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Dreyer SB, Jamieson NB, Cooke SL, Valle JW, McKay CJ, Biankin AV, Chang DK. PRECISION-Panc: the Next Generation Therapeutic Development Platform for Pancreatic Cancer. Clin Oncol (R Coll Radiol) 2020; 32:1-4. [PMID: 31378449 DOI: 10.1016/j.clon.2019.07.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/11/2019] [Indexed: 10/26/2022]
Affiliation(s)
- S B Dreyer
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - N B Jamieson
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - S L Cooke
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - J W Valle
- Division of Cancer Sciences, University of Manchester, The Christie NHS Foundation Trust, Manchester, UK
| | - C J McKay
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - A V Biankin
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - D K Chang
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK.
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Dreyer SB, Jamieson NB, Upstill-Goddard R, Bailey PJ, McKay CJ, Biankin AV, Chang DK. Defining the molecular pathology of pancreatic body and tail adenocarcinoma. Br J Surg 2018; 105:e183-e191. [PMID: 29341146 PMCID: PMC5817249 DOI: 10.1002/bjs.10772] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/14/2017] [Accepted: 10/30/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) remains a dismal disease, with very little improvement in survival over the past 50 years. Recent large-scale genomic studies have improved understanding of the genomic and transcriptomic landscape of the disease, yet very little is known about molecular heterogeneity according to tumour location in the pancreas; body and tail PDACs especially tend to have a significantly worse prognosis. The aim was to investigate the molecular differences between PDAC of the head and those of the body and tail of the pancreas. METHODS Detailed correlative analysis of clinicopathological variables, including tumour location, genomic and transcriptomic data, was performed using the Australian Pancreatic Cancer Genome Initiative (APGI) cohort, part of the International Cancer Genome Consortium study. RESULTS Clinicopathological data were available for 518 patients recruited to the APGI, of whom 421 underwent genomic analyses; 179 of these patients underwent whole-genome and 96 RNA sequencing. Patients with tumours of the body and tail had significantly worse survival than those with pancreatic head tumours (12·1 versus 22·0 months; P = 0·001). Location in the body and tail was associated with the squamous subtype of PDAC. Body and tail PDACs enriched for gene programmes involved in tumour invasion and epithelial-to-mesenchymal transition, as well as features of poor antitumour immune response. Whether this is due to a molecular predisposition from the outset, or reflects a later time point on the tumour molecular clock, requires further investigation using well designed prospective studies in pancreatic cancer. CONCLUSION PDACs of the body and tail demonstrate aggressive tumour biology that may explain worse clinical outcomes.
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Affiliation(s)
- S B Dreyer
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - N B Jamieson
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | | | - P J Bailey
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - C J McKay
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - A V Biankin
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - D K Chang
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
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Palani Velu LK, McKay CJ, Carter CR, McMillan DC, Jamieson NB, Dickson EJ. Serum amylase and C-reactive protein in risk stratification of pancreas-specific complications after pancreaticoduodenectomy. Br J Surg 2016; 103:553-63. [PMID: 26898605 DOI: 10.1002/bjs.10098] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 11/25/2015] [Accepted: 12/02/2015] [Indexed: 01/08/2023]
Abstract
Abstract
Background
Pancreas-specific complications (PSCs), comprising postoperative pancreatic fistula, haemorrhage and intra-abdominal collections, are drivers of morbidity and mortality after pancreaticoduodenectomy (PD). A serum amylase concentration of 130 units/l or more on postoperative day (POD) 0 has been shown to be an objective surrogate of pancreatic texture, a determinant of PSCs. This study evaluated serial measurements of C-reactive protein (CRP) to refine PSC risk stratification.
Methods
Consecutive patients undergoing PD between 2008 and 2014, with vascular resection if required and without preoperative chemoradiotherapy, had serum investigations from the day before operation until discharge. Receiver operating characteristic (ROC) curve analysis was used to identify a threshold value of serum CRP with clinically relevant PSCs for up to 30 days after discharge as outcome measure.
Results
Of 230 patients, 95 (41·3 per cent) experienced a clinically relevant PSC. A serum CRP level of 180 mg/l or higher on POD 2 was associated with PSCs, prolonged critical care stay and relaparotomy (all P < 0·050). Patients with a serum amylase concentration of 130 units/l or more on POD 0 who developed a serum CRP level of at least 180 mg/l on POD 2 had a higher incidence of morbidity. Patients were stratified into high-, intermediate- and low-risk groups using these markers. The low-risk category was associated with a negative predictive value of 86·5 per cent for development of clinically relevant PSCs. There were no deaths among 52 patients in the low-risk group, but seven deaths among 79 (9 per cent) in the high-risk group.
Conclusion
A serum amylase level below 130 units/l on POD 0 combined with a serum CRP level under 180 mg/l on POD 2 constitutes a low-risk profile following PD, and may help identify patients suitable for early discharge.
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Affiliation(s)
- L K Palani Velu
- West of Scotland Pancreatic Unit, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
- Academic Department of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - C J McKay
- West of Scotland Pancreatic Unit, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - C R Carter
- West of Scotland Pancreatic Unit, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - D C McMillan
- Academic Department of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - N B Jamieson
- West of Scotland Pancreatic Unit, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
- Academic Department of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - E J Dickson
- West of Scotland Pancreatic Unit, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
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Mayerle J, Beyer G, Simon P, Dickson EJ, Carter RC, Duthie F, Lerch MM, McKay CJ. Prospective cohort study comparing transient EUS guided elastography to EUS-FNA for the diagnosis of solid pancreatic mass lesions. Pancreatology 2015; 16:110-4. [PMID: 26602088 DOI: 10.1016/j.pan.2015.10.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Revised: 10/14/2015] [Accepted: 10/15/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Semiquantitative EUS-elastography has been introduced to distinguish between malignant and benign pancreatic lesions. This study investigated whether semiquantitative EUS-guided transient real time elastography increases the diagnostic accuracy for solid pancreatic lesions compared to EUS-FNA. PATIENTS AND METHODS This single centre prospective cohort study included all patients with solitary pancreatic lesions on EUS during one year. Patients underwent EUS-FNA and semiquantitative EUS-elastography during the same session. EUS and elastography results were compared with final diagnosis which was made on the basis of tissue samples and long-term outcome. RESULTS 91 patients were recruited of which 68 had pancreatic malignancy, 17 showed benign disease and 6 had cystic lesions and were excluded from further analysis. Strain ratios from malignant lesions were significantly higher (24.00; 8.01-43.94 95% CI vs 44.00; 32.42-55.00 95% CI) and ROC analysis indicated optimal cut-off of 24.82 with resulting sensitivity, specificity and accuracy of 77%, 65% and 73% respectively. B-mode EUS and EUS-FNA had an accuracy for the correct diagnosis of malignant lesions of 87% and 85%. When lowering the cut-off strain ratio for elastography to 10 the sensitivity rose to 96% with specificity of 43% and accuracy of 84%, resulting in the least accurate EUS-based method. This was confirmed by pairwise comparison. CONCLUSION Semiquantitative EUS-elastography does not add substantial value to the EUS-based assessment of solid pancreatic lesions when compared to B-mode imaging.
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Affiliation(s)
- J Mayerle
- Department of Medicine A, University Medicine Greifswald, Ernst-Moritz-Arndt-University Greifswald, Germany.
| | - G Beyer
- Department of Medicine A, University Medicine Greifswald, Ernst-Moritz-Arndt-University Greifswald, Germany
| | - P Simon
- Department of Medicine A, University Medicine Greifswald, Ernst-Moritz-Arndt-University Greifswald, Germany
| | - E J Dickson
- Lister Department of Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - R C Carter
- Lister Department of Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - F Duthie
- Department of Pathology, Southern General Hospital, Glasgow, United Kingdom
| | - M M Lerch
- Department of Medicine A, University Medicine Greifswald, Ernst-Moritz-Arndt-University Greifswald, Germany
| | - C J McKay
- Lister Department of Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom
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Abstract
Standard neutron fields are invariably accompanied by a photon component due to the neutron-generating reactions and secondary neutron interactions in the surrounding environment. A set of energy-compensated Geiger-Müller (GM) tubes and electronic personal dosemeters (EPDs) have been used to measure the photon dose rates in a number of standard radionuclide and accelerator-based neutron fields. The GM tubes were first characterised in standard radioisotope and X-ray photon fields and then modelled using MCNP to determine their photon dose response as a function of energy. Values for the photon-to-neutron dose equivalent ratios are presented and compared with other published values.
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Affiliation(s)
- N J Roberts
- National Physical Laboratory, Hampton Road, Teddington, Middlesex TW11 0LW, UK
| | - N A Horwood
- National Physical Laboratory, Hampton Road, Teddington, Middlesex TW11 0LW, UK
| | - C J McKay
- National Physical Laboratory, Hampton Road, Teddington, Middlesex TW11 0LW, UK
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Steele CW, Jamieson NB, Evans TRJ, McKay CJ, Sansom OJ, Morton JP, Carter CR. Exploiting inflammation for therapeutic gain in pancreatic cancer. Br J Cancer 2013; 108:997-1003. [PMID: 23385734 PMCID: PMC3619061 DOI: 10.1038/bjc.2013.24] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 11/19/2012] [Accepted: 01/03/2013] [Indexed: 12/19/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy associated with <5% 5-year survival, in which standard chemotherapeutics have limited benefit. The disease is associated with significant intra- and peritumoral inflammation and failure of protective immunosurveillance. Indeed, inflammatory signals are implicated in both tumour initiation and tumour progression. The major pathways regulating PDAC-associated inflammation are now being explored. Activation of leukocytes, and upregulation of cytokine and chemokine signalling pathways, both have been shown to modulate PDAC progression. Therefore, targeting inflammatory pathways may be of benefit as part of a multi-target approach to PDAC therapy. This review explores the pathways known to modulate inflammation at different stages of tumour development, drawing conclusions on their potential as therapeutic targets in PDAC.
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Affiliation(s)
- C W Steele
- The Beatson Institute for Cancer Research, Glasgow G61 1BD, UK
- Department of Surgery, West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow G4 0SF, UK
| | - N B Jamieson
- Department of Surgery, West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow G4 0SF, UK
| | - T R J Evans
- The Beatson Institute for Cancer Research, Glasgow G61 1BD, UK
- Institute of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G61 1BD, UK
| | - C J McKay
- Department of Surgery, West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow G4 0SF, UK
| | - O J Sansom
- The Beatson Institute for Cancer Research, Glasgow G61 1BD, UK
| | - J P Morton
- The Beatson Institute for Cancer Research, Glasgow G61 1BD, UK
| | - C R Carter
- Department of Surgery, West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow G4 0SF, UK
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Rajoriya N, Forrest EH, Gray J, Stuart RC, Carter RC, McKay CJ, Gaya DR, Morris AJ, Stanley AJ. Long-term follow-up of endoscopic Histoacryl glue injection for the management of gastric variceal bleeding. QJM 2011; 104:41-7. [PMID: 20871126 DOI: 10.1093/qjmed/hcq161] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Variceal bleeding is an acute medical emergency with high mortality. Although less common than oesophageal variceal haemorrhage, gastric variceal bleeding is more severe and more difficult to control. The optimal therapy for gastric variceal bleeding remains unclear although endoscopic injection of N-Butyl-2-Cyanoacrylate (Histoacryl) glue is often used. However, its long-term efficacy is poorly described. We studied the immediate and long-term effects of Histoacryl glue injection as treatment for bleeding gastric varices in a large UK hospital. METHOD Endoscopy records and case notes were used to identify patients receiving Histoacryl injection for gastric variceal bleeding over a 4-year period. RESULTS Thirty-one patients received Histoacryl for gastric variceal bleeding. Seventy-four per cent patients had alcohol-related liver disease and 61% of cirrhotics were Childs Pugh grade B or C. Fifty-eight per cent were actively bleeding during the procedure with 100% haemostasis rates achieved. Two patients developed pyrexia within 24 h of injection settling with antibiotics. No other complications were encountered. Mean overall follow-up was 35 months, with mean follow-up of survivors 57 months. Forty-eight per cent patients had endoscopic ultrasound assessment of varices during follow-up with no effect on rebleeding rates. Thirteen per cent required subsequent transjugular intrahepatic portosystemic shunt placement. Gastric variceal rebleeding rate was 10% at 1 year and 16% in total. One- and two-year mortality was 23% and 35%, respectively. CONCLUSION Endoscopic injection of Histoacryl glue appears to be a safe and effective treatment for gastric variceal bleeding. Further data are required to compare it with other therapies in this situation.
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Affiliation(s)
- N Rajoriya
- Department of Gastroenterology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4OSF, UK
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Orce JN, Holt JD, Linnemann A, McKay CJ, Lesher SR, Fransen C, Holt JW, Kumar A, Warr N, Werner V, Jolie J, Kuo TTS, McEllistrem MT, Pietralla N, Yates SW. Identification of mixed-symmetry states in an odd-mass nearly spherical nucleus. Phys Rev Lett 2006; 97:062504. [PMID: 17026168 DOI: 10.1103/physrevlett.97.062504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2006] [Indexed: 05/12/2023]
Abstract
The low-spin structure of 93Nb has been studied using the (n,n'gamma) reaction at neutron energies ranging from 1.5 to 3 MeV and the 94Zr(p,2ngamma)93Nb reaction at bombarding energies from 11.5 to 19 MeV. States at 1779.7 and 1840.6 keV, respectively, are proposed as mixed-symmetry states associated with the pi2p(1/2)-1x(2(1),MS+,94Mo) coupling. These assignments are derived from the observed M1 and E2 transition strengths to the 2p(1/2)-1x(2(1)+,94Mo) symmetric one-phonon states, energy systematics, spins and parities, and comparison with shell model calculations.
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Affiliation(s)
- J N Orce
- Department of Physics and Astronomy, University of Kentucky, Lexington, Kentucky 40506-0055, USA.
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Jamieson NB, Glen P, McMillan DC, McKay CJ, Foulis AK, Carter R, Imrie CW. Systemic inflammatory response predicts outcome in patients undergoing resection for ductal adenocarcinoma head of pancreas. Br J Cancer 2005; 92:21-3. [PMID: 15597096 PMCID: PMC2361749 DOI: 10.1038/sj.bjc.6602305] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
The aim of the present study was to examine the relationship between the clinicopathological status, the pre- and postoperative systemic inflammatory response and survival in patients undergoing potentially curative resection for ductal adenocarcinoma of the head of the pancreas. Patients (n=65) who underwent resection of ductal adenocarcinoma of the head of pancreas between 1993 and 2001, and had pre- and postoperative measurements of C-reactive protein, were included in the study. The majority of patients had stage III disease (International Union Against Cancer Criteria, IUCC), positive circumferential margin involvement (R1), tumour size greater than 25 mm with perineural and lymph node invasion and died within the follow-up period. On multivariate analysis, tumour size (hazard ratio (HR) 2.10, 95% confidence interval (CI) 1.20–3.68, P=0.009), vascular invasion (HR 2.58, 95% CI 1.48–4.50, P<0.001) and postoperative C-reactive protein (HR 2.00, 95% CI 1.14–3.52, P=0.015) retained independent significance. Those patients with a postoperative C-reactive protein ⩽10 mg l−1 had a median survival of 21.5 months compared with 8.4 months in those patients with a C-reactive protein >10 mg l−1 (P<0.001). The results of the present study indicate that, in patients who have undergone potentially curative resection for ductal adenocarcinoma of the head of pancreas, the presence of a systemic inflammatory response predicts poor outcome.
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Affiliation(s)
- N B Jamieson
- University Department of Surgery, Royal Infirmary, Glasgow G31 2ER, UK
| | - P Glen
- University Department of Surgery, Royal Infirmary, Glasgow G31 2ER, UK
| | - D C McMillan
- University Department of Surgery, Royal Infirmary, Glasgow G31 2ER, UK
- University Department of Surgery, Royal Infirmary, Glasgow G31 2ER, UK. E-mail:
| | - C J McKay
- University Department of Surgery, Royal Infirmary, Glasgow G31 2ER, UK
| | - A K Foulis
- Department of Pathology, Royal Infirmary, Glasgow G31 2ER, UK
| | - R Carter
- University Department of Surgery, Royal Infirmary, Glasgow G31 2ER, UK
| | - C W Imrie
- University Department of Surgery, Royal Infirmary, Glasgow G31 2ER, UK
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Eatock FC, Chong P, Menezes N, Murray L, McKay CJ, Carter CR, Imrie CW. A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis. Am J Gastroenterol 2005; 100:432-9. [PMID: 15667504 DOI: 10.1111/j.1572-0241.2005.40587.x] [Citation(s) in RCA: 240] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND After 50 yr in which nasoenteric feeding was considered contraindicated in acute pancreatitis (AP), several clinical studies have shown that early nasojejunal (NJ) feeding can be achieved in most patients. A pilot study of early nasogastric (NG) feeding in patients with objectively graded severe AP proved that this approach was also feasible. A randomized study comparing NG versus NJ feeding has been performed. METHODS A total of 50 consecutive patients with objectively graded severe AP were randomized to receive either NG or NJ feeding via a fine bore feeding tube. The end points were markers of the acute phase response APACHE II scores and C-reactive protein (CRP) measurements, and pain patterns by visual analogue score (VAS) and analgesic requirements. Complications were monitored and comparisons made of both total hospital and intensive-care stays. RESULTS A total of 27 patients were randomized to NG feeding and 23 to NJ. One of those in the NJ group had a false diagnosis, thereby reducing the number to 22. Demographics were similar between the groups and no significant differences were found between the groups in APACHE II score, CRP measurement, VAS, or analgesic requirement. Clinical differences between the two groups were not significant. Overall mortality was 24.5% with five deaths in the NG group and seven in the NJ group. CONCLUSIONS The simpler, cheaper, and more easily used NG feeding is as good as NJ feeding in patients with objectively graded severe AP. This appears to be a useful and practical therapeutic approach to enteral feeding in the early management of patients with severe AP.
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Affiliation(s)
- F C Eatock
- Lister Department of Surgery and Department of Nutrition and Dietetics, Glasgow Royal Infirmary, Alexandra Parade, Glasgow G31 2ER, Scotland
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Abstract
Local networks may aid decision making
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Affiliation(s)
- C J McKay
- Department of Surgery, Glasgow Royal Infirmary, 10 Alexandra Parade, Glasgow G31 2ER, UK
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Abstract
The majority of deaths from acute pancreatitis are a consequence of multiple organ dysfunction syndrome (MODS). In order to influence the outcome of this condition, we need to have a better understanding of the natural history of acute pancreatitis, particularly when complicated by MODS. This paper reviews the recent literature dealing with the natural history of acute pancreatitis and the relationship between MODS, pancreatic necrosis and mortality.
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Affiliation(s)
- C J McKay
- Lister Department of Surgery, Glasgow Royal Infirmary, Glasgow, Scotland, UK.
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14
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Affiliation(s)
- C J McKay
- West of Scotland Pancreatic Unit, Royal Infirmary, Glasgow, UK.
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Abstract
BACKGROUND All patients with organ dysfunction are currently classified as having severe acute pancreatitis. The aim of this study was to characterize the systemic inflammatory response syndrome (SIRS) and early organ dysfunction in patients with acute pancreatitis and the relationship with overall mortality. METHODS Patients with predicted severe acute pancreatitis of less than 48 h duration had daily organ dysfunction scores and SIRS criteria calculated. These features were then correlated with outcome. RESULTS Of 121 patients, 68 (56 per cent) did not develop organ dysfunction; only two of these patients died (mortality rate 3 per cent). Fifty-three (44 per cent) had early organ dysfunction, of whom 11 died (21 per cent). Organ dysfunction and persistent SIRS were both associated with an increased mortality rate, but on multivariate analysis only deteriorating organ dysfunction was an independent determinant of survival. CONCLUSION Early organ dysfunction in acute pancreatitis usually resolves and in itself has no significant influence on mortality. In contrast, worsening organ dysfunction was associated with death in more than half of the patients (11 of 20); it is this group of patients who should be classified as having severe acute pancreatitis.
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Affiliation(s)
- A Buter
- Lister Department of Surgery, 16 Alexandra Parade, Glasgow Royal Infirmary, Glasgow G31 2ER, UK
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Eatock FC, Brombacher GD, Steven A, Imrie CW, McKay CJ, Carter R. Nasogastric feeding in severe acute pancreatitis may be practical and safe. Int J Pancreatol 2001. [PMID: 11185707 DOI: 10.1385/ijgc: 28: 1: 23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Severe acute pancreatitis may be protracted and some form of nutritional support is frequently required to maintain the patient's nutritional status. Recent work has suggested that enteral feeding via a jejunal route of delivery may reduce the magnitude of the inflammatory response. Insertion of nasojejunal (NJ) tubes in the patient with severe acute pancreatitis involves both delay and inconvenience. We undertook a prospective, feasibility study to assess the safety and practicability of nasogastric (NG) feeding in patients with severe acute pancreatitis. PATIENTS AND METHODS Twenty-six patients with objective evidence of severe acute pancreatitis received nasogastric feeding within 48 h of admission to our unit. RESULTS Etiology was identified as cholelithiasis (18 patients), ethanol (5), and miscellaneous (3). The median Glasgow score was 4 (range 2-7), APACHE II score 10 (4-28), and C-reactive protein concentration 286 mg/L (79-469). Fifteen patients had pancreatic and/or peripancreatic necrosis. Eleven patients developed severe organ failure, necessitating ventilatory support. Six developed multiple organ system failure, requiring inotropic support and/or renal dialysis. There were four deaths (15.3%). Nine patients underwent early, and nine late, ERCP, respectively; six necrosectomy (5 proven infected necrosis, 1 continued deterioration despite maximal support) and 4 patients internal drainage of a pseudocyst. The feed was well-tolerated in 22 patients. In 3 patients gastric stasis proved troublesome. There was no evidence of clinical or biochemical deterioration on commencing nasogastric feeding. CONCLUSION It would appear that early NG feeding is usually possible in severe acute pancreatitis. In most patients it appears safe, well-tolerated, and worthy of further study.
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Affiliation(s)
- F C Eatock
- Department of Upper GI and Pancreatico-Biliary Surgery, Glasgow Royal Infirmary, Scotland
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Abstract
OBJECTIVE To describe the development of a minimally invasive technique aimed at surgical debridement in addition to simple drainage of the abscess cavity. SUMMARY BACKGROUND DATA Surgical intervention for secondary infection of pancreatic necrosis is associated with a death rate of 25% to 40%. Although percutaneous approaches may drain the abscess, they have often failed in the long term as a result of inability to remove the necrotic material adequately. METHODS Fourteen consecutive patients with infected necrosis secondary to acute pancreatitis were studied. The initial four patients underwent sinus tract endoscopy along a drainage tract for secondary sepsis after prior open necrosectomy. This technique was then modified to allow primary debridement for proven sepsis to be carried out percutaneously in a further 10 patients. The techniques and initial results are described. RESULTS Additional surgery for sepsis was successfully avoided in the initial four patients managed by sinus tract endoscopy, and none died. Of the following 10 patients managed by percutaneous necrosectomy, 2 died. The median inpatient stay was 42 days. There was one conversion for intraoperative bleeding. Eight patients recovered and were discharged from the hospital after a median of three percutaneous explorations. Only 40% of patients required intensive care management after surgery. CONCLUSIONS These initial results in an unselected group of patients are encouraging and show that unlike with percutaneous or endoscopic techniques, both resolution of sepsis and adequate necrosectomy can be achieved. The authors' initial impression of a reduction in postoperative organ dysfunction is particularly interesting; however, the technique requires further evaluation in a larger prospective series.
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Affiliation(s)
- C R Carter
- Department of Upper Gastrointestinal and Pancreatico-Biliary Surgery, Glasgow Royal Infirmary, Glasgow, Scotland.
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Eatock FC, Brombacher GD, Steven A, Imrie CW, McKay CJ, Carter R. Nasogastric feeding in severe acute pancreatitis may be practical and safe. Int J Pancreatol 2000; 28:23-9. [PMID: 11185707 DOI: 10.1385/ijgc:28:1:23] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Severe acute pancreatitis may be protracted and some form of nutritional support is frequently required to maintain the patient's nutritional status. Recent work has suggested that enteral feeding via a jejunal route of delivery may reduce the magnitude of the inflammatory response. Insertion of nasojejunal (NJ) tubes in the patient with severe acute pancreatitis involves both delay and inconvenience. We undertook a prospective, feasibility study to assess the safety and practicability of nasogastric (NG) feeding in patients with severe acute pancreatitis. PATIENTS AND METHODS Twenty-six patients with objective evidence of severe acute pancreatitis received nasogastric feeding within 48 h of admission to our unit. RESULTS Etiology was identified as cholelithiasis (18 patients), ethanol (5), and miscellaneous (3). The median Glasgow score was 4 (range 2-7), APACHE II score 10 (4-28), and C-reactive protein concentration 286 mg/L (79-469). Fifteen patients had pancreatic and/or peripancreatic necrosis. Eleven patients developed severe organ failure, necessitating ventilatory support. Six developed multiple organ system failure, requiring inotropic support and/or renal dialysis. There were four deaths (15.3%). Nine patients underwent early, and nine late, ERCP, respectively; six necrosectomy (5 proven infected necrosis, 1 continued deterioration despite maximal support) and 4 patients internal drainage of a pseudocyst. The feed was well-tolerated in 22 patients. In 3 patients gastric stasis proved troublesome. There was no evidence of clinical or biochemical deterioration on commencing nasogastric feeding. CONCLUSION It would appear that early NG feeding is usually possible in severe acute pancreatitis. In most patients it appears safe, well-tolerated, and worthy of further study.
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Affiliation(s)
- F C Eatock
- Department of Upper GI and Pancreatico-Biliary Surgery, Glasgow Royal Infirmary, Scotland
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19
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Abstract
BACKGROUND Death from acute pancreatitis within the first week after admission is usually a consequence of multiple organ dysfunction. Reports from specialist centres suggest that, with improvements in resuscitation and supportive care, such deaths are becoming uncommon but it is unclear if this is reflected in a decrease in early mortality rate from acute pancreatitis in the general population. METHODS Data concerning patients discharged with a diagnosis of acute pancreatitis (International Classification of Disease-9 code 577.0) between 1984 and 1995 were obtained from the Information and Statistics Division, National Health Service in Scotland, and analysed on a computer database. RESULTS The incidence of acute pancreatitis in Scotland continues to increase in both sexes. The in-hospital mortality rate (death from all causes) was 7.5 per cent and showed a slight but significant downward trend over the period of study. Death within 7 days of hospital admission accounted for 53.7 per cent of all deaths and the proportion of early deaths did not decline over the study interval. CONCLUSION These results suggest that scope remains for considerable improvement in the early management of acute pancreatitis. There is an urgent need to improve the early recognition of severe pancreatitis coupled to a willingness on behalf of clinicians to transfer these patients at an early stage to a centre with high-dependency and intensive care facilities supervised by a multidisciplinary team with expertise in the endoscopic, radiological and surgical management of these patients.
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Affiliation(s)
- C J McKay
- Lister Department of Surgery, Royal Infirmary, Glasgow, UK
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20
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Abstract
For a 30-year period beginning in 1958, the general basis of medical therapy of acute pancreatitis had as its focus the provision of supplementary antiprotease therapy usually given intravenously. This concept was based on the belief that the body's natural antiprotease defense mechanism, which relies heavily on alpha 2-macroglobulin, together with alpha 1-antiprotease (alpha 1-antitrypsin), was inadequate to cope with the vast enzyme release that occurred with the onset of the more severe forms of the disease. This article examines recent studies and emerging theories on the medical therapy of acute pancreatitis.
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Affiliation(s)
- C W Imrie
- Glasgow Royal Infirmary, Scotland, United Kingdom
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21
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Abstract
Staging of acute pancreatitis is important for selection of patients for clinical trials, comparison of results between centers, and the early identification of patients who may benefit from therapeutic intervention or transfer to a specialist unit. The APACHE-II score and other multiple-factor scoring systems are widely used for the first two indications, and of these, the APACHE-II score provides the best accuracy at an early stage in the course of the illness. Presently, however, no system provides sufficient predictive power to facilitate clinical decision making. At a time of increasing pressure to involve specialist units at an early stage in the management of these complex patients, a pressing need to identify a system for accurate early staging of acute pancreatitis remains.
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Affiliation(s)
- C J McKay
- Department of Surgery, Glasgow Royal Infirmary, United Kingdom
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22
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Abstract
The purpose of this chapter is to examine the possible role of platelet-activating factor (PAF) antagonist therapy as a means of modifying the systemic inflammatory response syndrome (SIRS) and multi-organ dysfunction syndrome (MODS) in the management of patients with severe acute pancreatitis (AP). Supposed specific treatments of AP have not shown clinical benefit, with antiprotease agents such as aprotinin and gabexate mesilate, as well as fresh frozen plasma, being ineffective. In addition, early peritoneal lavage, intravenous glucagon, somatostatin and octreotide have shown no benefit.
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Affiliation(s)
- C W Imrie
- Glasgow Royal Infirmary, Alexandra Parade, UK
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23
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Taylor I, Mullee MA, Carpenter R, Royle G, McKay CJ, Cross M. The significance of involved tumour bed biopsy following wide local excision of breast cancer. Eur J Surg Oncol 1998; 24:110-3. [PMID: 9591025 DOI: 10.1016/s0748-7983(98)91407-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM Following wide local excision of breast cancer approximately 25% of patients have residual disease in the tumour bed. The aim of this study was to determine whether positive bed biopsy correlated with either local recurrence or overall survival. METHOD Following wide excision bed biopsies were taken at four separate sites from the tumour bed. Histopathological assessment of the bed biopsies was made and compared to features within the primary tumour. Patients were followed-up over a median period of 6.17 years and local recurrence and survival data documented. RESULTS Two hundred and sixty-eight patients were included in the study and 63 had positive bed biopsies. In all, 85 patients had a recurrence of breast cancer and 69 died. Kaplan-Meier plots showed no evidence of a difference in survival between bed biopsy positive and negative patients. Bed biopsy positive patients were at greater risk of local recurrence. CONCLUSIONS These findings suggest that positive bed biopsy is associated with an increase in local recurrence rates but has no effect on overall survival following wide excision of breast cancer.
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Affiliation(s)
- I Taylor
- Department of Surgery, University College London, UK
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24
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McKay CJ, Curran F, Sharples C, Baxter JN, Imrie CW. Prospective placebo-controlled randomized trial of lexipafant in predicted severe acute pancreatitis. Br J Surg 1997. [PMID: 9313702 DOI: 10.1002/bjs.1800840912] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Many patients with severe acute pancreatitis develop organ system failure during the first few days of illness, and this accounts for the majority of early deaths. No specific therapy is available and treatment remains supportive. METHODS In a randomized controlled trial conducted in 11 hospitals in the West of Scotland, 50 patients with predicted severe acute pancreatitis were selected from 188 screened over a 14-month period. Patients received placebo or lexipafant, a potent platelet-activating factor antagonist, by continuous intravenous infusion at a dose of 100 mg/day for up to 7 days. Early systemic complications were assessed by the measurement of organ failure scores. RESULTS There was a significantly greater fall in organ failure score in the treatment group during the 7 days of study (mean and median changes in organ failure score were 0.17 and 0 in the placebo group versus -1.42 and -1 in the treatment group; P = 0.003, Wilcoxon rank sum test), associated with trends towards a reduction in mortality and a reduced incidence of systemic complications. CONCLUSION These results suggest that lexipafant may be a useful adjunct to full supportive care in the early management of patients with severe acute pancreatitis.
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Affiliation(s)
- C J McKay
- Department of Surgery, Glasgow Royal Infirmary, UK
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25
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Abstract
BACKGROUND Many patients with severe acute pancreatitis develop organ system failure during the first few days of illness, and this accounts for the majority of early deaths. No specific therapy is available and treatment remains supportive. METHODS In a randomized controlled trial conducted in 11 hospitals in the West of Scotland, 50 patients with predicted severe acute pancreatitis were selected from 188 screened over a 14-month period. Patients received placebo or lexipafant, a potent platelet-activating factor antagonist, by continuous intravenous infusion at a dose of 100 mg/day for up to 7 days. Early systemic complications were assessed by the measurement of organ failure scores. RESULTS There was a significantly greater fall in organ failure score in the treatment group during the 7 days of study (mean and median changes in organ failure score were 0.17 and 0 in the placebo group versus -1.42 and -1 in the treatment group; P = 0.003, Wilcoxon rank sum test), associated with trends towards a reduction in mortality and a reduced incidence of systemic complications. CONCLUSION These results suggest that lexipafant may be a useful adjunct to full supportive care in the early management of patients with severe acute pancreatitis.
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Affiliation(s)
- C J McKay
- Department of Surgery, Glasgow Royal Infirmary, UK
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26
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McKay CJ, Gallagher G, Brooks B, Imrie CW, Baxter JN. Increased monocyte cytokine production in association with systemic complications in acute pancreatitis. Br J Surg 1996; 83:919-23. [PMID: 8813775 DOI: 10.1002/bjs.1800830712] [Citation(s) in RCA: 115] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Tumour necrosis factor (TNF) alpha, interleukin (IL) 1 beta, IL-6 and IL-8 are thought to play a central role in the pathophysiology of sepsis but their role in acute pancreatitis is unknown. In the present study, monocytes were isolated from the peripheral blood of 26 patients with moderate or severe acute pancreatitis without biliary sepsis. Secretion of these cytokines in vitro was measured at intervals during the first week of illness. Sixteen patients developed systemic complications. Peak TNF-alpha secretion was significantly higher in patients who developed systemic complications (median (interquartile range (i.q.r.)) 18.5 (5.5-28.5) ng/ml) than in those with an uncomplicated course (3.7 (2.3-6.4) ng/ml, P < 0.01). Similarly, peak IL-6 and peak IL-8 secretion were significantly higher in the complicated group (IL-6: complicated median (i.q.r.) 48.9 (12.1-71.0) ng/ml, uncomplicated 16.3 (14.2-37.9) ng/ml, P < 0.05; IL-8: complicated 748 (643-901) ng/ml, uncomplicated 608 (496-749) ng/ml), P < 0.05). No significant difference in peak IL-1 beta secretion was observed between the two groups. Systemic complications of acute pancreatitis are associated with a significant increase in monocyte secretion of TNF-alpha, IL-6 and IL-8 suggesting that, as in sepsis, these cytokines play a central role in the pathophysiology of the disease.
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Affiliation(s)
- C J McKay
- University Department of Surgery, Glasgow Royal Infirmary, UK
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Steinhorn RH, Kriesmer PJ, Green TP, McKay CJ, Payne NR. Congenital diaphragmatic hernia in Minnesota. Impact of antenatal diagnosis on survival. Arch Pediatr Adolesc Med 1994; 148:626-31. [PMID: 8193691 DOI: 10.1001/archpedi.1994.02170060080016] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE We characterized the natural history and true mortality of congenital diaphragmatic hernia (CDH) in newborn patients by identifying all infants born with this condition in a fixed geographic region over a 2-year period. We examined this population to determine the frequency of intrauterine diagnosis, the outcome of prenatally diagnosed infants, and the impact of deaths in infants with an unsuspected diagnosis (the "hidden mortality") on the overall outcome of this condition. DESIGN This was a retrospective population survey of all infants born with CDH in Minnesota between June 1988 and June 1990. SETTING All Minnesota birth and death records were reviewed to identify patients with the diagnosis of CDH. A separate survey of all level 3 intensive care nurseries was conducted and the record of each identified patient was reviewed. Extracorporeal membrane oxygenation was available throughout the study period. MAIN OUTCOME MEASURE Survival to hospital discharge and short-term morbidity were examined for each patient. RESULTS Survival was 60% (29/48). Eleven of 19 deaths occurred in patients born prematurely and/or with coexisting major anomalies. Eight percent (4/48) of patients died within the first hour of life prior to diagnosis (hidden mortality). Intrauterine diagnosis of CDH was made in 15 patients. Survival was 60% (9/15) in infants whose conditions were diagnosed in utero, a rate identical to that for infants whose conditions were diagnosed in the postnatal period (61% [20/33]). There was no relationship between age at fetal diagnosis and mortality. CONCLUSIONS The hidden mortality of CDH was low. Almost half of the total mortality for CDH was associated with coexisting, additional anomalies. Patients who were not offered extracorporeal membrane oxygenation owing to prematurity, other major anomalies, or birth at a center that did not offer extracorporeal membrane oxygenation accounted for 84% (16/19) of deaths. These data will be useful for determining the impact of new therapeutic strategies on the mortality of CDH.
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Affiliation(s)
- R H Steinhorn
- Department of Pediatrics, University of Minnesota, Minneapolis
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Abstract
Somatostatin was first suggested for the treatment of acute pancreatitis more than 15 years ago but despite many studies, its role in the management of this condition remains unclear. The experimental and clinical studies are reviewed and the physiological actions of somatostatin, which may influence the course of acute pancreatitis are examined. It is concluded that although some reports suggest a trend towards improved survival and lessened complication rate with somatostatin treatment, insufficient evidence of benefit exists to support the use of somatostatin or its analogue in the treatment or prophylaxis against acute pancreatitis in routine clinical practice.
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Affiliation(s)
- C J McKay
- University Department of Surgery, Royal Infirmary, Glasgow
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Moller JH, Borbas C, Hagler DJ, McKay CJ, Stone FM. Pediatric cardiac care consortium. Demonstrated value of a physician-directed quality assessment system. Minn Med 1990; 73:26-32. [PMID: 2366709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A quality assessment system for analyzing the results of inpatient care of children with cardiac abnormalities is described. Three Minnesota institutions (the Mayo Clinic, Minneapolis Children's Medical Center, and the University of Minnesota) participate with 15 other similar centers elsewhere in the United States in this system. Patient data are analyzed and adjusted for case mix to allow for differences in patient populations and referral patterns. The statistical methods used are shown for two conditions: ventricular septal defect and aortic valvotomy. Data presented show reduction in length of stay for cardiac catheterization. This change occurred as physicians annually reviewed and discussed the data and, as a result, instituted changes. This physician-directed program seeks improvement in patient care through physician education.
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