Continuous regional arterial infusion for acute pancreatitis: a propensity score analysis using a nationwide administrative database

Inverse association of hospital volume with in-hospital mortality rate of patients receiving EUS-guided interventions for pancreatic fluid collections

BACKGROUND AND AIMS

EUS-guided interventions currently serve as first-line treatment for symptomatic pancreatic fluid collections (PFCs) but require high-level expertise and multidisciplinary care. Hospital caseload has not been fully examined in relation to clinical outcomes of patients with endoscopically managed PFCs.

METHODS

Using the Diagnosis Procedure Combination database (a Japanese nationwide inpatient database), we identified 4053 patients receiving EUS-guided treatment of PFCs at 486 hospitals between 2010 and 2020 and examined an association of hospital volume (average annual number of cases at a hospital) with in-hospital mortality. Associations with bleeding, length of stay, and total costs were examined as secondary analyses. Multivariable logistic regression analysis was conducted with adjustment for potential confounders.

RESULTS

The hospital volume was inversely associated with the risk of in-hospital mortality (Ptrend < .001). The adjusted odds ratio for in-hospital mortality comparing the extreme quintiles of hospital volume was .17 (95% confidence interval, .09-.33). A restricted cubic spline analysis yielded no statistically significant evidence on the nonlinear relationship (Pnonlinearity = .19). The types of stents (plastic vs lumen-apposing metal stent) seemed to have no effect modification on the volume-mortality relationship (Pinteraction = .58). Higher hospital volume was also associated with lower risk of bleeding, shorter length of stay, and lower medical costs of inpatient care.

CONCLUSIONS

Higher hospital volume was associated with a lower risk of in-hospital mortality of patients receiving EUS-guided treatment of PFCs. A further investigation is warranted to justify the volume-based selective referral of the patients.

Biomimetic Nanoparticles Loaded with Ulinastatin for the Targeted Treatment of Acute Pancreatitis

Ulinastatin is commonly used in the clinic to treat acute pancreatitis (AP), but its therapeutic effect was limited by the presence of the blood-pancreas barrier (BPB) and low specificity. Here, we prepared a macrophage biomimetic nanoparticle (MU) that delivered ulinastatin to address the above issues. Macrophage membrane was used as a shell for a mixture of PEG-PLGA and ulinastatin. It was found that MU showed good stability and biocompatibility in vitro and in vivo. According to in vivo fluorescence imaging, MU displayed a great inflammation targeting effect both in a subcutaneous inflammation model and in situ pancreatitis mouse model, which was ascribed to the presence of adhesion proteins. In vitro and in vivo results demonstrated that MU have a superior AP treatment effect by inhibiting pro-inflammatory factors and keeping cells viability. It was suggested the MU could provide a new strategy for targeted AP treatment.

Evaluation of the Effectiveness and Use of Anti-Methicillin-Resistant Staphylococcus aureus Agents for Aspiration Pneumonia in Older Patients Using a Nationwide Japanese Administrative Database

Studies indicated potential harm from empirical broad-spectrum therapy. A recent study of hospitalizations for community-acquired pneumonia suggested that empirical anti-methicillin-resistant Staphylococcus aureus (MRSA) therapy was associated with an increased risk of death and other complications. However, limited evidence supports empirical anti-MRSA therapy for older patients with aspiration pneumonia. In a nationwide Japanese database, patients aged ≥65 years on admission with aspiration pneumonia were analyzed. Patients were divided based on presence of respiratory failure and further sub-categorized based on their condition within 3 days of hospital admission, either receiving a combination of anti-MRSA agents and other antibiotics, or not using MRSA agents. An inverse probability weighting method with estimated propensity scores was used. Out of 81,306 eligible patients, 55,098 had respiratory failure, and 26,208 did not. In the group with and without respiratory failure, 0.93% and 0.42% of the patients, respectively, received anti-MRSA agents. In patients with respiratory failure, in-hospital mortality (31.38% vs. 19.03%, p < 0.001), 30-day mortality, and 90-day mortality were significantly higher, and oxygen administration length was significantly longer in the anti-MRSA agent combination group. Anti-MRSA agent combination use did not improve the outcomes in older patients with aspiration pneumonia and respiratory failure, and should be carefully and comprehensively considered.

Mechanical and oral antibiotics bowel preparation for elective rectal cancer surgery: A propensity score matching analysis using a nationwide inpatient database in Japan

Aim

The best bowel preparation method for rectal surgery remains controversial. In this study we compared the efficacy and safety of mechanical bowel preparation (MBP) alone and MOABP (MBP combined with oral antibiotic bowel preparation [OABP]) for rectal cancer surgery.

Methods

In this retrospective study we analyzed data from the Japanese Diagnosis Procedure Combination (DPC) database on 37 291 patients who had undergone low anterior resection for rectal cancer from 2014 to 2017. Propensity score matching analysis was used to compare postoperative outcomes between MBP alone and MOABP.

Results

A total of 37 291 patients were divided into four groups: MBP alone: 77.7%, no bowel preparation (NBP): 16.9%, MOABP: 4.7%, and OABP alone: 0.7%. In propensity score matching analysis with 1756 pairs, anastomotic leakage (4.84% vs 7.86%, P < 0.001), small bowel obstruction (1.54% vs 3.08%, P = 0.002) and reoperation (3.76% vs 5.98%, P = 0.002) were less in the MOABP group than in the MBP group. The mean duration of postoperative antibiotics medication was shorter in the MOABP group (5.2 d vs 7.5 d, P < 0.001) than in the MBP group. There was no significant difference between the two groups in the incidence of Clostridium difficile (CD) colitis (0.40% vs 0.68%, P = 0.250) and methicillin-resistant Staphylococcus aureus (MRSA) colitis (0.11% vs 0.17%, P = 0.654). There was no significant difference in in-hospital mortality between the two groups (0.00% vs 0.11% respectively, P = 0.157).

Conclusion

MOABP for rectal surgery is associated with a decreased incidence of postoperative complications without increasing the incidence of CD colitis and MRSA colitis.

JPN clinical practice guidelines 2021 with easy-to-understand explanations for the management of acute pancreatitis

BACKGROUND

In preparing the Japanese (JPN) guidelines for the management of acute pancreatitis 2021, the committee focused the issues raised by the results of nationwide epidemiological survey in 2016 in Japan METHOD: In addition to a systematic search using the previous JPN guidelines, papers published from January 2014 to September 2019 were searched for the contents to be covered by the guidelines based on the concept of GRADE system.

RESULTS

Thirty-six clinical questions (CQ) were prepared in 15 subject areas. Base on the facts that patients diagnosed with severe disease by both Japanese prognostic factor score and contrast-enhanced CT grade had a high fatality rate and that little prognosis improvement after 2 weeks of disease onset was not obtained, we emphasized the importance of Pancreatitis Bundles, which was shown to be effective in improving prognosis, and the CQ sections for local pancreatic complications had been expanded to ensure adoption of a step-up approach. Furthermore, on the facts that enteral nutrition for severe acute pancreatitis was not started early within 48 hours of admission and that unnecessary prophylactic antibiotics was used in almost all cases, we emphasized early enteral nutrition in small amounts even if gastric feeding is used and no prophylactic antibiotics in mild pancreatitis.

CONCLUSION

All the members of the committee have put a lot of effort into preparing the extensively revised guidelines in the hope that more people will have a common understanding and that better medical care will be spread.

Acute Pancreatitis in Japan: Comparison of Before and After Revision of the Clinical Guidelines

OBJECTIVES

Cases of acute pancreatitis (AP) are increasing worldwide, and mortality remains high in severe cases. In 2015, the Japanese guidelines for the management of AP were revised. We aimed to clarify the clinical practice of AP in Japan and its trend during the revision of the guidelines using a Japanese nationwide administrative database.

METHODS

We retrospectively analyzed 102,119 patients with AP who were hospitalized between April 2014 and March 2018. The study period was divided into the first period (the time before the revision: fiscal years 2014 and 2015) and second period (after the revision: 2016 and 2017).

RESULTS

Severe cases of AP accounted for 27.7% of total cases. The in-hospital mortality in severe cases was 5.7%. The mortality within 14 days of admission improved from 3.2% in the first period to 2.6% in the second period (P = 0.022). Referred patients had more severe diseases and a higher mortality. The mortality in patients who underwent endoscopic ultrasound-guided fistuloplasty for local complications (11.6%) was lower than that in patients who underwent percutaneous drainage (23.4%) or AP surgery (22.6%) (P < 0.001).

CONCLUSIONS

We clarified the clinical practice of AP including the improved mortality after the revision of the guidelines.

Impact of Corticosteroid Administration within 7 Days of the Hospitalization for Influenza Pneumonia with Respiratory Failure: A Propensity Score Analysis Using a Nationwide Administrative Database

Influenza pneumonia, which causes acute respiratory distress syndrome and multiple organ failure, has no established management protocol. Recently, corticosteroid therapy was used to treat coronavirus disease 2019 with respiratory failure; however, its effectiveness as a treatment for influenza pneumonia remains controversial. To investigate the impact of corticosteroid therapy for the early phase of severe influenza pneumonia, we compared influenza pneumonia patients with respiratory failure treated with or without corticosteroids within 7 days after hospital admission using a Japanese nationwide administrative database. The primary endpoint was the mortality rate. The secondary endpoints were duration of intensive-care unit management, invasive mechanical ventilation, and hospital stay. The inverse probability weighting method with estimated propensity scores was used to minimize the data collection bias. We included 3519 patients with influenza pneumonia with respiratory failure. Of these, 875 were treated with corticosteroids. There was no significant difference between the groups regarding 30-day and 90-day mortality, duration of intensive-care unit management, invasive mechanical ventilation, and hospital stay. However, the in-hospital mortality rate was higher in the corticosteroid group. The use of systematic corticosteroid therapy in patients with influenza pneumonia was associated with a higher in-hospital mortality rate.

Mortality association between obesity and pneumonia using a dual restricted cohort model

BACKGROUND

An obesity survival paradox has been reported among obese patients with pneumonia.

AIMS

To determine the impact of obesity on pneumonia outcomes and analyze the correlation between in-hospital all-cause mortality and obesity among patients with pneumonia.

METHODS

The United States Nationwide Readmissions Database (NRD) was retrospectively analyzed for patients with pneumonia from 2013 to 2014. We used a step-wise restricted and propensity score matching cohort model (dual model) to compare mortality rates and other outcomes among pneumonia patients based on BMI. Mortality was calculated by a Cox proportional hazard model, adjusted for potential confounders with propensity score matched analysis.

RESULTS

A total of 70,886,775 patients were registered in NRD during the study period. Of these, 7,786,913 patients (11.0%) were considered obese and 1,652,456 patients (2.3%) were admitted to the hospital with pneumonia. Based on the step-wise restricted cohort model, the hazard ratio comparing the mortality rates among obese pneumonia patients to mortality rates among normal BMI pneumonia patients was 0.75 (95% CI 0.60-0.94). The propensity score matched analysis estimated a hazard rate of 0.84 (95% CI 0.79-0.90) and the hazard ratio estimated from the dual model was 0.82 (95% CI 0.63-1.07).

CONCLUSIONS

With the application of a dual model, there appears to be no significant difference in mortality of obese patients with pneumonia compared to normal BMI patients with pneumonia.

Clinical practice of acute pancreatitis in Japan: An analysis of nationwide epidemiological survey in 2016

BACKGROUND

To provide updates on clinical practice of acute pancreatitis (AP) in Japan, we conducted a nationwide epidemiological survey.

METHODS

This study consisted of a two-staged survey; the number of AP patients was estimated by the first-stage survey and their clinical features were examined by the second-stage survey. We surveyed AP patients who had visited hospitals in 2016.

RESULTS

The estimated number of AP patients in 2016 was 78,450, with an overall incidence of 61.8 per 100,000 persons. We obtained detailed clinical information of 2994 AP patients, including 706 (23.6%) severe cases classified according to the Japanese severity criteria. The male-to-female sex ratio was 2.0, and the mean age at onset was 59.9 years in males and 66.5 years in females. Alcohol was the most common etiology (42.8%) in males and gallstones in females (37.7%). The AP-associated mortality was 6.1% in severe AP cases, which was decreased by 40% compared to the 2011 survey. Antibiotics were administered to most cases, with carbapenem being frequently used. Enteral nutrition was given in 31.8% of severe cases, but majority cases received after 48 h. Among the 107 patients who received intervention for walled-off necrosis, five patients received surgery-first approach, 66 received endoscopic ultrasound-guided transluminal drainage, and 19 underwent step-up approach.

CONCLUSIONS

We clarified the current status of AP in Japan including the significant reduction of mortality in severe cases, shift to endoscopic approaches for walled-off necrosis, and poor compliance of the recommendations in the guidelines including management of enteral nutrition and antibiotic administration.

Association between comprehensive geriatric assessment and short-term outcomes among older adult patients with stroke: A nationwide retrospective cohort study using propensity score and instrumental variable methods

BACKGROUND

Comprehensive geriatric assessment (CGA) is a multidimensional and multidisciplinary method to identify geriatric conditions among older patients. The aim of the present study was to examine the associations between CGA and short-term outcomes among older adult inpatients with stroke.

METHODS

The study was a nationwide, retrospective cohort study. We used the Diagnosis Procedure Combination database, a national Japanese inpatient database, to identify older adult stroke patients from 2014 to 2017. The associations between CGA and in-hospital mortality, length of hospital stay, readmission rate, rehabilitation intervention, and introduction of home health care were evaluated using propensity score matching and instrumental variable analysis.

FINDINGS

We identified 338,720 patients, 21·3% of whom received CGA. A propensity score-matched analysis of 53,861 pairs showed that in-hospital mortality was significantly lower in the CGA group than in the non-CGA group (3·6% vs. 4·1%, p < 0·001). The rate of long-term hospitalization (> 60 days) was significantly lower in the CGA group than in the non-CGA group (8·7% vs. 10·1%, p < 0·001), and the rates of rehabilitation intervention (30·3% vs. 24·9%, p < 0·001) and home health care (8·3% vs. 7·6%, p = 0·001) were both higher in the CGA group than in the non-CGA group. Instrumental variable analysis showed similar results.

INTERPRETATION

CGA was significantly associated with the examined short-term outcomes. These findings from Japan, one of the most aged countries worldwide, highlight the possible benefits of CGA for short-term outcomes and can be of use for health policy in other international contexts.

FUNDING

This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan (19AA2007 and H30-Policy-Designated-004) and the Ministry of Education, Culture, Sports, Science and Technology, Japan (17H04141).

Open colectomy vs. laparoscopic colectomy in Japan: a retrospective study using real-world data from the diagnosis procedure combination database

PURPOSE

To compare the short-term outcomes of conventional open colectomy with those of laparoscopic colectomy for colon cancer.

METHODS

We retrieved data between January 2014 and March 2016 from the Diagnosis Procedure Combination database. A total of 69,418 patients who underwent colectomy for colon cancer were analyzed from among 15,901,766 cases of colorectal cancer. We applied a multilevel logistic regression model using a 2-level structure of individuals nested from 1065 hospitals.

RESULTS

A total of 22,440 open colectomy and 46,978 laparoscopic colectomy procedures were performed. The in-hospital mortality rate was significantly lower in the laparoscopic group than in the open group (0.28% vs. 0.06%, odds ratio [OR] 0.40, p < 0.001). Similarly, the 30-day postoperative mortality rate (0.14% vs. 0.03%, OR 0.47, p = 0.019) and surgical morbidity rate (43.0% vs. 25.3%, OR 0.47, p < 0.001) were significantly lower in the laparoscopic group than in the open group. The postoperative length of stay was significantly longer in the open group (mean difference - 5.6 days, p < 0.001) than in the open group. The admission cost was significantly greater in the open group than in the laparoscopic group (mean difference - 95,080 yen, p < 0.001).

CONCLUSIONS

Laparoscopic colectomy is safe and effective in the short term.

Continuous regional arterial infusion versus intravenous administration of the protease inhibitor nafamostat mesilate for predicted severe acute pancreatitis: a multicenter, randomized, open-label, phase 2 trial

BACKGROUND

Continuous regional arterial infusion (CRAI) of protease inhibitor nafamostat mesilate (NM) is used in the context of predicted severe acute pancreatitis (SAP) to prevent the development of pancreatic necrosis. Although this therapy is well known in Japan, its efficacy and safety remain unclear.

METHODS

This investigator-initiated and -driven, multicenter, open-label, randomized, controlled trial (UMIN000020868) enrolled 39 patients with predicted SAP and low enhancement of the pancreatic parenchyma on computed tomography (CT). Twenty patients were assigned to the CRAI group, while 19 served as controls and were administered NM at the same dose intravenously (IV group). The primary endpoint was the development of pancreatic necrosis as determined by CT on Day 14, judged by blinded central review.

RESULTS

There was no difference between the CRAI and IV groups regarding the percentages of participants who developed pancreatic necrosis (more than 1/3 of the pancreas: 25.0%, range 8.7-49.1% vs. 15.8%, range 3.4-39.6%, respectively, P = 0.694; more than 2/3 of the pancreas: 20%, range 5.7-43.7% vs. 5.3%, range 0.1-26.0%, respectively, P = 0.341). The early analgesic effect was evaluated based on 24-h cumulative fentanyl consumption and additional administration by intravenous patient-controlled analgesia. The results showed that the CRAI group used significantly less analgesic. There were two adverse events related to CRAI, namely bleeding and splenic infarction.

CONCLUSIONS

CRAI with NM did not inhibit the development of pancreatic necrosis although early analgesic effect of CRAI was superior to that of IV. Less-invasive IV therapy can be considered a viable alternative to CRAI therapy.

Antibacterial and Antifungal Therapy for Patients with Acute Pancreatitis at High Risk of Pancreatogenic Sepsis (Review)

Controlling infection is crucial in treating patients with acute pancreatitis (AP). The infectious process in AP often predisposes to subsequent sepsis by damaging not only the pancreas, but retroperitoneal tissues as well. Among other AP-associated factors, are the rapidly developing immune imbalance, the poor penetration of antimicrobial agents into necrotic tissue, and the impossibility of a single surgical debridement. Antibacterial and antifungal therapy for patients with infected necrosis and AP-associated extra-pancreatic infections remains a complex and largely unresolved problem, partially due to the high occurrence of multiresistant pathogens. The preventive use of antimicrobial agents has been discussed in the literature; however, the lack of consistent results makes it difficult to develop a unified strategy and clinical guidelines on this specific issue. Recent meta-analyses provide no conclusive evidence that antibacterial prophylaxis reduces the infection rate, mortality, or the need for surgical treatment in patients with necrotizing pancreatitis. We found only two studies indicating the benefits of using carbapenems for prophylactic purposes and one meta-analysis indicating a reduction in mortality under antibiotic treatment started no later than 72 h after the onset of the attack. Selective bowel decontamination is considered as one of the preventive anti-infection measures, although the available data may not be fully reliable. The main indications for antibacterial therapy in patients with AP are confirmed infected necrosis or extra-pancreatic infection, as well as clinical symptoms of suspected infection. Intra-arterial administration or local treatment with antibiotics can increase the efficacy of antibacterial therapy. No randomized studies on antifungal prophylaxis in AP are available; some reports though recommend using such therapy among patients at high risk of invasive candidiasis.

Mortality association between obesity and pneumonia using a dual restricted cohort model

BACKGROUND

An obesity survival paradox has been reported among obese patients with pneumonia.

AIMS

To determine the impact of obesity on pneumonia outcomes and analyze the correlation between in-hospital all-cause mortality and obesity among patients with pneumonia.

METHODS

The United States Nationwide Readmissions Database (NRD) was retrospectively analyzed for patients with pneumonia from 2013 to 2014. We used a step-wise restricted and propensity score matching cohort model (dual model) to compare mortality rates and other outcomes among pneumonia patients based on BMI. Mortality was calculated by a Cox proportional hazard model, adjusted for potential confounders with propensity score matched analysis.

RESULTS

A total of 70,886,775 patients were registered in NRD during the study period. Of these, 7,786,913 patients (11.0%) were considered obese and 1,652,456 patients (2.3%) were admitted to the hospital with pneumonia. Based on the step-wise restricted cohort model, the hazard ratio comparing the mortality rates among obese pneumonia patients to mortality rates among normal BMI pneumonia patients was 0.75 (95% CI 0.60-0.94). The propensity score matched analysis estimated a hazard rate of 0.84 (95% CI 0.79-0.90) and the hazard ratio estimated from the dual model was 0.82 (95% CI 0.63-1.07).

CONCLUSIONS

With the application of a dual model, there appears to be no significant difference in mortality of obese patients with pneumonia compared to normal BMI patients with pneumonia.

Pharmacologic management and prevention of acute pancreatitis

PURPOSE OF REVIEW

The present article will focus in pharmacologic agents that have been studied to improve acute pancreatitis outcomes, and to prevent the disease at different levels.

RECENT FINDINGS

Too little and too much early fluid resuscitation can be harmful. The optimal volume, rate, and duration of intravenous fluid therapy is still unknown. Nonopioid analgesics should be the first line of analgesia in patients with acute pancreatitis. A few pharmacologic agents evaluated in acute pancreatitis have resulted in positive pilot trials; however, larger randomized clinical trials (RCTs) are needed before final conclusions. Statin use is associated with lower incidence of acute pancreatitis in the general population and ongoing studies are evaluating its preventive role in acute pancreatitis recurrences. The preventive role of rectal indomethacin in post-endoscopic retrograde cholangiopancreatography pancreatitis is indisputable, with subject selection and timing of administration requiring further investigation.

SUMMARY

There is still no proven effective disease-specific pharmacologic therapy that changes the natural history of acute pancreatitis. New therapeutic targets and pharmacologic agents are in the horizon. Careful refinement in study design is needed when planning future RCTs. There is also a need for drug development aiming at reducing the incidence of the disease and preventing its sequelae.

Impact of continuous regional arterial infusion in the treatment of acute necrotizing pancreatitis: analysis of a national administrative database

BACKGROUND

Although continuous regional arterial infusion (CRAI) of protease inhibitors and broad antibiotics has been suggested as one of the therapeutic option for patients with acute necrotic pancreatitis (ANP), the effectiveness has not been well-corroborated in clinical studies.

METHODS

We conducted a retrospective cohort study using a Japanese national administrative database. Severe acute pancreatitis patients with a poorly enhanced pancreas region (i.e., definitive or clinically suspected ANP) were identified and dichotomized according to whether CRAI was performed. We compared the outcomes of in-hospital mortality, surgical interventions, hospital-free days, and healthcare costs between groups adjusted by the well-validated case-mix adjustment model using a multivariate mixed-effect regression analysis and a propensity score matching analysis.

RESULTS

Of 243,312 acute pancreatitis patients, 702 eligible patients were identified, of these 339 patients underwent CRAI. The case-mix adjustment model established had good predictability for in-hospital mortality with an area under the receiver operating characteristics curve of 0.87. CRAI was significantly associated with reduced in-hospital mortality [14.5% in the CRAI group vs. 18.2% in the non-CRAI group, adjusted odds ratio (95% confidence interval; CI) = 0.60 (0.36-0.97)]. Significant associations were not observed for the frequency of surgical interventions and mean hospital-free days; however, significantly higher healthcare costs were observed in the CRAI group. Results of the propensity score matching analysis did not alter these results.

CONCLUSIONS

Analysis of a nationwide large-scale database suggested that CRAI was significantly associated with reduced in-hospital mortality for patients with ANP. Further randomized controlled trials are warranted.

Comparative effectiveness of elemental formula in the early enteral nutrition management of acute pancreatitis: a retrospective cohort study

Background

Although enteral nutrition has become one of the standard therapies for patients with acute pancreatitis, the optimal formulae for enteral nutrition have been under debate. Elemental formula is assumed to be suitable in the treatment of patients with acute pancreatitis because it has less stimulating effects for exocrine secretions of the pancreas, simultaneously maintaining gut immunity; however, clinical studies corroborating this assumption have been scarce.

Methods

We conducted a retrospective cohort study using a Japanese national administrative database between 2010 and 2015. Patients with acute pancreatitis who received enteral feeding within 3 days of admission were identified and divided into two groups according to whether elemental formula was administered. We assessed the impact of elemental formula for the outcomes (primary, in-hospital mortality; secondary, development of sepsis, hospital-free days at 90 days, and total health-care costs) using a multivariate mixed-effect regression analysis and propensity score matching analysis adjusted by a well-validated case-mix adjustment model. Analysis for the subpopulation of patients with severe acute pancreatitis was also performed.

Results

Of 243,312 patients with acute pancreatitis, 948 patients were identified and classified into the elemental formula group (N = 382) and the control group (N = 566). No significant differences were observed for in-hospital mortality [10.2% in the elemental formula group vs. 11.0% in the control group; adjusted adds ratio (95% confidence interval; CI) = 0.94 (0.53–1.67)], sepsis development [5.0 vs. 7.1%; adjusted adds ratio (95% CI) = 0.66 (0.34–1.28)], mean hospital-free days [54 days vs. 51 days; adjusted difference (95% CI) = 2 days (− 2 to 5)], and mean total health-care costs [$29,360 vs. $34,214; adjusted difference (95% CI) = − $4250 (− 8643 to 141)]. Similar results were also observed in patients with severe acute pancreatitis.

Conclusions

The results of our retrospective cohort study using a large-scale national database did not demonstrate the benefit of elemental formula compared to semi-elemental and polymeric formulae in patients with acute pancreatitis. Further assessment of alternative nutritional strategy is expected.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0414-6) contains supplementary material, which is available to authorized users.

Impact of end-stage renal disease on hospital outcomes among patients admitted to intensive care units: A retrospective matched-pair cohort study

AIM

We aimed to estimate the burden of end-stage renal disease (ESRD) among patients admitted to intensive care units (ICUs), by comparing hospital outcomes between patients with and without ESRD.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we identified patients aged 20 years or older who were admitted to ICUs for ≥3 days (2 nights) in 2011. We created a matched cohort of patients with and without ESRD for hospital, age, sex, main diagnosis category, and ICU admission type (medical or surgical) at a maximum ratio of 1:3. For these matched patients, we compared patient characteristics, treatment regimens at ICU admission, and hospital outcomes. We also performed a multivariable logistic regression analysis for the associations between ESRD and 28-day (counting from ICU admission) and in-hospital mortality.

RESULTS

Among the 164 423 eligible patients, 7998 (4.9%) had ESRD, from which 5228 ESRD and 12 274 non-ESRD patients were matched for the aforementioned factors. Compared to non-ESRD patients, ESRD patients were on more intensive treatment regimens, including mechanical ventilation, vasoactive drugs, and blood transfusion. Patients with ESRD showed significantly higher ICU, 28-day, and in-hospital mortality and longer lengths of stay in the ICU and hospital (28-day mortality: 11.7% vs. 8.3%; P < 0.001, in-hospital mortality: 21.1% vs. 12.0%; P < 0.001). After adjusting for confounding factors, ESRD was independently associated with 28-day mortality (adjusted odds ratio: 1.36, 95% confidence interval [CI]: 1.22-1.52) and in-hospital mortality (adjusted odds ratio: 1.85, 95% CI: 1.69-2.02).

CONCLUSION

This study involving the Japanese national inpatient database, with a matched-pair cohort design, suggested that ESRD is an important burden in the critical care setting.

Journal of Clinical Monitoring and Computing 2017 end of year summary: cardiovascular and hemodynamic monitoring

Hemodynamic monitoring provides the basis for the optimization of cardiovascular dynamics in intensive care medicine and anesthesiology. The Journal of Clinical Monitoring and Computing (JCMC) is an ideal platform to publish research related to hemodynamic monitoring technologies, cardiovascular (patho)physiology, and hemodynamic treatment strategies. In this review, we discuss selected papers published on cardiovascular and hemodynamic monitoring in the JCMC in 2017.

The relationship between high-dose corticosteroid treatment and mortality in acute respiratory distress syndrome: a retrospective and observational study using a nationwide administrative database in Japan

Background

In the 1980s, randomized-controlled trials showed that high-dose corticosteroid treatment did not improve the mortality of acute respiratory distress syndrome (ARDS). However, while the diagnostic criteria for ARDS have since changed, and supportive therapies have been improved, no randomized-controlled trials have revisited this issue since 1987; thus, the effect of high-dose corticosteroid treatment may be different in this era. We evaluated the effect of high-dose corticosteroid treatment in patients with ARDS using a nationwide administrative database in Japan in a retrospective and observational study.

Methods

This study was performed with a large population using the 2012 Japanese nationwide administrative database (diagnostic procedure combination). We evaluated the mortality of ARDS patients receiving or not receiving high-dose corticosteroid treatment within 7 days of hospital admission. We employed propensity score weighting with a Cox proportional hazards model in order to minimize the bias associated with the retrospective collection of data on baseline characteristics and compared the mortality between the high-dose and non-high-dose corticosteroid groups.

Results

Data from 2707 patients were used; 927 patients were treated with high-dose corticosteroid and 1780 patients were treated without high-dose corticosteroid, within 7 days of admission. After adjusting for confounds, mortality rates within 3 months were significantly higher in the high-dose corticosteroid group compared to the non-high-dose corticosteroid group (weighted hazard ratio: 1.59; 95% CI: 1.37-1.84; P <  0.001).

Conclusions

Our results suggest that high-dose corticosteroid treatment does not improve the prognosis of patients with ARDS, even in this era. However, this study has limitations owing to its retrospective and observational design.

Continuous Regional Arterial Infusion of Protease Inhibitors Has No Efficacy in the Treatment of Severe Acute Pancreatitis: A Retrospective Multicenter Cohort Study

OBJECTIVE

The aim of this study is to assess the effectiveness of continuous regional arterial infusion (CRAI) of protease inhibitors in patients with severe acute pancreatitis (SAP) including acute necrotizing pancreatitis.

METHODS

This retrospective study was conducted among 44 institutions in Japan from 2009 to 2013. Patients 18 years or older diagnosed with SAP according to the criteria of the Japanese Ministry of Health, Labour and Welfare study group (2008) were consecutively enrolled. We evaluated the association between CRAI of protease inhibitors and mortality, incidence of infection, and the need for surgical intervention using multivariable logistic regression analysis.

RESULTS

Of 1159 patients admitted, 1097 patients with all required data were included for analysis. Three hundred and seventy-four (34.1%) patients underwent CRAI of protease inhibitors and 723 (65.9%) did not. In multivariable analysis, CRAI of protease inhibitors was not associated with a reduction in mortality, infection rate, or need for surgical intervention (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.47-1.32, P = 0.36; OR 0.97, 95% CI 0.61-1.54, P = 0.89; OR 0.76, 95% CI 0.50-1.15, P = 0.19; respectively).

CONCLUSIONS

Continuous regional arterial infusion of protease inhibitors was not efficacious in the treatment of patients with SAP.

N,N-Dimethyl Tertiary Amino Group Mediated Dual Pancreas- and Lung-Targeting Therapy against Acute Pancreatitis

Acute pancreatitis (AP) is a sudden inflammation of the pancreas with high mortality rate worldwide. As a severe complication to AP, acute lung injury has been the major cause of death among patients with AP. Poor penetration across the blood pancreas barrier (BPB) and insufficient drug accumulation at the target site often result in poor therapeutic outcome. Our previous work successfully demonstrated a dual-specific targeting strategy to pancreas and lung using a phenolic propanediamine moiety. Inspired by this, a simplified ligand structure, N,N-dimethyl tertiary amino group, was covalently conjugated to celastrol (CLT) to afford tertiary amino conjugates via either an ester (CP) or an amide linkage (CTA). With sufficient plasma stability, CTA was subjected to the following studies. Compared to CLT, CTA exhibited excellent cellular uptake efficiency in both rat pancreatic acinar cell line (AR42J) and human pulmonary alveolar epithelial cell line (A549). Organic cation transporters were proven to be responsible for this active transport process. Given systemically, CTA specifically distributed to pancreases and lungs in rats thus resulting in a 2.59-fold and 3.31-fold increase in tissue-specific accumulation as compared to CLT. After CTA treatment, tissue lesions were greatly alleviated and the levels of proinflammatory cytokines were downregulated in rats with sodium taurocholate induced AP. Furthermore, CTA demonstrated marginal adverse effect against major organs with reduced cardiac toxicity compared to CLT. Together, tertiary amine mediated dual pancreas- and lung-targeting therapy represents an efficient and safe strategy for AP management.

Clinical features and practice patterns of treatment for adrenal crisis: a nationwide cross-sectional study in Japan

CONTEXT

Adrenal crisis is an endocrine emergency that requires prompt diagnosis and treatment. However, the clinical features and practice patterns of treatment for adrenal crisis are not completely understood.

OBJECTIVE

To investigate patient characteristics, comorbidities and treatments of adrenal crisis.

METHODS

We conducted a cross-sectional study of patients who received intravenous glucocorticoids for adrenal crisis at admission from 1 July 2007 to 31 March 2014, using a national inpatient database in Japan.

RESULTS

Among approximately 34 million inpatients in the database, we identified 799 patients diagnosed with adrenal crisis and coexisting primary or secondary adrenal insufficiency at admission. The median (interquartile range) age was 58 (28-73) years, and the overall in-hospital mortality was 2.4% (19 of 799 patients). The most common comorbidity at admission was infections excluding pneumonia and gastroenteritis (15.0%). There were 68 (8.5%) patients with gastroenteritis, and no deaths occurred among these patients. The patients with secondary adrenal insufficiency showed significantly higher proportions of admission to ICU, extracellular fluid resuscitation, insulin therapy and catecholamine use than the patients with primary adrenal insufficiency. There were no significant between-group differences in mortality rate and variation in intravenous glucocorticoids (short-acting glucocorticoid, hydrocortisone; moderate-acting glucocorticoid, prednisolone or methylprednisolone; long-acting glucocorticoid, dexamethasone or betamethasone). Of the 19 dead patients, 15 were aged above 60 years, 12 had impaired consciousness at admission and 13 received insulin therapy.

CONCLUSIONS

Clinicians should be aware that older patients with impaired consciousness and diabetes mellitus are at relatively high risk of death from adrenal crisis.

Protection Provided by a Gabexate Mesylate Thermo-Sensitive In Situ Gel for Rats with Grade III Pancreatic Trauma

Background/Aims

This study investigated the protection provided by gabexate mesylate thermo-sensitive in-situ gel (GMTI) against grade III pancreatic trauma in rats.

Methods

A grade III pancreatic trauma model with main pancreatic duct dividing was established, and the pancreas anatomical diagram, ascites, and serum biochemical indices, including amylase, lipase, C-reactive protein (CRP), interleukin 6 (IL-6), and tumor necrosis factor-α (TNF-α), were examined. The pancreas was sliced and stained with hematoxylin eosin and subjected to terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining.

Results

Ascites, serum amylase, lipase, CRP, IL-6, and TNF-α levels were significantly increased in the pancreas trauma (PT) groups with prolonged trauma time and were significantly decreased after GMTI treatment. The morphological structure of the pancreas was loose, the acinus was significantly damaged, the nuclei were irregular and hyperchromatic, and there was inflammatory cell invasion in the PT group compared to the control. After GMTI treatment, the morphological structure of the pancreas was restored, and the damaged acinus and inflammatory cell invasion were decreased compared to the PT group. Moreover, the cell apoptosis index was significantly increased in the PT group and restored to the same levels as the control group after GMTI treatment.

Conclusions

GMTI, a novel formulation and drug delivery method, exhibited specific effective protection against PT with acute pancreatitis therapy and has potential value as a minimally invasive adjuvant therapy for PT with acute pancreatitis.

No weekend effect on outcomes of severe acute pancreatitis in Japan: data from the diagnosis procedure combination database

BACKGROUND

In the early phase of severe acute pancreatitis, timely multidisciplinary management is required to reduce mortality. The aim of this observational study was to evaluate the impact of weekend hospital admission on outcomes using population-based data in Japan.

METHODS

Data on adult patients (≥20 years) with severe acute pancreatitis were extracted from a nationwide Japanese administrative database covering over 1000 hospitals. In-hospital mortality, length of stay, and total costs were compared between weekend and weekday admissions, with adjustment for disease severity according to the current Japanese severity scoring system for acute pancreatitis, and other potential risk factors.

RESULTS

In total, 8328 patients hospitalized during the study period 2010-2013 were analyzed (2242 admitted at weekends and 6086 on weekdays). In-hospital mortality rates were not significantly different: 5.9 vs. 5.4 % for weekend and weekday admissions, respectively (multivariate-adjusted odds ratio, 1.06; 95 % confidence interval, 0.83-1.35). The impact of weekend admission was not significant either for length of hospitalization (median, 18 vs. 19 days) and total costs (median, 6161 vs. 6233 US dollars) (both p > 0.19 in multivariate-adjusted linear regression). The rates of, and time to, specific treatments were also similar between patients with weekend and weekday admissions.

CONCLUSIONS

A weekend effect in severe acute pancreatitis admissions was not evident. Adjustments to weekend staffing and selective hospital referral of patients admitted at weekends are not indicated for severe acute pancreatitis in current clinical practice in Japan.

Editor's Choice- Inside the cold heart: A review of therapeutic hypothermia cardioprotection

Targeted temperature management has been originally used to reduce neurological injury and improve outcome in patients after out-of-hospital cardiac arrest. Myocardial infarction remains a major cause of death in the world and several investigators are studying the effect of mild therapeutic hypothermia during an acute cardiac ischemic injury. A search on MEDLINE, Scopus and EMBASE databases was conducted to obtain data regarding the cardioprotective properties of therapeutic hypothermia. Preclinical studies have shown that therapeutic hypothermia provides a cardioprotective effect in animals. The proposed pathways for the cardioprotective effects of therapeutic hypothermia include stabilization of mitochondrial permeability, production of nitric oxide, equilibration of reactive oxygen species, and calcium channels homeostasis. Clinical trials in humans have yielded controversial results. Current trials are therefore seeking to combine therapeutic hypothermia with other treatment modalities in order to improve the outcomes of patients with acute ischemic injury. This article provides a review of the hypothermia effects on the cardiovascular system, from the basic science of physiological changes in the human body and molecular mechanisms of cardioprotection to the bench of clinical trials with therapeutic hypothermia in patients with acute ischemic injury.

Revised Japanese guidelines for the management of acute pancreatitis 2015: revised concepts and updated points

BACKGROUND

Taking together the recent dramatic changes of the revised Atlanta classification and evidence newly obtained such as the role of step-up approach for necrotizing pancreatitis, the revision committee of the Japanese (JPN) Guidelines 2015 was prompted to perform an extensive revision of the guidelines.

METHODS

The JPN Guidelines 2015 was compared to the former edition 2010, and revision concepts and major revision points were reviewed. We compared the JPN 2015 with the other two guidelines, International Association of Pancreatology (IAP)/American Pancreas Association (APA) 2013 and American College of Gastroenterology (ACG) 2013, in order to clarify the distinct points.

RESULTS

The meta-analysis team conducted a new meta-analysis of four subjects that have been associated with conflicting results. It is apparent that the revised guidelines have been created more systematically and more objectively. As of antibiotics prophylaxis, its use in early phase (within 72 h of onset) for severe acute pancreatitis is recommended in JPN 2015 according to the results of original meta-analysis, whereas the other two guidelines do not recommend its routine use. An approach and management of local complications in necrotizing pancreatitis including infected necrosis are almost similar in the three guidelines. JPN 2015 alone emphasizes the implementation of the pancreatitis bundles that specify the management and treatment within the first 48 h after the onset of severe acute pancreatitis.

CONCLUSION

The JPN Guidelines 2015 prove to be the highest quality in terms of systematic literature review conducting original analyses by the meta-analysis team, determining the grading of recommendations and providing pancreatitis bundles.

[Recent Advances in Management of Acute Pancreatitis]

Acute pancreatitis is common but remains a condition with significant morbidity and mortality. Despite a better understanding of the pathophysiology of acute pancreatitis achieved during the past few decades, there is no specific pharmacologic entity available. Therefore, supportive care is still the mainstay of treatment. Recently, novel interventions for increasing survival and minimizing morbidity have been investigated, which are highlighted in this review.

Comparison of short-term mortality and morbidity between parenteral and enteral nutrition for adults without cancer: a propensity-matched analysis using a national inpatient database

BACKGROUND

Proper artificial nutrition for patients who are unable to eat normally is an ongoing, unresolved concern in geriatric medicine and home medical care. Controversy surrounds prognostic differences between parenteral and enteral nutrition, 2 methods for artificial nutrition.

OBJECTIVES

Short-term outcomes of parenteral and enteral nutrition for patients who are unable to eat normally were compared and analyzed.

DESIGN

Data were acquired from patients selected from a national inpatient database covering 1057 hospitals in Japan. Participants had received artificial nutrition between April 2012 and March 2013, were aged ≥20 y, and did not have cancer. They were separated into 2 groups: those who received parenteral nutrition and those who received enteral nutrition. We performed one-to-one propensity score matching between the groups. The primary outcome measurements were mortality rates at 30 and 90 d after the start of the procedure. The secondary outcomes were postprocedural complications, pneumonia, and sepsis. We analyzed survival length of stay after the procedure with the use of a Cox proportional hazards model.

RESULTS

There were 3750 patients in the parenteral group and 22,166 patients in the enteral group. Propensity score matching created 2912 pairs in the 2 groups. Patients with a similar propensity score (probability of being assigned to the enteral group) calculated from the baseline condition were matched. Mortality rates at 30 and 90 d after start of treatment were 7.6% and 5.7% (P = 0.003) and 12.3% and 9.9% (P = 0.002) in the parenteral and enteral groups, respectively. In Cox regression analysis, the HR for the enteral group relative to the parenteral group was 0.62 (95% CI: 0.54, 0.71; P < 0.001). The incidences of postprocedural pneumonia and sepsis were 11.9% and 15.5% (P < 0.001) and 4.4% and 3.7% (P = 0.164) for the parenteral and enteral groups, respectively.

CONCLUSION

The present analysis showed the better survival rate with enteral compared with parenteral nutrition for adults who were not suffering from cancer. This trial was registered at clinicaltrials.gov as NCT02512224.

Acute Pancreatitis-Progress and Challenges: A Report on an International Symposium

An international symposium entitled "Acute pancreatitis: progress and challenges" was held on November 5, 2014 at the Hapuna Beach Hotel, Big Island, Hawaii, as part of the 45th Anniversary Meeting of the American Pancreatic Association and the Japanese Pancreas Society. The course was organized and directed by Drs. Stephen Pandol, Tooru Shimosegawa, Robert Sutton, Bechien Wu, and Santhi Swaroop Vege. The symposium objectives were to: (1) highlight current issues in management of acute pancreatitis, (2) discuss promising treatments, (3) consider development of quality indicators and improved measures of disease activity, and (4) present a framework for international collaboration for development of new therapies. This article represents a compilation and adaptation of brief summaries prepared by speakers at the symposium with the purpose of broadly disseminating information and initiatives.

Continuous Regional Arterial Infusion of Protease Inhibitors for Treatment of Severe Acute Pancreatitis: Systematic Review and Meta-Analysis

OBJECTIVE

We performed a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs) to assess the benefit and risk of continuous regional arterial infusion (CRAI) of protease inhibitors (CRAIpis) in patients with severe acute pancreatitis (SAP) or acute necrotizing pancreatitis (ANP).

METHODS

The search was performed using the key words "pancreatitis" and "regional arterial infusion." All language studies involving adult cases of SAP or ANP, which assessed the impact of the CRAIpis, were included.

RESULTS

Our analysis included 8 observational studies and 2 RCTs from 376 potentially relevant articles. With regard to the observational studies, the CRAIpi was significantly associated with decreased both mortality (odds ratio, 0.40; 95% confidential interval [CI], 0.25-0.64; P = 0.0001) and the need for urgent surgical intervention (odds ratio, 0.22; 95% CI, 0.12-0.3; P < 0.0001). In the RCTs, the application of CRAIpi tends to decrease the mortality but does not reach the significance (risk reduction, -0.12; 95% CI, -0.36-0.12; P = 0.33).

CONCLUSIONS

The CRAIpi has the potential to reduce the mortality or the need for urgent surgical intervention in cases of SAP or ANP. Further, large multicenter trials are needed to refute or confirm our findings.

Short-term outcomes following elective transcatheter arterial embolization for splenic artery aneurysms: data from a nationwide administrative database

Background

Splenic artery aneurysm (SAA) rupture is life-threatening. Although elective transcatheter arterial embolization (TAE) suggested low in-hospital death in previous studies, there has been no large multi-center study of elective TAE for SAA.

Purpose

To examine the short-term outcomes of TAE for splenic artery aneurysm (SAA) and analyze the factors associated with the outcomes, including liver cirrhosis, using a nationwide administrative inpatient database.

Material and Methods

We identified patients who received elective TAE with a principal diagnosis of SAA. We assessed the patient background characteristics, comprising age, sex, and specific co-morbidities, including liver cirrhosis. The outcomes included the rate of TAE-related complications (acute pancreatitis, splenic infarction, splenic abscess, or intraperitoneal hematoma), length of stay, and in-hospital mortality.

Results

Among 18.3 million inpatients in the database between July 2010 and March 2013, we identified 534 patients who received elective TAE for SAA at 229 participating hospitals. Fifty-four (10.1%) patients had liver cirrhosis. No in-hospital deaths were observed. Thirty-two (6.0%) patients had at least one TAE-related complication. A multivariate linear regression analysis revealed that liver cirrhosis was significantly associated with longer length of stay (9.5 days; 95% confidence interval [CI], 7.0–12.0 days; P < 0.001). A logistic regression analysis showed that liver cirrhosis was not significantly associated with TAE-related complications (odds ratio, 0.99; 95% CI, 0.29–3.39; P = 0.980).

Conclusion

The results revealed no in-hospital mortality and a low complication rate associated with elective TAE for SAA including liver cirrhosis patients.

Hypnotics and the Occurrence of Bone Fractures in Hospitalized Dementia Patients: A Matched Case-Control Study Using a National Inpatient Database

BACKGROUND

Preventing falls and bone fractures in hospital care is an important issue in geriatric medicine. Use of hypnotics is a potential risk factor for falls and bone fractures in older patients. However, data are lacking on the association between use of hypnotics and the occurrence of bone fracture.

METHODS

We used a national inpatient database including 1,057 hospitals in Japan and included dementia patients aged 50 years or older who were hospitalized during a period of 12 months between April 2012 and March 2013. The primary outcome was the occurrence of bone fracture during hospitalization. Use of hypnotics was compared between patients with and without bone fracture in this matched case-control study.

RESULTS

Of 140,494 patients, 830 patients suffered from in-hospital fracture. A 1:4 matching with age, sex and hospital created 817 cases with fracture and 3,158 matched patients without fracture. With adjustment for the Charlson comorbidity index, emergent admission, activities of daily living, and scores for level walking, a higher occurrence of fractures were seen with short-acting benzodiazepine hypnotics (odds ratio, 1.43; 95% confidence interval, 1.19-1.73; P<0.001), ultrashort-acting non-benzodiazepine hypnotics (1.66; 1.37-2.01; P<0.001), hydroxyzine (1.45; 1.15-1.82, P=0.001), risperidone and perospirone (1.37; 1.08-1.73; P=0.010). Other drug groups were not significantly associated with the occurrence of in-hospital fracture.

CONCLUSIONS

Short-acting benzodiazepine hypnotics and ultrashort-acting non-benzodiazepine hypnotics may increase risk of bone fracture in hospitalized dementia patients.

Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015

BACKGROUND

Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines.

METHODS

A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines.

RESULTS

Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles.

CONCLUSIONS

The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.

Efficacy of continuous regional arterial infusion with low-molecular-weight heparin for severe acute pancreatitis in a porcine model

OBJECTIVE

Administration of heparin or its derivatives has been proved to be beneficial in the treatment of severe acute pancreatitis (SAP). However, drugs administered by conventional intravenous way are difficult to reach the pancreatic tissue and may cause bleeding complications due to coagulation and microcirculatory disturbance following initiation of SAP. In this study, we aimed to assess the effects of low-molecular-weight heparin (LMWH) administered with continuous regional arterial infusion (CRAI) technique in a porcine model of SAP.

METHODS

Following baseline measurements, 18 animals were divided into three groups: CRAI group (LMWH infused through placed arterial catheter), venous group (LMWH infused through central venous catheter), and SAP control group. We used retrograde intraductal infusion of sodium taurocholate to induce SAP. Global hemodynamic profiles, urine output, systemic oxygenation, and inflammatory and serum biochemical parameters of the animals were studied. At the end of the experiment, histological examination of pancreas, intestine, and lung was performed.

RESULTS

Continuous regional arterial infusion with LMWH remarkably stabilized hemodynamic profiles, improved systemic oxygenation and peripheral perfusion, alleviated histological injury of pancreas (especially for the necrosis scale), and downregulated inflammatory response when compared with the other two groups. Moreover, serum D-dimer level also decreased most significantly in the CRAI group (474 ± 144 vs. 664 ± 155 µg/L in the venous group and 945 ± 351 µg/L in the controls at the end), partly indicating ameliorated coagulation disorders in the study group. No bleeding complication was observed in the CRAI group, whereas two animals in the venous group presented gastrointestinal hemorrhage.

CONCLUSIONS

Continuous regional arterial infusion with LMWH exhibits strong therapeutic effects in the course of SAP with great safety. Human studies using this novel therapy are required to assess these potential benefits in the clinical setting.

Continuous regional arterial infusion for the treatment of severe acute pancreatitis: a meta-analysis

BACKGROUND

Continuous regional arterial infusion (CRAI) is a drug delivery system, which dramatically increases the drug concentration in the pancreas. Previous clinical and basic studies have demonstrated the possible therapeutic efficacy of CRAI for severe acute pancreatitis (SAP). This meta-analysis of all published randomized controlled trials (RCTs) was conducted to assess the efficacy and safety of CRAI for the treatment of SAP.

DATA SOURCES

Up to August 10, 2014, RCTs comparing CRAI with intravenous infusion for SAP in PubMed, Embase, EBSCO, MEDLINE, Science Citation Index Expanded, Cochrane Library, China Academic Journals Full-Text Database, Chinese Biomedical Literature Database, and Chinese Scientific Journals Database were selected by two independent reviewers. The relative risk (RR) and their 95% confidence intervals (CI) for duration of elevated serum amylase and urine amylase, duration of abdominal pain, infection rate, incidence of complication, overall mortality, curative rate, hospital stay and details of subgroup analysis were extracted. Meta-analyses were made using the software Review Manager (RevMan version 5.10).

RESULTS

Six RCTs with 390 patients meeting the inclusion criteria were included in the final analysis. Compared with intravenous infusion route, CRAI significantly shortened the duration of elevated urine amylase (MD=-2.40, 95% CI=-3.20, -1.60; P<0.00001) and the duration of abdominal pain (MD=-1.46, 95% CI=-1.94, -0.98; P<0.00001), decreased the incidence of complication (RR=0.35, 95% CI=0.15, 0.81; P=0.01) and overall mortality (RR=0.25, 95% CI=0.08, 0.78; P=0.02), shortened the duration of hospital stay (MD=-10.36, 95% CI=-17.05, -3.68; P=0.002), and increased the curative rate (RR=1.66, 95% CI=1.13, 2.46; P=0.01). No mortality and catheter-related infections due to CRAI administration was reported in these studies. Subgroup analysis showed that the combination of drug administration via CRAI did not significantly improve the outcomes.

CONCLUSION

CRAI is effective for the treatment of SAP, and the combination of drug administration via CRAI did not have a significant effect on the improvement of the outcomes.

Clinical features of isolated dissections of abdominal aortic branches

Isolated dissection of an abdominal aortic branch is a rare entity, and previous reports regarding the condition have been based only on small case-series studies. Using a national inpatient database in Japan, we describe the clinical features of patients with isolated celiac, superior mesenteric, splenic, and hepatic artery dissections (ICAD, ISMAD, ISAD, and IHAD). We extracted data on inpatients who were diagnosed with ICAD, ISMAD, ISAD, or IHAD from the Japanese diagnosis procedure combination database, including patients' age and sex, putative risk factors (smoking status and specific comorbidities), treatments (blood transfusion, transcatheter arterial embolization (TAE) and surgical procedures), and outcomes (in-hospital complications and death). Among 18.3 million inpatients in the database between July 2010 and March 2013, we identified 276 ICAD, 715 ISMAD, 23 ISAD and 11 IHAD. The percentage of males was 78-92 %, and the mean age was 54.7-56.8 years. Hypertension was seen in 48-65, and 35-65 % were smokers. Fourteen in-hospital deaths were identified in total. In the ICAD group, splenectomy was performed in one patient and TAE was performed in 26 patients. In the ISMAD group, 16 patients received surgical intervention. Most patients with isolated dissection of an abdominal aortic branch were treated conservatively, while a small percentage required TAE or open surgery. A small proportion of dissections resulted in death.

Antithrombin and mortality in severe pneumonia patients with sepsis-associated disseminated intravascular coagulation: an observational nationwide study

BACKGROUND

The association between antithrombin use and mortality in patients with sepsis-associated disseminated intravascular coagulation (DIC) remains controversial.

OBJECTIVES

To examine the hypothesis that antithrombin could be effective in the treatment of patients with sepsis-associated DIC following severe pneumonia.

METHODS

Propensity score and instrumental variable analyses were performed by use of a nationwide administrative database, the Japanese Diagnosis Procedure Combination inpatient database. The main outcome was 28-day mortality.

RESULTS

Severe pneumonia patients diagnosed with sepsis-associated DIC (n = 9075) were categorized into antithrombin (n = 2663) and control (n = 6412) groups. Propensity score matching created a matched cohort of 2194 pairs of patients with and without antithrombin use. Mortality differences were found between the two groups (antithrombin vs. control: unmatched, 40.8% vs. 45.7%; propensity-matched, 40.6% vs. 44.2%; inverse probability-weighted, 41.1% vs. 45.1%). Multiple logistic regression analyses showed an association between antithrombin use and 28-day mortality (unmatched with propensity score adjusted, adjusted odds ratio [OR] 0.87, 95% confidence interval [CI] 0.78-0.97; propensity-matched, adjusted OR 0.85, 95% CI 0.75-0.97; inverse probability-weighted, adjusted OR 0.85, 95% CI 0.79-0.90). An analysis with the hospital antithrombin-prescribing rate as an instrumental variable showed that receipt of antithrombin was associated with a 9.9% (95% CI 3.5-16.3) reduction in 28-day mortality.

CONCLUSIONS

This retrospective, large, nationwide database study demonstrates that antithrombin administration may be associated with reduced 28-day mortality in patients with severe pneumonia and sepsis-associated DIC. A large, multinational randomized trial is required.

Treatment options for acute pancreatitis

This Review covers the latest developments in the treatment of acute pancreatitis. The Atlanta Classification of acute pancreatitis has been revised, proposing several new terms and abandoning some of the old and confusing terminology. The 2012 Revised Atlanta Classification and the determinant-based classification aim to universally define the different local and systemic complications and predict outcome. The most important differences between these classifications are discussed. Several promising treatment options for the early management of acute pancreatitis have been tested, including the use of enteral nutrition and antibiotics as well as novel therapies such as haemofiltration and protease inhibitors. The results are summarized and the quality of evidence is discussed. Finally, new developments in the management of patients with infected pancreatic necrosis are addressed, including the use of the 'step-up approach' and results of minimally invasive necrosectomy.