Physicians Treated for Alcoholism: A Follow-Up Study

Studying alcoholism and chemical dependency among members of the medical profession, the authors discovered that, despite the special problems associated with alcoholic physicians, the number responding to treatment and showing improvement is high, and the overall results are encouraging.     

Outcome of Necrosectomy in Acute Pancreatitis: the Case for Continued Vigilance

Background: Surgery for pancreatic necrosis complicating acute severe pancreatitis carries a high risk of mortality and may be influenced by a range of variables including patterns of referral, case selection and quality of care. Methods: An observational study of a consecutive series of 54 patients undergoing pancreatic necrosectomy in a specialist Hepatobiliary unit over an 8-year study period. Principal outcomes were organ dysfunction and physiological derangement in relation to surgery, microbial colonization of necrosis and relation to outcome, re-operation rates, requirement for peri-operative nutritional support, trends in mortality and survival analysis. Results: Necrosectomy was associated with statistically significant deterioration in immediate postoperative organ dysfunction scores (ANOVA P < 0.01). Infected necrosis was present in 36 (68%). Fungal colonization of necrosis was present in 5 (9%). Mortality in this subgroup was 80% (4 deaths). There was no association between bacterial colonization of necrosis and death in this study ( P = 0.77; Fisher exact test; relative risk 0.9, 95% confidence interval 0.54-1.54). Twenty patients (37%) required further surgical intervention with an average of 1.5 surgical procedures per patient. Twenty-three patients (43%) died. Patient survival to discharge was best predicted by admission APACHE-II score with relative risk of death increasing 14% for each unit increase in APACHE-II score at admission. Conclusions: The results of the present study illustrate that there is no place for complacency in the surgical management of patients with severe acute pancreatitis. A clinical governance approach would promote pre-defined protocols between admitting hospitals and tertiary referral centres. Future research should target new interventions in patients with high admission APACHE-II scores in whom prognosis is particularly poor and explore the role of infection of necrotic tissue.     

急性坏死性胰腺炎治疗的临床分析

目的:对急性坏死性胰腺炎(ANP)的内、外科治疗进行临床分析。方法:对58例ANP进行了分析,其中非手术组15例,手术组43例。在治疗的以下几个方面进行了对比:在非手术组中是否使用胰液/胰酶抑制剂;在手术组中72小时内和72小时后手术;在抗生素治疗上,二联用药(头孢唑啉 甲硝唑)与多联用药。结果:非手术组中用过胰液分泌抑制剂或胰酶抑制剂者死亡率为12、5％,显著低于未用过胰液分泌抑制剂或胰酶抑制剂者(71.4％,P<0.05);手术组中72小时以内手术者死亡率为36.7％,显著低于72小时以上者(84.6％,P<0.01);抗生素治疗方面,二联用药(头孢唑啉 甲硝唑)与广谱、多联用药的死亡率无显著差异(P>0.05)。结论:由于胰液/胰酶抑制剂能降低轻症ANP的死亡率,轻症病人应积极采用胰液/胰酶抑制剂为主的综合治疗,重症病人应早期手术;而在抗生素治疗上,除非有严重感染,一般仅需二联用药,无需多种广谱抗生素联用。     

Predictors of Critical Acute Pancreatitis: A Prospective Cohort Study

Critical acute pancreatitis (CAP) has recently emerged as the most ominous severity category of acute pancreatitis (AP). As such there have been no studies specifically designed to evaluate predictors of CAP. In this study, we aimed to evaluate the accuracy of 4 parameters (Acute Physiology and Chronic Health Evaluation [APACHE] II score, C-reactive protein [CRP], D-dimer, and intra-abdominal pressure [IAP]) for predicting CAP early after hospital admission. During the study period, data on patients with AP were prospectively collected and D-dimer, CRP, and IAP levels were measured using standard methods at admission whereas the APACHE II score was calculated within 24 hours of hospital admission. The receiver-operating characteristic (ROC) curve analysis was applied and the likelihood ratios were calculated to evaluate the predictive accuracy. A total of 173 consecutive patients were included in the analysis and 47 (27%) of them developed CAP. The overall hospital mortality was 11% (19 of 173). APACHE II score ≥11 and IAP ≥13 mm Hg showed significantly better overall predictive accuracy than D-dimer and CRP (area under the ROC curve—0.94 and 0.92 vs 0.815 and 0.667, correspondingly). The positive likelihood ratio of APACHE II score is excellent (9.9) but of IAP is moderate (4.2). The latter can be improved by adding CRP (5.8). In conclusion, of the parameters studied, APACHE II score and IAP are the best available predictors of CAP within 24 hours of hospital admission. Given that APACHE II score is rather cumbersome, the combination of IAP and CRP appears to be the most practical way to predict critical course of AP early after hospital admission.     

Clinical Significance and Outcome of Gastric Mucosal Erosions: A Long-Term Follow-Up Study

Our purpose was to evaluate the long-term clinical significance of gastric erosions. A series of 117 patients with gastric erosions without peptic ulcer disease, and matched controls were studied in 1974–1979. All available subjects were reinvestigated 17 years later, including detailed clinical history and laboratory analysis. At follow-up, erosions were still more prevalent (39%; 20/50) in the erosion group than in the controls (11; 7/66). In Helicobacter pylori–positive participants, peptic ulcer or a scar was more common in the erosion group (17%; 9/52) than in controls (5%; 3/66). Overall malignancy rate was higher in controls (15%; 17/117) than in erosion group (5%; 6/117; P = .025), but no other differences were seen between the groups or related with current erosion. We conclude that a significant proportion of gastric erosions are chronic or recurrent but mostly without serious complications. However, H. pylori–positive patients with erosions have significant risk to develop a peptic ulcer.     

A Prospective Cohort Study of Smoking in Acute Pancreatitis

Background/Aims: Little is known about risk factors for acute pancreatitis other than gallstones and alcohol consumption. The aim of this study was to investigate if smoking or body mass index (BMI) are associated with acute pancreatitis and to determine relative risks (RR) for acute pancreatitis related to smoking, BMI, and alcohol consumption. Methods: From 1974 to 1992, selected birth-year cohorts of residents in Malmö, Sweden (born 1921–1949) were invited to a health-screening investigation including physical examination, blood sampling and a questionnaire. In total, 33,346 individuals participated. Cases of acute pancreatitis were identified from diagnosis registries (n = 179). Incidence rates were calculated in different risk factor categories. A Cox's analysis revealed RR. Results: Current versus never smoking at baseline was associated with acute pancreatitis (RR 2.14, 95% confidence interval (CI) 1.48–3.09) after adjustment for age, sex, BMI and alcohol consumption. This association was stronger in heavy smokers (20–30 cigarettes/day) (RR 3.19, 95% CI 2.03–5.00). Smoking was associated with a RR of 3.57 (95% CI 0.98–13.0) for acute pancreatitis in subjects who reported no alcohol consumption. An increased risk for acute pancreatitis was also found for high versus low risk, self-reported alcohol consumption (RR 2.55,95% CI 1.59–4.08) and for γ-GT levels in the highest versus the lowest quartile (RR 2.14,95%CI 1.32–3.49). There was alsoa weakcorrelation between BMI and acute pancreatitis. Conclusions: Smoking is associated with the incidence of acute pancreatitis in a dose-response manner.     

Evaluation of Severity in Patients with Acute Pancreatitis

We compared the multiple organ system failure (MOSF) score, the Acute Physiologic and Chronic Health Evaluation (APACHE) II, and Ranson and Imrie scores for their predictive value in evaluating severity of acute pancreatitis. Of the 259 patients, 73 (28%) had severe disease. Fifty-two (20%) patients had organ system failure (OSF) on admission, and 59% of patients with severe disease had OSF. Shortly after admission, only MOSF and APACHE II scores were available, and in patients with severe disease, these predictions were correct in 64% and 60%, respectively. Forty-eight hours later, the MOSF score was the most sensitive, and correctly predicted outcome in 67% of patients, compared with about 60% for other scores. Of four scoring systems, only MOSF and APACHE II scores allowed repetitive assessment to monitor the course of the disease. MOSF score is organ-specific and may be better than APACHE II in reflecting disease activity. Our results suggest that the MOSF score is valuable in early identification and close monitoring of high risk patients and in deciding on therapy in these patients.     

A 2-Year Follow-Up of 120 Swedish Female Alcoholics Treated Early in Their Drinking Career: Prediction of Drinking Outcome

BACKGROUND: One hundred twenty women alcoholics recruited to a treatment program called EWA (Early Treatment for Women With Alcohol Addiction) were studied. The selected women were not previously treated for alcohol abuse. METHODS: The women were followed up by use of a structured personal interview, biomarkers sensitive for alcohol abuse (i.e., glutamyl transpeptidase), and questionnaires, by using defined criteria for abstinence, social drinking, satisfactory drinking outcome, and unsatisfactory drinking outcome. RESULTS: Drinking outcome was good (i.e., total abstinence, social drinking, or satisfactory drinking outcome) for 67% of the women during the total follow-up time, by use of strict criteria for relapse. The results were corroborated by the biomarkers. Similar results were reported from two previously studied groups of women from the same department. However, the frequency of abstinence was higher and social drinking was significantly lower among this sample of women. Daily drinking, the use of sedatives, and a long duration of pretreatment alcohol abuse predicted an unfavorable outcome. However, a long duration of outpatient treatment predicted a good outcome, whereas treatment dropout was related to an unsatisfactory drinking outcome. A majority of the women (96%) rated the treatment experience and the treatment program favorably. The overall good results might reflect the selection of the subjects studied. CONCLUSIONS: Improving treatment program adherence would probably improve outcome for the women with an unsatisfactory drinking outcome.     

国产甲磺酸加贝酯治疗急性水肿型胰腺炎556例临床研究

自1993年5月－1994年5月，我们应用国产注射用甲磺酸加贝酯（gabexate mesllate,GM;日本商品为Foy)治疗556例急性水肿型胰腺炎。380例单独应用GM（GA组），176例除GM外合并应用H2受体拮抗剂（GB组），另设C组为对照组。三组基础治疗相同，疗程7－10天。治疗结果：GA组血，尿淀粉酶3天内复常者占70．24％，55．79％。GB组占74．43％，50％。7天内复常者两组分别为96．58％，92．37％，97．16％，90．35％。主要症状如恶心，呕吐，上腹部痛，三天内消失率GA组分别为83．8％，87．11％，47％；GB组分别为：88．7％，96．48％，47．7％。7天内消失率两组为94．100％。化验检查及主要症状的恢复两组相比（P＞0．05）差异无显著性。与对照组相比差异显著（P＜0．05）。治疗中少数患者（3．06％）发生静脉炎及注射部位疼痛等一些不良反应。以上结果表明：单独应用GM治疗与加用H2受体拮抗剂二组疗效相同，总有效率显著高于对照组。GM治疗急性水肿型胰腺炎具有缓解症状迅速，血尿淀粉酶恢复正常需时短的优点。而且不易复发，不良反应发生率低。因此GM可作为急性水肿型胰腺炎的首选药物，疗效可靠而又安全。     

Acetaminophen Poisoning and Risk of Acute Pancreatitis: A Population-Based Cohort Study

The aim of this study was to assess whether acetaminophen poisoning is associated with a higher risk of acute pancreatitis.We conducted a retrospective cohort study by using the longitudinal population-based database of Taiwan''s National Health Insurance (NHI) program between 2000 and 2011. The acetaminophen cohort comprised patients aged ≥20 years with newly identified acetaminophen poisoning (N = 2958). The comparison cohort comprised randomly selected patients with no history of acetaminophen poisoning. The acetaminophen and comparison cohorts were frequency matched by age, sex, and index year (N = 11,832) at a 1:4 ratio. Each patient was followed up from the index date until the date an acute pancreatitis diagnosis was made, withdrawal from the NHI program, or December 31, 2011. Cox proportional hazard regression models were used to determine the effects of acetaminophen on the risk of acute pancreatitis.The risk of acute pancreatitis was 3.11-fold higher in the acetaminophen cohort than in the comparison cohort (11.2 vs 3.61 per 10,000 person-years), with an adjusted hazard ratio of 2.40 (95% confidence interval, 1.29–4.47). The incidence rate was considerably high in patients who were aged 35 to 49 years, men, those who had comorbidities, and within the first year of follow-up.Acetaminophen poisoning is associated with an increased risk of acute pancreatitis. Additional prospective studies are necessary to verify how acetaminophen poisoning affects the risk of acute pancreatitis.     

国产加贝酯治疗急性出血坏死性胰腺炎疗效观察

根据卫生部卫药发（１９９２）３５号文件，我们进行了开放、对照、多中心Ⅲ期临床研究，以探讨加贝酯对急性出血坏死性胰腺炎的疗效。共观察８５例，治疗组４９例，对照组３６例，我们发现：治疗组有效率为７４．２％，而对照组为３６．０％（Ｐ＜０．０５）；死亡率分别为４．１％与２２．２％（Ｐ＜０．０５）；两组在缓解症状、消退体征与血淀粉酶恢复正常的有效率分别为７５．４％、７１．８％与８１．６％以及３８．８％、３６．０％与４４．４％（Ｐ＜０．０５，三者均同），两组在缓解症状、消退体征与血淀粉酶恢复正常的时间分别为５．４１±２．３８、５．７６±２．３２与４．５８±２．３９以及７．１１±２．４７、７．５５±２．４８与７．５８±１．９５日（Ｐ＜０．０５三者均同）。治疗后血象、肝、肾功能无明显改变。以上表明：本品对急性出血坏死性胰腺炎的治疗安全可靠，有迅速缓解临床症状、降低死亡率与提高存活率之效。     

Buprenorphine or Procaine for Pain Relief in Acute Pancreatitis A Prospective Randomized Study

Background: To assess the analgesic efficacy and side effects of buprenorphine and procaine in patients with acute pancreatitis. Methods: Forty patients (average age, 50 years; 23 male) with acute pancreatitis or an acute bout of a chronic pancreatitis were prospectively randomized to receive buprenorphine or procaine for pain relief. Both analgesics were administered as constant intravenous (i.v.) infusions and additional analgesics were given on demand. Pain scores were assessed on a visual analogue scale. Close clinical control and laboratory checks were performed during the three-day study period. Results: Patients receiving buprenorphine were significantly less likely to demand additional analgesics (1 versus 14 patients; P &lt; 0.0001). The pain scores for patients in the buprenorphine group were significantly lower over the treatment period in comparison to procaine (P &lt; 0.05). The reduction of pain score was significantly greater during the initial two treatment days using buprenorphine (day 1: 55 versus 25, P &lt; 0.0001; day 2: 62 versus 40, P = 0.005). Side effects were comparable for both groups with the exception of a slightly higher sedation rate under buprenorphine. Conclusions: Constant i.v. application of buprenorphine is more effective than the recommended procaine for pain relief in acute pancreatitis.     

The Impact of an Inpatient Pancreatitis Service and Educational Intervention Program on the Outcome of Acute Pancreatitis

BackgroundWe introduced an inpatient pancreatitis consultative service aimed to 1) provide guideline-based recommendations to acute pancreatitis inpatients and 2) educate inpatient teams on best practices for acute pancreatitis management. We assessed the impact of pancreatitis service on acute pancreatitis outcomes.MethodsInpatients with acute pancreatitis (2008-2018) were included in this cohort study. Primary outcomes included length of stay and refeeding time. The educational intervention was a guideline-based decision support tool, reinforced at hospital-wide educational forums. In Part A (n = 965), we compared outcomes pre-service (2008-2010) to post-service (2012-2018), excluding 2011, when the pancreatitis service was introduced. In Part B (n = 720, 2012-2018), we divided patients into 2 groups based on if co-managed with the pancreatitis service, and compared outcomes, including subgroup analysis based on severity, focusing on mild acute pancreatitis.ResultsIn Part A, for mild acute pancreatitis, length of stay (111 vs 88.4 h, P = .001), refeeding time (61.8 vs 47.4 h, P = .002), and infections (10.0% vs 1.87%, P < .001) were significantly improved after the pancreatitis service was introduced, with multivariable analysis showing reduced length of stay (odds ratio 0.83; 95% confidence interval, 0.82-0.84; P < .001) and refeeding time (odds ratio 0.75; 95% confidence interval, 0.74-0.77; P < .001). In Part B, for mild acute pancreatitis, refeeding time (44.2 vs 50.3 h, P = .123) and infections (5.58% vs 4.70%, P = .80) were similar in patients cared for without and with the service. Length of stay was higher in the pancreatitis service group (93.3 vs 81.2 h, P = .05), as they saw more gallstone acute pancreatitis patients who had greater length of stay and magnetic resonance cholangiopancreatography. In the post-service period, a majority of patients with moderate/severe acute pancreatitis and nearly all intensive care unit admits received care from the pancreatitis service.ConclusionsImplementation of an inpatient pancreatitis service was associated with improved outcomes in mild acute pancreatitis. Guideline-based educational interventions have a beneficial impact on management of mild acute pancreatitis by admitting teams even without pancreatitis consultation.     

Patient-Reported Outcome and Clinical Scores Are Equally Accurate in Predicting Mucosal Healing in Ulcerative Colitis: A Prospective Study

Digestive Diseases and Sciences - Optimal management of patients with ulcerative colitis (UC) requires the accurate, objective assessment of disease activity. We aimed to determine how strong...