admission and its relation to severity of illness and length of stay in the intensive care unit.

Methods

Prospective cohort study conducted in the intensive care unit of a public teaching hospital. Over three months, communicative and oriented patients were interviewed within the first 72 hours of intensive care unit admission; 91 individuals participated. The APACHE II score was used to assess severity of illness, and the SF-36 questionnaire was used to measure health-related quality of life.

Results

The reliability of SF-36 was verified in all dimensions using Cronbach's alpha coefficient. In six dimensions of eight domains the value exceeded 0.70. The average SF-36 scores of the health-related quality of life dimensions for the patients before admission to intensive care unit were 57.8 for physical functioning, 32.4 for role-physical, 53.0 for bodily pain, 63.2 for general health, 50.6 for vitality, 56.2 for social functioning, 54.6 for role-emotional and 60.3 for mental health. The correlations between severity of illness and length of stay and the health-related quality of life scores were very low, ranging from -0.152 to 0.175 and -0.158 to 0.152, respectively, which were not statistically significant.

Conclusion

In the sample studied, the SF-36 demonstrated good reliability when used to measure health-related quality of life in critically ill patients before admission to the intensive care unit. The worst score was role-physical and the best was general health. Health-related quality of life of patients before admission was not correlated with severity of illness or length of stay in the intensive care unit.

Increased admission serum estradiol level is correlated with high mortality in patients with severe acute pancreatitis

BACKGROUND

Sexual dimorphism in critical diseases has been documented. Severe acute pancreatitis is a disease with high mortality. We hypothesized that admission sex hormone levels may be used as an early predictor of outcome in these patients.

METHODS

A prospective cohort of patients with severe acute pancreatitis admitted to the intensive care unit for at least 48 h were enrolled (n = 62). Serum levels of estradiol, progesterone, and testosterone were determined on admission. The association of sex hormone levels and various disease severity scoring systems with patient outcome was analyzed.

RESULTS

There was no difference in overall mortality between the sexes. However, estradiol was significantly elevated in nonsurvivors (39 vs. 206 pg/mL, p < 0.001). The estradiol level was the best single-variable predictor of mortality (area under the curve 0.97), followed by the sequential organ failure assessment score, the multiple organ dysfunction score, and the acute physiology and chronic health care evaluation II (APACHE II) score. A serum estradiol level of 102 pg/mL was both sensitive and specific to predict mortality. There were no differences between survivors and non-survivors in terms of age, body mass index, or progesterone and testosterone levels.

CONCLUSIONS

Admission serum estradiol level is a good marker of disease severity and predictor of death in patients with severe acute pancreatitis.

Multivariate analysis of factors influencing medical costs of acute pancreatitis hospitalizations based on a national administrative database

BACKGROUND

Little information is available on the analysis of medical costs of acute pancreatitis hospitalizations.

AIM

This study aimed to determine the factors affecting medical costs of patients with acute pancreatitis during hospitalization using a Japanese administrative database.

METHODS

A total of 7193 patients with acute pancreatitis were referred to 776 hospitals. We defined "patients with high medical costs" as patients whose medical costs exceeded the 90th percentile in medical costs during hospitalization and identified the independent factors for patients with high medical costs with and without controlling for length of stay.

RESULTS

Multiple logistic regression analysis demonstrated that necrosectomy was the most significant factor for medical costs of acute pancreatitis during hospitalization. The odds ratio of necrosectomy was 33.64 (95% confidence interval, 14.14-80.03; p<0.001). Use of an intensive care unit was the most significant factor for medical costs after controlling for LOS. The OR of an ICU was 6.44 (95% CI, 4.72-8.81; p<0.001).

CONCLUSION

This study demonstrated that necrosectomy and use of an ICU significantly affected the medical costs of acute pancreatitis hospitalization. These results highlight the need for health care implementations to reduce medical costs whilst maintaining the quality of patient care, and targeting patients with severe acute pancreatitis.

[Severe and acute pancreatitis admitted in intensive care: a prospective epidemiological multiple centre study using CClin network database]

OBJECTIVES

To describe the demographic characteristics, incidence of extra-abdominal hospital-acquired infections and outcome of patients admitted to intensive care unit (ICU) with severe acute pancreatitis.

STUDY DESIGN

A retrospective, observational multiple center (65 centers) analysis of prospectively acquired data.

PATIENTS AND METHODS

During 2 years, all consecutive admitted patients to ICU for severe acute pancreatitis in the centers participating in the nosocomial infections surveillance network CClin Sud-Est were included. Patients whose ICU stay was less than 48 hours were not included. Demographic characteristics, extra-abdominal hospital-acquired infections and clinical course were described.

RESULTS

During the study period, 510 patients were included which represented 2 % of patients with a length of stay longer than 48 hours in the 65 participating ICUs. The global attack rate of extra-abdominal hospital-acquired infections (pneumonia, bacteremia, urinary tract or central venous catheter infection) was 23 % in overall patients and it was 33 % in the 294 mechanically ventilated patients. ICU mortality was 20 % in overall patients and it was 34 % in mechanically ventilated patients.

CONCLUSION

Severe acute pancreatitis represents 2 % of ICU stay longer than 48 hours. Its clinical course is frequently complicated by hospital-acquired infections and is associated with an high ICU mortality rate. This epidemiological observational study may be used for calculating sample size for future multicenter interventional therapeutic studies.

Quality of life after intensive care: a systematic review of the literature

OBJECTIVES

To evaluate quality of life at least 12 months after discharge from the intensive care unit of adult critically ill patients, to evaluate the methodology used to assess long-term quality of life, and to give an overview of factors influencing quality of life.

DATA SOURCES

EMBASE-PubMed, MEDLINE (OVID), SCI/Web of Science, the Cochrane Library, Google Scholar, and personal files.

DATA EXTRACTION

Data extraction was performed independently and cross-checked by two reviewers using a predefined data extraction form. Eligible studies were published between 1999 and 2009 and assessed quality of life ≥12 months after intensive care unit discharge by means of the Medical Outcomes Study 36-Item Short Form Health Survey, the RAND 36-Item Health Survey, EuroQol-5D, and/or the Nottingham Health Profile in adult intensive care unit patients.

DATA SYNTHESIS

Fifty-three articles (10 multicenters) were included, with the majority of studies performed in Europe (68%). The Medical Outcomes Study 36-Item Short Form Health Survey was used in 55%, and the EuroQol-5D, the Nottingham Health Profile, the RAND 36-Item Health Survey, or a combination was used in 21%, 9%, 8%, or 8%, respectively. A response rate of ≥80% was attained in 26 studies (49%). Critically ill patients had a lower quality of life than an age- and gender-matched population, but quality of life tended to improve over years. The worst reductions in quality of life were seen in cases of severe acute respiratory distress syndrome, prolonged mechanical ventilation, severe trauma, and severe sepsis. Study quality criteria, defined as a baseline quality of life assessment, the absence of major exclusion criteria, a description of nonresponders, and a comparison with a reference population were met in only four studies (8%). Results concerning the influence of severity of illness, comorbidity, preadmission quality of life, age, gender, or acquired complications were conflicting.

CONCLUSIONS

Quality of life differed on diagnostic category but, overall, critically ill patients had a lower quality of life than an age- and gender-matched population. A minority of studies met the predefined methodologic quality criteria. Results concerning the influence of the patients' characteristics and illnesses on long-term quality of life were conflicting.

Pancreatic function, quality of life and costs at long-term follow-up after acute pancreatitis

AIM: To evaluate long-term endocrine and exocrine pancreatic function, quality of life and health care costs after mild acute pancreatitis and severe acute pancreatitis (SAP).

METHODS: Patients prospectively included in 2001-2005 were followed-up after 42 (36-53) mo. Pancreatic function was evaluated with laboratory tests, the oral glucose tolerance test (OGTT), fecal elastase-1 and a questionnaire. Short Form (SF)-36, was completed.

RESULTS: Fourteen patients with a history of SAP and 26 with mild acute pancreatitis were included. Plasma glucose after OGTT was higher after SAP (9.2 mmol/L vs 7.0 mmol/L, P = 0.044). Diabetes mellitus or impaired glucose tolerance in fasting plasma glucose and/or 120 min plasma glucose were more common in SAP patients (11/14 vs 11/25, P = 0.037). Sick leave, time until the patients could take up recreational activities and time until they had recovered were all longer after SAP (P < 0.001). No significant differences in SF-36 were seen between the groups, or when comparing with age and gender matched reference groups. Total hospital costs, including primary care, follow-up and treatment of complications, were higher after SAP (median €16 572 vs€5000, P < 0.001).

CONCLUSION: Endocrine pancreatic function was affected, especially after severe disease. SAP requires greater resource use with long recovery, but most patients regained a good quality of life.

Acute pancreatitis: risk of recurrence and late consequences of the disease

Research into the clinical management of acute pancreatitis has primarily focused on the immediate complications of the disease, whereas its late consequences have received less attention. These late sequelae of acute pancreatitis refer to complications that arise after the convalescence period, which lasts for 3-6 months after the initial episode. In patients who do not undergo necrosectomy that involves removal of the exocrine gland, pancreatic exocrine function usually improves rather than deteriorates during follow-up. By contrast, glucose intolerance is likely to worsen over time in all patients with acute pancreatitis. Despite the risk of late complications for patients with acute pancreatitis, their long-term quality of life is usually good. The number of pancreatitis episodes a patient has experienced is an important factor that determines the severity of late complications of acute pancreatitis. Risk factors for the recurrence of acute pancreatitis episodes have now been identified. This Review focuses on data from studies that investigated the risk factors for recurrent attacks of acute pancreatitis, and discusses the late consequences of this disease.

Evaluation of patient-reported outcome in subjects treated medically for acute pancreatitis: a follow-up study

AIMS

To explore the quality of life in patients treated medically during the acute phase of pancreatitis as well as at 2 and 12 months after discharge from the hospital.

PATIENTS

40 patients were studied. The etiology of the pancreatitis was biliary causes in 31 patients and non-biliary causes in 9; mild disease was present in 29 patients and severe disease in 11. 30 patients completed the two surveys at 2 and 12 months after hospital discharge.

METHODS

The SF-12 and EORTC QLQ-C30 questionnaires were used for the purpose of the study.

RESULTS

The two physical and mental component summaries of SF-12, all the domains of EORTC QLQ-C30 (except for physical functioning and cognitive functioning) and some symptom scales of EORTC QLQ-C30 (fatigue, nausea/vomiting, pain, and constipation) were significantly impaired during the acute phase of pancreatitis. There was a significant improvement in the SF-12 physical component summary, and global health, role functioning, social functioning, nausea/vomiting, pain, dyspnea, and financial difficulties (EORTC QLQ-C30) at 2 months after discharge as compared to the basal evaluation. Similar results were found after 12 months except for the mental component score at 12-month evaluation, which was significantly impaired in acute pancreatitis patients in comparison to the norms. The physical functioning of the EORTC QLQ-C30 at basal evaluation was significantly impaired in patients with severe pancreatitis in comparison to patients with mild pancreatitis.

CONCLUSIONS

Two different patterns can be recognized in the quality of life of patients with acute pancreatitis: physical impairment is immediately present followed by mental impairment which appears progressively in the follow-up period.

Critical Care of the Patient with Acute Pancreatitis

Acute pancreatitis is an inflammatory process of the pancreas with variable involvement of regional tissues and remote organs. This review gives a comprehensive overview of the aetiology, pathophysiology, diagnosis and therapy of acute pancreatitis relevant to the intensivist. Recent international guidelines on the management of acute pancreatitis are summarised.

Eighty percent of acute pancreatitis episodes are related either to gallstones or to alcohol abuse. Independent of its aetiology, the pathophysiologic hallmark of acute pancreatitis is the premature activation of trypsin, which leads to massive pancreas inflammation, systemic overproduction of pro-inflammatory mediators and ultimately remote organ dysfunction. All guidelines agree that the diagnosis of acute pancreatitis should include clinical symptoms, increased serum amylase or lipase levels and/or characteristic findings on computed tomography. Endoscopic retrograde cholangiopancreatography is recommended as a causative therapy in patients with acute cholangitis or a strong suspicion of gallstones. All guidelines underline the importance of vigorous fluid resuscitation and supplemental oxygen therapy and prefer enteral over parenteral nutrition, with the majority favouring the nasojejunal route. In view of lacking scientific evidence, antibiotic prophylaxis to prevent infection of pancreatic necroses is discouraged by most guidelines. Computed tomography-guided fine needle aspiration is the technique of choice to differentiate between sterile and infected pancreas necrosis. While sterile pancreatic necrosis should be managed conservatively, infected pancreatic necrosis requires debridement and drainage supplemented by antibiotic therapy. Surgical necrosectomy is the traditional approach, but less invasive techniques (retroperitoneal or laparoscopic necrosectomy, computed tomography-guided percutaneous catheter drainage) may be equally effective.

Redox status of acute pancreatitis as measured by cyclic voltammetry: initial rodent studies to assess disease severity

OBJECTIVE

To determine whether serum antioxidant capacity as measured by the electrochemical technique cyclic voltammetry could be used to resolve differences in the severity of an inflammatory disease such as acute pancreatitis.

DESIGN

Experimental animal study.

SETTING

Animal laboratory, Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, New Zealand.

SUBJECTS

Male Wistar rats.

INTERVENTIONS

A total of 48 inbred male Wistar rats were studied in five experimental groups. Group 1 (baseline reference, immediate euthanasia, n = 14) had no surgical intervention. Group 2 (sham, n = 9) had identical surgical procedures to the pancreatitis groups except for the intraductal infusion. Groups 3-5 (n = 9, n = 10, and n = 6, respectively) had acute pancreatitis induced by the pancreatic intraductal infusion of 3%, 4%, or 5% sodium taurocholate, respectively. Groups 2-5 were killed after 12 hrs.

MEASUREMENTS AND MAIN RESULTS

Cyclic voltammetry involves scanning the voltage of a working electrode while recording the anodic current produced as the low molecular weight antioxidants in the solution are oxidized on the surface of the working electrode. The current produced is proportional to the combined concentration of the antioxidants. There was a significant positive correlation of the first cyclic voltammetric peak maximum with pancreatic histologic severity (Spearman's r = .51, p = .007) and with a number of other markers of systemic severity, notably bicarbonate (r = -.57, p = .002), base excess (r = -.65, p < .001), urea (r = .68, p < .001), and calcium (r = -.60, p = .008). The first cyclic voltammetric peak maximum was superior at indicating the severity of the disease state compared with a standard method of total antioxidant capacity measurement.

CONCLUSIONS

In experimental pancreatitis, the first cyclic voltammetric peak maximum showed significant correlations with histologic and systemic indices of severity. Further clinical studies are now needed to define the role of cyclic voltammetry in monitoring the progression of this and other severe illness in the critical care setting.

In situ high-volume modified continuous closed and/or open lavage for infected necrotizing pancreatitis

OBJECTIVES

To evaluate the clinical significance of high-volume modified continuous closed and/or open lavage for the treatment of infected necrotizing pancreatitis.

METHODS

From August 1997 to December 2006, 53 patients with infected necrotizing pancreatitis who underwent in situ high-volume (>20 L/d) continuous closed lavage using a single-lumen rubber catheter and/or open lavage were retrospectively studied in our hospital, and the advantages of this new technique were analyzed.

RESULTS

Modified continuous closed lavage was the initial treatment for all patients; in 6 patients with secondary retroperitoneal sepsis or abscess, continuous open lavage was performed. Impaired tube patency and lavage fluid retention did not occur in any of these patients. The overall mortality was 17.0% (9/53). Twelve patients underwent early surgery, and 5 (41.7%) died; 41 patients underwent delayed surgery, and 4 (9.8%) died. Significant local complications occurred in 14 patients (26.4%); the incidence of bleeding, abscess, and fistula was 13.2% (7/53), 9.4% (5/53), and 9.4% (5/53), respectively.

CONCLUSIONS

Our technique of in situ high-volume modified continuous closed and/or open lavage has produced a better control of infected necrotizing pancreatitis.

Biliary versus alcohol-related infected pancreatic necrosis: similarities and differences in the follow-up

OBJECTIVES

Infected pancreatic necrosis (IPN) is a serious complication of acute pancreatitis. Data concerning survivors' quality of life and pancreatic functions are scarce. Follow-up of the patients with alcohol and biliary etiology of IPN treated with open necrosectomy was performed.

METHODS

Twenty-eight survivors after operative treatment (Bradley procedure) of IPN were followed up 24 to 96 months after discharge from the hospital (10 biliary and 18 alcohol patients). Their exocrine and endocrine pancreatic functions and quality of life (Functional Assessment of Chronic Illness Therapy scale) were evaluated. Pancreatic tissue remaining after necrosectomy was visualized by use of contrast-enhanced computed tomography (CT).

RESULTS

In 44.4% of alcohol-induced IPN patients, the presence of the whole pancreas was shown on the follow-up CT, contrary to the biliary group, where the partial lack of the pancreas was observed in all cases. Pancreatic tissue calcifications were present on CT in 8 patients of alcohol-induced acute pancreatitis group only. Median stool elastase 1 concentrations were 318.1 U/mL in the biliary group and 238.3 U/mL in the alcohol-induced group (not significant). The Functional Assessment of Chronic Illness Therapy scale showed significantly higher social/family and emotional well-being in patients with biliary acute necrotizing pancreatitis.

CONCLUSIONS

Patients after alcohol-induced IPN had lower quality of life compared with biliary etiology. Biliary and alcohol-induced IPN patients after surgical treatment have nonsignificant differences of endocrine and exocrine pancreatic functions.

The Pancreatitis Outcome Prediction (POP) Score: a new prognostic index for patients with severe acute pancreatitis

OBJECTIVE

Severe acute pancreatitis, defined as pancreatitis with distant organ dysfunction, is a condition carrying a high mortality and morbidity. Current outcome prediction scores are based on small populations, usually from single specialist centers. Some scores cannot be applied until several days into hospital admission. We thus sought to develop a new and more sensitive outcome prediction score--the Pancreatitis Outcome Prediction (POP) Score--for these high-risk patients.

DESIGN

Retrospective cohort study of a large multicenter intensive care database.

SETTING

One hundred fifty-nine U.K. intensive care units.

PATIENTS

Participants were 2,462 patients admitted to intensive care units with severe acute pancreatitis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic, physiologic, and biochemical data collected within the first 24 hrs of intensive care unit admission were used to develop a risk prediction score using logistic regression. The six variables with the strongest relationship to hospital outcome--arterial pH, age, serum urea, mean arterial pressure, PaO2/FIO2 ratio, and total serum calcium (in order of decreasing impact)--produced a model with a prognostic discrimination (area under the receiver operating characteristic curve = 0.838) superior to other models. These six factors were used to develop an objectively weighted multivariate prognostic score ranging from 0 to 40 points.

CONCLUSIONS

Prognostic stratification of patients with severe acute pancreatitis requiring intensive care offers a useful audit tool to gauge unit performance and improve delineation of subsets for prospective trials. Prospective validation of this new outcome prediction score is required, preferably in different countries. The validity of the POP Score for either hospital or intensive care admission could also be tested and assessed for superiority over existing scores.

Toward an update of the atlanta classification on acute pancreatitis: review of new and abandoned terms

OBJECTIVES

The 1992 Atlanta classification is a clinically based classification system that defines the severity and complications of acute pancreatitis. The purpose of this review was to assess whether the terms abandoned by the Atlanta classification are really discarded in the literature. The second objective was to review what new terms have appeared in the literature since the Atlanta symposium.

METHODS

We followed a Medline search strategy in review and guideline articles after the publication of the Atlanta classification. This search included the abandoned terms: "phlegmon," "infected pseudocyst," "hemorrhagic pancreatitis," and "persistent pancreatitis."

RESULTS

A total of 239 publications were reviewed, including 10 guideline articles and 42 reviews. The abandoned terms "hemorrhagic pancreatitis" and "persistent pancreatitis" are hardly encountered, in contrast, both "infected pseudocyst" and "phlegmon" are frequently used, and several authors question their abandonment. New terminology in acute pancreatitis consists of "organized pancreatic necrosis," "necroma," "extrapancreatic necrosis," and "central gland necrosis."

CONCLUSIONS

This review demonstrates that the Atlanta classification is still not universally accepted. Several abandoned terms are frequently used, and new terms have emerged that describe manifestations in acute pancreatitis that were not specifically addressed during the Atlanta symposium.

[Late complications of open abdomen]

Open abdomen is the final result of a variety of diseases and their treatment strategies. The aim of this article is to present systematically late complications after open abdominal therapy and our own treatment results from 2003 to 2005. The main diagnoses for open abdomen are persistent peritonitis, abdominal compartment syndrome, and abdominal injuries. A perioperative mortality rate of 10-56%, long stays at the ICU, and a mean of 3-5 reoperations are characteristic for the severity of such diseases. Late complications may include incisional hernia (47-78%), gastrointestinal and pancreatic fistulas (8-41%), postoperative delayed abscess (10-21%), polyneuropathy (21%), psychic disorders (24%), indigestion (12%), and ossification (17%). These postoperative disorders may range in severity from clinically less significant to therapy-relevant with surgical consequences. Despite the high morbidity, approximately 75% of surviving patients achieve good quality of life. In our opinion, this justifies the extensive treatment concepts and associated high costs.

Evidence-based treatment of acute pancreatitis: a look at established paradigms

BACKGROUND

The management of acute pancreatitis (AP) is still based on speculative and unproven paradigms in many centers. Therefore, we performed an evidence-based analysis to assess the best available treatment.

METHODS

A comprehensive Medline and Cochrane Library search was performed evaluating the indication and timing of interventional and surgical approaches, and the value of aprotinin, lexipafant, gabexate mesylate, and octreotide treatment. Each study was ranked according to the evidence-based methodology of Sackett; whenever feasible, we performed new meta-analyses using the random-effects model. Recommendations were based on the available level of evidence (A=large randomized; B=small randomized; C=prospective trial).

RESULTS

None of the evaluated medical treatments is recommended (level A). Patients with AP should receive early enteral nutrition (level B). While mild biliary AP is best treated by primary cholecystectomy (level B), patients with severe biliary AP require emergency endoscopic papillotomy followed by interval cholecystectomy (level A). Patients with necrotizing AP should receive imipenem or meropenem prophylaxis to decrease the risk of infected necrosis and mortality (level A). Sterile necrosis per se is not an indication for surgery (level C), and not all patients with infected necrosis require immediate surgery (level B). In general, early necrosectomy should be avoided (level B), and single necrosectomy with postoperative lavage should be preferred over "open-packing" because of fewer complications with comparable mortality rates (level C).

CONCLUSIONS

While providing new insights into key aspects of AP management, this evidence-based analysis highlights the need for further clinical trials, particularly regarding the indications for antibiotic prophylaxis and surgery.

Efficacy of continuous regional arterial infusion of a protease inhibitor and antibiotic for severe acute pancreatitis in patients admitted to an intensive care unit

To investigate the efficacy of continuous regional arterial infusion (CRAI) of a protease inhibitor and antibiotic for severe acute pancreatitis (SAP) in patients admitted to an intensive care unit (ICU). A total of 51 patients with SAP requiring admission to an ICU were studied. The patients were divided into two groups: one received the protease inhibitor nafamostat mesylate and the antibiotic imipenem by continuous regional arterial infusion (CRAI group) and the other received protease inhibitors and antibiotics by intravenous infusion (non-CRAI group). To evaluate the therapeutic usefulness of CRAI of a protease inhibitor and antibiotic for SAP, the rate of surgery and the cumulative survival rate were compared between the non-CRAI group and the CRAI group. The rate of surgery was 32% in the non-CRAI group and 9% in the CRAI group (P = 0.08). Cumulative survival rates at 1, 6, and 12 months were 77.9%, 48.9%, and 48.9% in the non-CRAI group compared with 100.0%, 100.0%, and 87.1% in the CRAI group. Outcome was thus significantly better in the CRAI group than in the non-CRAI group (P = 0.002). CRAI of a protease inhibitor and antibiotic may decrease the need for surgical therapy and reduce mortality in patients with SAP.

Long-term health-related quality of life in survivors of severe acute pancreatitis

OBJECTIVE

To evaluate the health-related quality of life (HRQL) and postdischarge outcome after severe acute pancreatitis.

DESIGN AND SETTING

Observational study in a department of surgery (surgical and general intensive care unit) in a tertiary care hospital.

PATIENTS AND PARTICIPANTS

Of 283 patients with severe acute pancreatitis 211 survived; during a follow-up period an additional 27 died. The Rand 36-item Health Survey with accessory question was mailed to 174 eligible patients. The final study population comprised 145 patients (83% response rate). Age- and sex-matched Finnish population scores were compared with the study population; accessory questions were analyzed separately.

RESULTS

No clinically significant differences were found in long-term HRQL between study patients and the general population. Of the 145 patients 87% returned to work, 27% suffered recurrent pancreatitis, and 43% developed diabetes. Of 113 patients with alcohol-induced severe acute pancreatitis 30% were abstinent and 28% problem drinkers, alcohol-dependent, or alcoholics.

CONCLUSIONS

Up to 13% of severe acute pancreatitis patients surviving initial hospitalization die within a few years. Among the survivors long-term HRQL is comparable to that of the normal population. The majority return to work and reduce their alcohol consumption markedly.

Resource use in the ICU: short- vs. long-term patients

BACKGROUND

Intensive care medicine uses a disproportionate share of medical resources, and little is known about the distribution of resources between different patient groups.

METHODS

In this prospective observational study, all patients admitted between 1 January 1998 and 31 December 1999 to our medical-surgical university's ICU were assigned to one of two groups according to length of stay (LOS): patients staying more than 7 days in the unit (group L) and those staying a maximum of 7 days (group S). Resource use was estimated using TISS-28, number of nursing shifts, use of mechanical ventilation, and use of renal replacement therapy. Further, SAPS II and ICU and hospital mortalities were recorded.

RESULTS

Of 5481 patients, 583 (10.6%) were in group L and 4898 in group S (89.4%). Patients in group L were more severely sick upon admission than those in group S. Patients in group L stayed a total of 9726 days in the ICU (52.5% of the total LOS). In group L, 69.2% of all shifts with respiratory support and 80.1% of all shifts with renal replacement were used. Further, group L patients consumed 53.4% (909225) of all TISS points provided. The ICU-mortality rates were 14.4% in group L and 7.2% in group S, and the hospital mortality rates were 19.9% and 9.8%, respectively. A mean of 1898 TISS points was used per patient surviving the hospital stay in group L compared with 190 points in group S.

CONCLUSIONS

In this university-based, medical-surgical adult ICU, 11% of all patients stayed more than 7 days in the unit and consumed more than 50% of all resources. Thus, a highly disproportionate amount of resources were used per survivor in group L compared with those in group S.

Impact of transrectal ultrasound guided prostate biopsy on quality of life: a prospective randomized trial comparing 6 versus 12 cores

PURPOSE

Recent studies advocating an increase in the number of cores of sextant transrectal ultrasound guided biopsy of the prostate to improve the cancer detection rate often have not addressed the impact on quality of life. We performed a prospective randomized trial comparing 6 to 12 prostate biopsy cores to determine the impact on the cancer detection rate, pain and morbidity, and quality of life. We report the impact on health related and screening specific quality of life in men undergoing 6 versus 12 core transrectal ultrasound guided prostate biopsy.

MATERIALS AND METHODS

We prospectively randomized 244 men with a mean age plus or minus standard deviation of 65 +/- 8 years, serum total prostate specific antigen between 2.5 and 20.0 ng./ml., and/or digital rectal examination findings suspicious of cancer to undergo 6 or 12 core peripheral zone tissue biopsy. Of the men 71 (29%) were black. All patients completed a self-administered questionnaire before, and 2 questionnaires 2 and 4 weeks after the procedure. Health related quality of life was measured using 2 subscales (emotional well-being and role limitation due to physical health) of the short form 36-Item Health Survey. Screening specific quality of life was addressed by questions on the functional consequences of the procedure (return to daily activity, work-employment and sports-exercise). Health related and screening specific quality of life responses were compared in the groups.

RESULTS

After controlling for cancer diagnosis, patient age, race, education, report of pain and baseline emotional well-being there was no significant difference in the mean change in emotional well-being scores at 2 and 4 weeks in the 6 and 12 core groups (p = 0.7 and 0.3, respectively). Similarly after controlling for these factors and baseline role limitation due to physical health there was no significant difference in the mean change in role limitation due to physical health scores at 2 and 4 weeks in the 2 groups (p = 0.3 and 0.5, respectively). There was no difference in the percent of men returning to routine daily activity (p = 0.6), work-employment (p = 0.5) or sports-exercise (p = 0.3) at 0 to 1, 2 to 3 and 4 to 7 days or longer than 1 week after the procedure in the groups.

CONCLUSIONS

Doubling the sextant biopsy does not affect the quality of life in regard to emotional well-being, role limitation due to physical health, or return to routine daily activity, work-employment or sports-exercise.