Sequential organ failure assessment score in predicting outcome in patients with acute pancreatitis

Aims/Objectives

To evaluate the sequential organ failure assessment (SOFA) score pertaining to the severity and outcome in acute pancreatitis, and compare its outcome with the APACHE II score in terms of accuracy and ease of operation with a view to establishing whether the SOFA scoring system can replace APACHE II in predicting severity and outcome of acute pancreatitis.

Methods

Fifty cases of acute pancreatitis were evaluated in this prospective study. These patients were treated as per standard protocols and followed up daily. Both SOFA and APACHE II scores were calculated at admission and thereafter at 48-hour intervals till discharge or death. Subsequently, the data were analysed, and receiver operating characteristic curves were made for SOFA, APACHE II and other biochemical parameters; a p-value < 0.05 was taken as significant.

Results

The SOFA score showed a significant association in predicting the severity of the disease, especially during the first week. Moreover, it decreased the predicted severity of APACHE II by 18% and mortality by 4.5%.

Conclusion

On the day of admission, SOFA scores were comparable with APACHE II in predicting the outcome with a higher area under the ROC curve, and displayed better predicting capability as compared to APACHE II.     

A modified gastrointestinal failure score for patients with severe acute pancreatitis

Purpose

No consensus has been reached to define gastrointestinal failure (GIF) associated with severe acute pancreatitis (SAP). Reintam and colleagues proposed a scoring system of GIF for critically ill patients, but its suitability for patients with SAP is questionable. The present study evaluates a modified GIF score we developed to assess the GIF of patients with SAP.

Methods

The subjects of this study were 52 patients with SAP treated between September 2010 and July 2011. We recorded the Reintam’s GIF score, our modified GIF score, the acute physiology and chronic health evaluation (APACHE) II score, the sequential organ failure assessment (SOFA) score, and other clinical values during the first 3 days after admission. The prognostic value of the modified GIF score, for evaluating the severity and outcomes of SAP, was also assessed.

Results

Compared with the Reintam’s GIF score, the modified GIF score seemed to be more valuable for predicting hospital mortality (the area under curve, AUC 0.915 vs. 0.850), multiple organ dysfunction syndrome (MODS) (AUC 0.829 vs. 0.766), and pancreatic infection (AUC 0.796 vs. 0.776). Moreover, combining the modified GIF score and the SOFA or APACHEII scores resulted in more accurate prediction of the prognosis of SAP than either score alone.

Conclusion

The modified GIF score is useful for assessing gastrointestinal system function, which may serve as an early prognostic tool to evaluate the severity and predict the outcomes of SAP.     

Effects of Abdominal Fat Distribution Parameters on Severity of Acute Pancreatitis

Background

Obesity is a well-established risk factor for acute pancreatitis. Increased visceral fat has been shown to exacerbate the pro-inflammatory milieu experienced by patients. This study aimed to investigate the relationship between the severity of acute pancreatitis and abdominal fat distribution parameters measured on computed tomography (CT) scan.

Methods

Consecutive patients admitted to Cork University Hospital with acute pancreatitis between January 2005 and December 2010 were evaluated for inclusion in the study. An open source image analysis software (Osirix, v 3.9) was used to calculate individual abdominal fat distribution parameters from CT scans by segmentation of abdominal tissues.

Results

A total of 214 patients were admitted with pancreatitis between January 2005 and December 2010. Sixty-two of these patients underwent a CT scan and were thus eligible for inclusion. Visceral fat volume was the volumetric fat parameter that had the most significant association with severe acute pancreatitis (P?=?0.003). There was a significant association between visceral fat volume and subsequent development of systemic complications of severe acute pancreatitis (P?=?0.003). There was a strong association between mortality and visceral fat volume (P?=?0.019). Multivariate regression analysis, adjusted for gender, did not identify any individual abdominal fat distribution index as an independent risk factor for severe acute pancreatitis.

Conclusions

Overall, estimation of abdominal fat distribution parameters from CT scans performed on patients with acute pancreatitis indicates a strong association between visceral fat, severe acute pancreatitis, and the subsequent development of systemic complications. These data suggest that visceral fat volume should be incorporated into future predictive scoring systems.     

Validation of AAST EGS Grade for Acute Pancreatitis

Background

The AAST recently developed an emergency general surgery (EGS) disease grading system to measure anatomic severity. We aimed to validate this grading system for acute pancreatitis and compare cross sectional imaging-based AAST EGS grade and compare with several clinical prediction models. We hypothesize that increased AAST EGS grade would be associated with important physiological and clinical outcomes and is comparable to other severity grading methods.

Methods

Single institution retrospective review of adult patients admitted with acute pancreatitis during 10/2014–1/2016 was performed. Patients without imaging were excluded. Imaging, operative, and pathological AAST grades were assigned by two reviewers. Summary and univariate analyses were performed. AUROC analysis was performed comparing AAST EGS grade with other severity scoring systems.

Results

There were 297 patients with a mean (±SD) age of 55?±?17 years; 60% were male. Gallstone pancreatitis was the most common etiology (28%). The overall complication, mortality, and ICU admission rates were 51, 1.3, and 25%, respectively. The AAST EGS imaging grade was comparable to other severity scoring systems that required multifactorial data for readmission, mortality, and length of stay.

Conclusions

The AAST EGS grade for acute pancreatitis demonstrates initial validity; patients with increasing AAST EGS grade demonstrated longer hospital and ICU stays, and increased rates of readmission. AAST EGS grades assigned using cross sectional imaging findings were comparable to other severity scoring systems. Further studies should determine the generalizability of the AAST system.Level of Evidence: IVStudy Type: Single institutional retrospective review

     

Peritoneal Lavage for Severe Acute Pancreatitis: A Systematic Review of Randomised Trials

Background

The use of peritoneal lavage in patients with acute pancreatitis remains controversial. While recent guidelines do not make a positive recommendation for its use, there continues to be reports of clinical benefits from peritoneal lavage in this setting. The aim of this study was to systematically review the available randomized controlled trials of peritoneal lavage in patients with severe acute pancreatitis.

Methods

The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and four major Chinese biomedical databases were searched. A random effects model was used in meta-analysis. The summary estimates were reported as risk ratios (RR) with corresponding 95% confidence interval.

Results

Ten randomized controlled trials, encompassing a total of 469 patients, were included. When compared with conservative treatment, the use of peritoneal lavage did not result in a statistically significant difference in the risk of mortality (RR = 0.82; 95% CI 0.32–1.79; p = 0.69) and complications (RR = 1.33; 95% CI 0.99–2.12; p = 0.06). The use of peritoneal lavage with antiproteases, in comparison with peritoneal lavage only, also did not result in a statistically significant difference in the risk of mortality and complications.

Conclusion

The lavage of the peritoneal cavity in patients with severe acute pancreatitis does not appear to confer a clinical benefit. Whether lavage of the pancreatic bed after necrosectomy is beneficial has yet to be determined.     

Scoring-Systeme bei peripherer arterieller Verschlusskrankheit

Background

In recent years new scoring systems to predict the outcome of distinctive revascularization methods in the myriad of peripheral arterial disease treatment options have been introduced.

Aim

In this article it will be demonstrated whether scoring systems in the course of the demographic development can be of assistance for clinical decision making.

Material and methods

The scoring systems are presented and differentiated according to the morphological and functional approach and the evidential value as well as practical relevance are discussed.

Results

Simple morphological scoring systems, such as the Bollinger score and the Society for Vascular Surgery (SVS) score are differentiated from new systems which include risk factors as well as functional parameters. Physician and patient oriented outcome predictors, such as Finnvasc and the LEGS score or the BASIL survival predictor must be differentiated. The scoring systems presented vary greatly with respect to the application and evidential value. The best validation has been carried out for the P III risk score and the Finnvasc score. The CRAB index extends the latter by an important risk factor and together with the CLI score they are the only ones to consider the functional patient status before intervention.

Conclusion

Scoring systems can provide valuable support for difficult decision making on the necessity for treatment.     

Bridging knee arthrodesis for limb salvage using an intramedullary cemented nail: a retrospective outcome analysis of a case series

Introduction

Failed total knee replacement with compromised bone and soft-tissues can be challenging. In these situations, arthrodesis remains a treatment option of a limb-saving procedure.

Methods

We investigated the outcome of treatment with an intramedullary cemented knee arthrodesis nail implanted in 22 consecutive patients with forlorn situations after failed total knee replacement.

Results

There were three major complications due to re-infection and two minor complications due to wound-healing disturbances that healed with the implant retained after an average follow-up of 3.4?years. Clinical examination, Short Form-36 and Oxford knee scores revealed low pain levels, safe implant anchorage, and improved stability of the knee, whilst autonomous mobility utilizing walking aids was still possible.

Conclusion

Bridging knee arthrodesis with an intramedullary nail is a valuable salvage procedure with acceptable clinical results. As recurring infection remains the most challenging complication, regular clinical and radiological follow-up examinations are necessary following implant-related knee arthrodesis to allow timely intervention in case of loosening.     

Evaluation of the Appendicitis Inflammatory Response Score for Patients with Acute Appendicitis

Background

Acute appendicitis is still a difficult diagnosis. Scoring systems are designed to aid in the clinical assessment of patients with acute appendicitis. The Alvarado score is the most well known and best performing in validation studies. The purpose of the present study was to externally validate a recently developed appendicitis inflammatory response (AIR) score and compare it to the Alvarado score.

Methods

The present study selected consecutive patients who presented with suspicion of acute appendicitis between 2006 and 2009. Variables necessary to evaluate the scoring systems were registered. The diagnostic performance of the two scores was compared.

Results

The present study included 941 consecutive patients with suspicion of acute appendicitis. There were 410 male patients (44%) and 531 female patients (56%). The area under the receiver operating characteristic curve of the AIR score was 0.96 and significantly better than the area under the curve of 0.82 of the Alvarado score (p?Conclusions This study externally validates the AIR Score for patients with acute appendicitis. The scoring system has a high discriminating power and outperforms the Alvarado score.     

The Prognostic Value of the Neutrophil–Lymphocyte Ratio (NLR) in Acute Pancreatitis: Identification of an Optimal NLR

Introduction

The neutrophil–lymphocyte ratio (NLR), calculated from the white cell differential count, provides a rapid indication of the extent of an inflammatory process. The aim of this study was to investigate the prognostic value of the NLR in acute pancreatitis (AP) and determine an optimal ratio for severity prediction.

Materials and Methods

NLRs were calculated on days 0, 1, and 2, and correlated with severity. Severity was defined using the Atlanta classification.

Results

One hundred forty-six consecutive patients managed were included, 22 with severe acute pancreatitis (SAP). NLR in SAP was significantly higher than in the favorable prognosis group on all 3 days (day 0, 15.5 vs. 10.5; day 1, 13.3 vs. 9.8; day 2, 10.8 vs. 7.6). The optimal cut-offs from ROC curves were 10.6 (day 0), 8.1 (day 1), and 4.8 (day 2) giving sensitivities of 63–90 %, specificities of 50–57 %, negative predictive value of 89.5–96.4 %, positive predictive values of 21.2–31.1 %, and accuracies of 57.7–60 %.

Conclusions

Elevation of the NLR during the first 48 h of admission is significantly associated with severe acute pancreatitis and is an independent negative prognostic indicator in AP.     

Surgical techniques for the dissection of encased perforators in giant clinoidal meningiomas

Background

Surgical treatment of giant clinoidal meningiomas remains a challenging task for neurosurgeons. Here, we present details of the surgical techniques for the dissection of encased perforators.

Methods

The dissection of encased perforators is summarized as follows: (1) split the tumor above the encased arteries and perforators; (2) find the entrance and exit points of the perforators, and estimate the running course of the perforators within the tumor; (3) dissect and expose the perforators along the estimated line.

Conclusions

The surgical techniques described in this article will aid in achieving maximum tumor resection while preserving encased perforators.     

M. Perthes

Background

The clinical course of Legg-Calvé-Perthes disease (LCPD) is variable. Diagnosis, nonsurgical and surgical methods of treatment have evolved over many decades, from abduction casts and braces to advanced surgical containment methods which are now the mainstay of treatment.

Methods

This article presents a general view and a critical evaluation of the literature.

Results

The main prognostic factors are patient age at the onset of LCPD, the range of motion and the extent of the necrotic process according to the classification of Herring and Catterall. The main aims of surgical and nonsurgical treatment of LCPD are to prevent prearthrotic deformity of the femoral head, relief of symptoms, containment of the femoral head and restoration of congruence of the hip joint.

Conclusions

Each patient needs to be evaluated individually. Every child must receive an adapted treatment and continued follow-up at regular intervals.     

Testing the raters: inter-rater reliability of standardized anaesthesia simulator performance

Purpose

Assessment of physician performance has been a subjective process. An anaesthesia simulator could be used for a more structured and standardized evaluation but its reliability for this purpose is not known. We sought to determine if observers witnessing the same event in an anaesthesia simulator would agree on their rating of anaesthetist performance.

Methods

The study had the approval of the research ethics board. Two one-hour clinical scenarios were developed, each containing five anaesthetic problems. For each problem, a rating scale defined the appropriate score (no response to the situation: score=0; compensating intervention defined as physiological correction: score= 1; corrective treatment: defined as definitive therapy score=2). Video tape recordings, for assessment of inter-rater reliability, were generated through role-playing with recording of the two scenarios three times each resulting in a total of 30 events to be evaluated. Two clinical anaesthetists, uninvolved in the development of the study and the clinical scenarios, reviewed and scored each of the 30 problems independently. The scores produced by the two observers were compared using the kappa statistic of agreement.

Results

The raters were in complete agreement on 29 of the 30 items. There was excellent inter-rater reliability (=0.96, P < 0.001).

Conclusion

The use of videotapes allowed the scenarios to be scored by reproducing the same event for each observer. There was excellent inter-rater agreement within the confines of the study. Rating of video recordings of anaesthetist performance in a simulation setting can be used for scoring of performance. The validity of the scenarios and the scoring system for assessing clinician performance have yet to be determined.     

Clinical judgment is the most important element in overhydration assessment of chronic hemodialysis patients

Background

The assessment of hydration status remains a challenging task in hemodialysis (HD) management. There are only limited data available on the relevance of clinical decisions in the estimation of dialysis overhydration (OH). The objective of this study was to examine the significance of clinical judgment in the assessment of pre-dialysis OH.

Methods

We compared the performance of three methods of OH assessment: (1) clinical judgment guided by a single clinical examination with (2) multifrequency bioimpedance analysis (BIA) and (3) complex systematic clinical approach. We additionally studied the associations of these methods with selected laboratory and imaging parameters.

Results

Any of the single parameters alone reached a sufficient level of accuracy for reliable prediction of OH. Clinical judgment was the single most important factor in OH estimation, and also had the highest contribution when in combination with other parameters. BIA reliably measured extracellular fluid, but the automatically calculated OH_BIA exhibited a substantial degree of inaccuracy that precludes the use of BIA as a standard at present. The combination of clinical judgment with additional clinical parameters had the highest prediction accuracy for OH. Among the parameters studied, vena cava collapsibility index and calf circumference showed the strongest association with OH. Echocardiography, cardiothoracic index, atrial natriuretic peptide levels and spirometry did not have acceptable sensitivity.

Conclusion

The systematic clinical approach combining physician and patient inputs, laboratory and imaging data enables an individualized decision and a superior accuracy in OH assessment.     

The current diagnosis and treatment of benign biliary stricture

Purpose

As laparoscopic cholecystectomy and liver transplantation (LT) have become more common, so has biliary stricture. Fortunately, endoscopic treatment has almost simultaneously been developed. This article reviews the recent reports concerning the management of benign biliary strictures (BBS).

Methods

The literature regarding the diagnosis and treatment of BBS is reviewed after an electronic search of PubMed from 1982 to 2009 was performed.

Results

Despite the existence of diagnostic tools including tumor markers, brush cytology, intraductal ultrasonography and other imaging modalities, differentiating BBS from malignant stricture remains challenging, as does differentiating IgG4-related sclerosing cholangitis from other benign strictures. Endoscopic treatment with balloon dilation of the stricture and serial insertions of stents is the preferred initial treatment for BBS. However, the outcomes of endoscopic treatments for primary sclerosing cholangitis or chronic pancreatitis are poorer than those for post-surgical biliary stricture. When endoscopic treatments fail to repair complicated biliary strictures such as Bismuth types III, IV, and V, surgical repair is recommended. Among the non-anastomotic BBS, intrahepatic bilateral type strictures after LT may require repeat transplantation.

Conclusion

Early referral to tertiary centers with an alliance among hepatobiliary surgeons, interventional radiologists, and endoscopists is necessary to assure optimal results.     

Molecular Absorbent Recirculating System therapy (MARS®) in pediatric acute liver failure: a single center experience

Background

Supportive care as a bridge to transplant or recovery remains challenging in children suffering from acute liver failure (ALF). We report our experience in children using the Molecular Absorbent Recirculating System (MARS®).

Methods

Retrospective data from children receiving therapy using MARS® from October 2009 to October 2012 were included in this single-center retrospective study. Patient characteristics, clinical presentation and complications of ALF, clinical and biological data before and after each MARS® session, technical modalities and adverse events were recorded.

Results

A total of six children underwent 17 MARS® sessions during the study period. Two adolescents were treated with the adult filter MARSFLUX® and four infants were treated with the MiniMARS® filter. The mean PEdiatric Logistic Dysfunction (PELOD) score at admission was 19 (range 11–33). All patients were mechanically ventilated, and four had acute kidney injury. The neurological course improved in one case, judged as stable in two cases and worsened in one case; data were unavailable in two cases. Mean serum ammonia levels decreased significantly following treatment with MARS® from an initial 89?±?29 to 58?±?35 mcmol/L (p?=?0.02). No other significant biological improvement was observed. Hemodynamic status improved/remained unchanged in the adolescent group, but in the infants four of the seven sessions were poorly tolerated and two sessions were aborted. Three patients died, two were successfully transplanted and one recovered without transplantation.

Conclusion

In our experience, treatment with MARS® is associated with encouraging results in adolescents, but it needs modification for very sick infants to improve tolerance.     

Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review

Objective

We performed a systematic review to assess the outcome of endoscopic transluminal necrosectomy in necrotising pancreatitis with additional focus on indication, disease severity, and methodological quality of studies.

Design

We searched the literature published between January 2005 and June 2013. Cohorts, including patients with (infected) necrotising pancreatitis, undergoing endoscopic necrosectomy were included. Indication, disease severity, and methodological quality were described. The main outcomes were mortality, major complications, number of endoscopic sessions, and definitive successful treatment with endoscopic necrosectomy alone.

Results

After screening 581 papers, 14 studies, including 455 patients, fulfilled the eligibility criteria. All included studies were retrospective analyses except for one randomized, controlled trial. Overall methodological quality was moderate to low (mean 5, range 2–9). Less than 50 % of studies reported on pre-procedural severity of disease: mean APACHE-II score before intervention was 8; organ failure was present in 23 % of patients; and infected necrosis in 57 % of patients. On average, four (range 1–23) endoscopic interventions were performed per patient. With endoscopic necrosectomy alone, definitive successful treatment was achieved in 81 % of patients. Mortality was 6 % (28/460 patients) and complications occurred in 36 % of patients. Bleeding was the most common complication.

Conclusions

Endoscopic transluminal necrosectomy is an effective treatment for the majority of patients with necrotising pancreatitis with acceptable mortality and complication rates. It should be noted that methodological quality of the available studies is limited and that the combined patient population of endoscopically treated patients is only moderately ill.     

The effects of low-intensity pulsed ultrasound and pulsed electromagnetic fields bone growth stimulation in acute fractures: a systematic review and meta-analysis of randomized controlled trials

Introduction

The aim of this systematic review and meta-analysis was to evaluate the best currently available evidence from randomized controlled trials comparing pulsed electromagnetic fields (PEMF) or low-intensity pulsed ultrasound (LIPUS) bone growth stimulation with placebo for acute fractures.

Materials and methods

We performed a systematic literature search of the medical literature from 1980 to 2013 for randomized clinical trials concerning acute fractures in adults treated with PEMF or LIPUS. Two reviewers independently determined the strength of the included studies by assessing the risk of bias according to the criteria in the Cochrane Handbook for Systematic Reviews of Interventions.

Results

Seven hundred and thirty-seven patients from 13 trials were included. Pooled results from 13 trials reporting proportion of nonunion showed no significant difference between PEMF or LIPUS and control. With regard to time to radiological union, we found heterogeneous results that significantly favoured PEMF or LIPUS bone growth stimulation only in non-operatively treated fractures or fractures of the upper limb. Furthermore, we found significant results that suggest that the use of PEMF or LIPUS in acute diaphyseal fractures may accelerate the time to clinical union.

Conclusions

Current evidence from randomized trials is insufficient to conclude a benefit of PEMF or LIPUS bone growth stimulation in reducing the incidence of nonunions when used for treatment in acute fractures. However, our systematic review and meta-analysis suggest that PEMF or LIPUS can be beneficial in the treatment of acute fractures regarding time to radiological and clinical union. PEMF and LIPUS significantly shorten time to radiological union for acute fractures undergoing non-operative treatment and acute fractures of the upper limb. Furthermore, PEMF or LIPUS bone growth stimulation accelerates the time to clinical union for acute diaphyseal fractures.     

Ulcerative colitis in patient with sickle cell disease: A conspiracy of nature that turns surgeon’s decision into a challenge

Introduction

Concurrent presentation of ulcerative colitis and sickle cell disease is a very rare incident. We report the fifth case to be reported worldwide.

Case Report

A 21-year-old woman with coincidental ulcerative colitis and sickle cell disease presented complaining of an acute abdominal pain, rendering the differential diagnosis as a very challenging task. Finally, she underwent surgery involving a long-term and multistep procedure.

Discussion

Abdominal pain could be ascribed to ulcerative colitis or a sickle cell crisis. Surgical intervention is reserved for acute complications of both diseases. If surgery is chosen as the treatment modality in a surgical emergency, a multistep and extended procedural plan must be considered to ensure the optimal outcome of the patient.

Conclusion

The rarity of this coincidental abdominal pain renders differential diagnosis a very challenging task for the attending physician. If surgical intervention is inevitable, both the patient and surgeon must understand the long-term and multistep plan to ensure an optimal outcome.