Serum amyloid A is a better early predictor of severity than C-reactive protein in acute pancreatitis

BACKGROUND: Serum amyloid A (SAA) is an early and sensitive marker of the extent of tissue trauma and inflammation. The aim of this study was to compare the early prognostic accuracy of SAA with that of serum C-reactive protein (CRP) in acute pancreatitis. METHODS: In a prospective multicentre trial, plasma SAA and CRP levels were measured in patients with severe and mild acute pancreatitis, and in a control group with acute abdominal pain. Plasma samples were collected on admission and at 6-h intervals for 48 h, every 12 h between 48 and 72 h, then daily for 5 days. Plasma SAA was measured by a new enzyme-linked immunosorbent assay and CRP was measured by immunoturbidometry. RESULTS: There were 137 patients with mild and 35 with severe acute pancreatitis, and 74 control patients. SAA levels were significantly higher in patients with severe acute pancreatitis than in those with mild acute pancreatitis, on admission, at 24 h or less after symptom onset, and subsequently. Whereas plasma CRP concentration was also significantly higher in patients with severe acute pancreatitis on admission, it failed to distinguish mild from severe acute pancreatitis until 30-36 h after symptom onset. SAA levels predicted severity (sensitivity 67 per cent, specificity 70 per cent, negative predictive value 89 per cent, mean(s.d.) area under curve 0.7(0.05)) significantly better than CRP (57 per cent, 60 per cent, 84 per cent, 0.59(0.06) respectively) on admission (P = 0.02) and at 24 h following symptom onset (area under curve 0.65(0.09) versus 0.58(0.09) respectively; P < or = 0.02). CONCLUSION: Plasma SAA concentration is an early marker of severity in acute pancreatitis and is superior to CRP estimation on hospital admission and at 24 h or less after symptom onset. This study suggests that plasma SAA concentration is clinically useful, with the potential to replace CRP in the management of acute pancreatitis.     

Improved prediction of outcome in patients with severe acute pancreatitis by the APACHE II score at 48 hours after hospital admission compared with the APACHE II score at admission. Acute Physiology and Chronic Health Evaluation

HYPOTHESIS: The 48-hour APACHE (Acute Physiology and Chronic Health Evaluation) II score is a better predictor of pancreatic necrosis, organ failure, and mortality in patients with severe acute pancreatitis than the score at hospital admission. DESIGN: A retrospective analysis of 125 patients with acute pancreatitis. SETTING: A tertiary public teaching hospital. PATIENTS: Patients with severe acute pancreatitis as defined by 3 or more Ranson criteria or a hospital stay of longer than 6 days. MAIN OUTCOME MEASURES: Pancreatic necrosis, organ failure, and mortality. RESULTS: A significant association was found between the 48-hour score and the presence of pancreatic necrosis (P<.001), organ failure (P =.001), and death (P<.001). By contrast, the APACHE II score at admission was significantly associated only with the presence of organ failure (P =.007). Deteriorating APACHE II scores over 48 hours were significantly associated with a fatal outcome (P =.03). The combined APACHE II score (defined as the sum of the admission and 48-hour scores) was significantly higher among nonsurvivors than survivors (P<.001), and was strongly associated with the presence of pancreatic necrosis (P =.001) and organ failure (P<.001). The 48-hour and combined scores accurately predicted outcome in 93% of the patients compared with 75% by the admission score. CONCLUSIONS: The 48-hour APACHE II score has improved predictive value compared with the admission score for identifying patients with severe acute pancreatitis who have a poor outcome. A deteriorating APACHE II score at 48 hours after admission may identify patients at risk for an adverse outcome.     

Urinary trypsinogen activation peptide as a marker of severe acute pancreatitis

BACKGROUND: Trypsinogen activation peptide (TAP) may be an early marker of severe pancreatitis. Previous studies have included all patients with organ failure in the group with severe pancreatitis, although patients with transient organ failure may have a good prognosis. The aim of this study was to determine the value of urinary TAP estimation for prediction of severity of acute pancreatitis, and to validate use of several markers of prediction of severity against a new, stringent definition of severity. METHODS: Patients with acute pancreatitis were recruited within 24 h of onset of symptoms. Urine and blood samples were collected for 24 h, and Acute Physiology And Chronic Health Evaluation (APACHE) II (24 h), Ranson (48 h) and Glasgow (48 h) scores were calculated. Severe acute pancreatitis was defined by the presence of a local complication or the presence of organ failure for more than 48 h. RESULTS: Urinary TAP levels were significantly greater in patients with severe pancreatitis than in those with mild disease during the first 36 h of admission. The highest of three estimations of TAP in the first 24 h was as effective as APACHE II at 24 h in predicting severity. At 24 h after admission, urinary TAP was better than C-reactive protein (CRP) in predicting severity. The combination of TAP and CRP at 24 h allowed identification of high- and low-risk groups. The new definition of severity excluded 24 of 190 patients with transient organ failure; none of these patients died. CONCLUSION: Use of TAP improved early prediction of the severity of acute pancreatitis. Organ failure that resolves within 48 h does not signify a severe attack of acute pancreatitis.     

Serum interleukin-15 level is a useful predictor of the complications and mortality in severe acute pancreatitis

BACKGROUND: In severe acute pancreatitis, multiple organ dysfunction syndrome and infectious complications are contributors to high mortality. Interleukin (IL)-15 is a novel cytokine that shares many biologic properties with IL-2. Serum IL-15 levels have not yet been determined in SAP. METHODS: Serum IL-15 concentrations were measured in 54 patients with severe acute pancreatitis on admission. The relationships with severity, organ dysfunction, infection, and prognosis were analyzed. Utility of IL-15 for the prediction of clinical outcome was evaluated by receiver operator characteristic (ROC) curve analysis. RESULTS: Serum IL-15 levels were increased significantly in severe acute pancreatitis (5.8 +/- 0.5 pg/mL), and they were correlated with Ranson, APACHE II, and Japanese severity score. Serum IL-15 levels were greater in patients with organ dysfunction, patients with infection, and nonsurvivors (P < 05 each). Incidences of organ dysfunction in patients whose IL-15 levels were less than 3.0, 3.0-5.3, and greater than or equal to 5.3 pg/mL, were 8%, 31%, and 89%, respectively (P < .001). Usefulness of IL-15 for the prediction of organ dysfunction was superior to CRP, IL-6, and IL-8, and it was similar to Ranson, APACHE II, and Japanese severity score. Incidences of infection in patients whose IL-15 levels were less than 5.5, 5.5-9.0, and greater than or equal to 9.0 pg/mL, were 7%, 25%, and 50%, respectively (P < .05). Mortality rates in patients whose IL-15 levels were less than 5.5, 5.5-9.0, and greater than or equal to 9.0 pg/mL, were 11%, 25%, and 80%, respectively (P < .001). Usefulness of IL-15 for the prediction of death was superior to CRP, IL-6, and IL-8. CONCLUSIONS: Serum IL-15 level is a useful predictor of the complications (especially organ dysfunction) and mortality in severe acute pancreatitis.     

Early ascorbic acid depletion is related to the severity of acute pancreatitis.

BACKGROUND: Ascorbic acid (AA) is an important endogenous antioxidant in plasma and has been shown to be decreased at the time of hospital admission in patients with acute pancreatitis. The aim of this study was to determine whether plasma AA concentration continues to decrease after admission and whether the extent of decrease is related to the severity of pancreatitis. METHODS: Consecutive patients with mild (n = 62) and severe (n = 23) acute pancreatitis had plasma AA concentration measured on the day of recruitment and on days 2 and 5 by high-performance liquid chromatography. RESULTS: The plasma AA concentration in patients with acute pancreatitis was significantly less than that in normal volunteers on days 0, 2 and 5 (P < 0.0001) and this was more marked in those with severe disease. There was a decrease in plasma AA concentration from day 0 to day 2 in patients with mild (P < 0.0001) and severe (P = 0.0005) pancreatitis, and from day 2 to day 5 in patients with severe pancreatitis (P = 0.023). CONCLUSION: Endogenous plasma AA continues to decrease over the first 5 days in hospital and the extent is related to the severity of acute pancreatitis. Presented to a meeting of the Australasian Surgical Research Society, Auckland, New Zealand, August 1995 and published in abstract form as Aust N Z J Surg 1996; 66: 243     

Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis

BACKGROUND: Mortality in patients with acute pancreatitis is associated with the number of failing organs and the severity and reversibility of organ dysfunction. The aim of this study was to assess the significance of early systemic inflammatory response syndrome (SIRS) in the development of multiorgan dysfunction syndrome (MODS) and death from acute pancreatitis. METHODS: Data for all patients with a diagnosis of acute pancreatitis between January 2000 and December 2004 were reviewed. Serum C-reactive protein (CRP), Acute Physiology And Chronic Health Evaluation (APACHE) II scores and presence of SIRS were recorded on admission and at 48 h. Marshall organ dysfunction scores were calculated during the first week of presentation. Presence of SIRS and raised serum CRP levels on admission and at 48 h were correlated with the cumulative organ dysfunction scores in the first week. RESULTS: A total of 759 patients with acute pancreatitis were identified, of whom 45 (5.9 per cent) died during the index admission. SIRS was identified in 162 patients on admission and was persistent in 138 at 48 h. The median (range) cumulative Marshall score in patients with persistent SIRS was significantly higher than that in patients in whom SIRS resolved and in those with no SIRS (4 (0-12), 3 (0-7) and 0 (0-9) respectively; P < 0.001). Thirty-five patients (25.4 per cent) with persistent SIRS died from acute pancreatitis, compared with six patients (8 per cent) with transient SIRS and four (0.7 per cent) without SIRS (P < 0.001). No correlation was observed between CRP level on admission and Marshall score (P = 0.810); however, there was a close correlation between CRP level at 48 h and Marshall score (P < 0.001). CONCLUSION: Persistent SIRS is associated with MODS and death in patients with acute pancreatitis and is an early indicator of the likely severity of acute pancreatitis.     

Levels of the chemokines growth-related oncogene alpha and epithelial neutrophil-activating protein 78 are raised in patients with severe acute pancreatitis

BACKGROUND: Multiple organ dysfunction syndrome secondary to systemic leucocyte activation is the major cause of death following an attack of acute pancreatitis. Although plasma levels of interleukin (IL) 8 are known to be raised in acute pancreatitis, levels of other CXC chemokines such as growth-related oncogene (GRO) alpha and epithelial neutrophil-activating protein (ENA) 78, which are also potent neutrophil chemoattractants and activators, have not been measured.METHODS: Timed plasma samples were obtained from 51 patients with acute pancreatitis, 27 with a severe attack and 24 with mild disease according to the Atlanta classification. Samples were analysed to determine levels of C-reactive protein (CRP), IL-8, GRO-alpha and ENA-78.RESULTS: Plasma levels of IL-8, GRO-alpha and ENA-78 were increased in patients with severe as opposed to mild acute pancreatitis as early as 24 h following disease onset. Using cut-off levels of 7 pg/ml for IL-8, 70 pg/ml for GRO-alpha and 930 pg/ml for ENA-78, peak levels within the first 24 h of admission had an accuracy of 81, 71 and 87 per cent respectively in predicting the severity of an attack of acute pancreatitis.CONCLUSION: In patients with severe acute pancreatitis plasma levels of GRO-alpha and ENA-78 were raised in addition to those of IL-8, suggesting that all three chemokines are involved in the inflammatory response in this condition.     

Identification of severe acute pancreatitis using an artificial neural network

BACKGROUND: The aim of this study was to construct and validate an artificial neural network (ANN) model to identify severe acute pancreatitis (AP) and predict fatal outcome. METHODS: All patients who presented with AP from January 2000 to September 2004 were reviewed. Presentation data on admission and at 48 hours were collected. Acute Physiology and Chronic Health Evaluation (APACHE) II and Glasgow severity (GS) score were calculated. A feed-forward ANN was created and trained to predict development of severe AP and mortality from AP; 25% of the data set was withheld from training and was used to evaluate the accuracy of the ANN. Accuracy of the ANN in predicting severity of AP was compared with APACHE II and GS scores. RESULTS: A total of 664 patients with AP were identified of whom 181 (27.3%) fulfilled the clinical and radiologic criteria for severe pancreatitis and 42 patients died (6.3%). Median APACHE II score at 48 hours was 4 (range, 0 to 23). ANN was more accurate than APACHE II or GS scoring systems at predicting progression to a severe course (P < .05 and P < .01, respectively), predicting development of multiorgan dysfunction syndrome (P < .05 and P < .01) and at predicting death from AP (P < .05). CONCLUSIONS: An ANN was able to predict progression to severe disease, development of organ failure and mortality from acute pancreatitis with considerable accuracy and outperformed other clinical risk scoring systems. Further studies are required to assess its utility in aiding management decisions in patients with AP.     

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.     

急性胰腺炎患者血清ACE与ACE2的动态变化及其临床意义

目的 探讨急性胰腺炎（acute pancreatitis,AP）病程一周内血清血管紧张素转化酶（ACE）、血管紧张素转化酶2（ACE2）水平的动态变化及其临床意义。方法 选取2015年9月至2018年11月杭州师范大学附属医院AP住院患者60例,按《中国急性胰腺炎诊治指南》分为轻度急性胰腺炎组（MAP,45例）和 中重度急性胰腺炎组[（M）SAP,15例],进行规范化治疗,并与同期健康体检的志愿者进行比较（对照组,10例）。采用酶联免疫吸附法测定各组第1、3、7天的血清ACE、ACE2水平,并将ACE、ACE2、ACE2/ACE分别与急性生理与慢性评分II（APACHE II）作相关性分析。结果 随着病情发展,MAP组和（M）SAP组患者APACHE II评分呈下降趋势,但（M）SAP组患者评分始终高于MAP组（P＜0.05）。MAP组患者随APACHE II评分下降,ACE、ACE2、ACE2/ACE逐渐升高,但差异无统计学意义（P＞0.05）。(M)SAP组患者随APACHEII评分下降,ACE逐渐下降（P=0.006）;ACE2无明显变化（P=0.750）;ACE2/ACE逐渐升高（P＜0.001）。相关性分析表明,ACE与APACHE II评分呈线性正相关（r=0.543,P＜0.01）,ACE2/ACE与APACHE II评分呈线性负相关（r=-0.297,P＜0.05）。ACE、ACE2、ACE2/ACE用于判断病情严重程度的敏感性分别为51.1%、33.3%、84.4%,特异性分别为70.0%、86.7%、63.7%。结论 血清ACE、ACE2均参与了AP疾病的发生、发展,以ACE为代表的经典轴会促进胰腺炎发展;以ACE2为代表的新轴来拮抗经典轴,具有抗炎症作用。ACE2/ACE是判断病情严重程度敏感性的较高指标。     

活化蛋白C、脑钠肽及APACHE Ⅱ评分在老年重症肺炎患者中的动态变化及与预后的相关性

目的探讨活化蛋白C（APC）、脑钠肽（BNP）及急性生理学与慢性健康状况评分系统Ⅱ（APACHE Ⅱ）评分在老年重症肺炎患者中的动态变化，并分析其与预后的相关性。 方法选取2016年6月至2018年6月于成都市西区医院诊治的288例老年重症肺炎患者为研究对象，根据患者28天生存情况分为生存组（168例）和死亡组（120例）。用化学发光法和酶联免疫吸附法检测各组患者血清APC和BNP表达水平，用APACHE Ⅱ评分评估各组患者预后，分析两组患者入组后第1天、第4天和第7天APC、BNP和APACHE Ⅱ评分的动态变化；应用Logistic回归分析影响老年重症肺炎预后的危险因素，采用ROC曲线分析3项指标联合预测老年重症肺炎预后的价值。 结果与死亡组患者相比，生存组患者入组后第1天、第4天和第7天BNP水平[（494.62 ± 34.82）pg/ml、（318.42 ± 27.42）pg/ml和（274.61 ± 20.84）pg/ml]和APACHE Ⅱ评分[（24.05 ± 4.82）、（18.62 ± 3.71）和（12.13 ± 2.62）]显著增高，差异均有统计学意义（P均< 0.001），但APC水平[（289.34 ± 18.39）ng/ml、（357.64 ± 32.71）ng/ml和（427.25 ± 18.45）ng/ml]则显著降低，差异均有统计学意义（t = 5.512、35.499、78.552，P均< 0.001）。生存组患者随住院时间延长，其BNP水平与APACHE Ⅱ评分逐渐降低（F = 24.538、P < 0.001；F = 12.945、P < 0.001），而APC水平则逐渐升高（F = 23.947、P < 0.001）。死亡组患者随住院时间的延长，其BNP水平[（749.14 ± 42.92）pg/ml、（814.62 ± 50.47）pg/ml和（904.25 ± 57.15）pg/ml]与APACHE Ⅱ评分[（28.34 ± 5.17）、（34.51 ± 6.35）和（39.55 ± 7.32）]逐渐升高，差异有统计学意义（F = 15.302、P < 0.001，F = 10.389、P < 0.001）；而APC水平[（276.23 ± 21.84）ng/ml、（226.38 ± 28.26）ng/ml和（183.43 ± 33.81）ng/ml]逐渐下降，差异有统计学意义（F = 34.165、P < 0.001）。生存组和死亡组在吸烟史[36.90%（62/168） vs. 53.33（64/120）]、慢性呼吸系统病史[（46.43（78/168） vs. 65.83（79/120）]、氧分压[（83.27 ± 6.92）mmHg vs. （76.82 ± 8.65）mmHg]及机械通气方面[35.12（59/168） vs. 52.50（63/120）]，差异均有统计学意义（χ² = 7.677、P = 0.006，χ² = 10.630、P = 0.001，t = 9.881、P < 0.001，χ² = 8.661、P = 0.003）。Logistic回归分析显示，机械通气（OR = 4.627，P < 0.001）、APC（OR = 2.637，P = 0.012）、BNP（OR = 3.325，P = 0.005）和APACHE Ⅱ评分（OR = 4.831，P < 0.001）均为影响老年重症肺炎预后的独立危险因素。ROC曲线显示，与APC、BNP或APACHE Ⅱ评分单项指标预测比较，3项指标联合预测老年重症肺炎死亡的敏感性、特异性、阳性预测值及阴性预测值（89.42%、81.61%、84.72%和86.03%）均显著升高。 结论APC、BNP和APACHE Ⅱ评分在老年重症肺炎疾病转归中变化明显，为影响老年重症肺炎预后的独立危险因素，3项指标联合可显著提高其预后预测价值。     

尿中胰蛋白酶原激活肽对重症急性胰腺炎的早期预测价值

目的　评估尿中胰蛋白酶原激活肽（TAP）对重症急性胰腺炎（SAP）患者的早期预测价值。方法　出现首发症状后48h内入院的急性胰腺炎（AP）患者41例（轻型29例、重症12例）及对照组11例,在入院时、24h、48h及72h取尿样测定TAP浓度,同时对每个患者在入院后48h进行APACHEⅡ评分。结果　入院时重症组尿TAP值（95nmol/L)高于轻型组（20nmol/L,P＜0.005)及对照组(15nmol/L,P＜0.005)。入院时尿中TAP值≥35nmol/L预测SAP的特异性和敏感性分别为89.7%和91.7%,而APACHEⅡ≥9诊断SAP的特异性和敏感性仅为72.7%和75.0%。90%的患者可通过TAP预测AP的严重程度,而APACHEⅡ评分仅能对73%的患者进行正确评价。结论　首发症状出现后48h内入院的AP患者尿中TAP浓度可早期预测SAP。     

中度急性胰腺炎临床特征分析

目的探讨中度急性胰腺炎的临床特征。方法回顾性分析2013年1月至12月,青海省交通医院普通外科收治的103例急性胰腺炎（acute pancreatitis,AP）患者临床资料,根据国际AP专题研讨会最新修订的诊断和分类标准（2012年,美国亚特兰大）诊断为轻度急性胰腺炎（mildacutepancreatitis,MAP）61例、中度急性胰腺炎（moderately severe acute pancreatitis,MSAP）25例、重度急性胰腺炎（severe acute pancreatitis,SAP）17例,对比三组患者一般资料、局部并发症发生此例、器官功能衰竭发生比例、入住ICU比例和天数、干预措施、住院天数、病死率。结果三组患者性别、年龄和病因学情况差异均无统计学意义,但MSAP组APACHEⅡ评分显著高于MAP组,同时低于SAP组（均P〈0．05）。MAP、MSAP和SAP三组出现局部并发症的比例分别为0、92．0％（23125）和76．5％（13／17）（P〈0．05）。MAP组无器官功能表竭发生,MSAP组5例出现一过性（〈48h）器官功能表竭,SAP组均出观特续性（〉48h）器官功能衰竭,SAP组器官功能衰竭比例显著高于MSAP组（P〈0．05）。MAP组无入住ICU病例,均无需介入、内镜或外科干预,无死亡病例。MSAP组入住ICU此例、ICU时间、住院时间和病死率显著低于SAP组（P〈0．05）。结论中度急性胰腺炎为有别于轻度和重度急性胰腺炎的独立类型,伴有局部并发症或一过性（48h内）器官功能表竭,但病死率较低,预后明显好于重度急性胰腺炎。     

α1-酸性糖蛋白和超敏C-反应蛋白动态监测在急性胰腺炎早期严重度评估中的意义

目的 探讨动态监测α1-酸性糖蛋白(α1-AGP)和超敏C-反应蛋白(HsCRP)在急性胰腺炎(AP)早期严重度评估中的价值.方法 74例AP患者(23例重症患者和51例轻症患者)在入院后动态检测血清α1-AGP、HsCRP水平和进行APACHEⅡ评分及增强CT检查,并对结果进行对照分析.结果 重症组和轻症组患者在住院期间α1-AGP和HsCRP水平变化在同一时比较差异均有统计学意义(P<0.01),AP患者在入院后24 h检测α1-AGP浓度评估严重度与APACHEⅡ评分有较好的吻合性(P<0.01),入院后3 d检测α1-AGP和HsCRP水平与APACHE Ⅱ评分有极佳吻合性(P均<0.01).结论 α1-酸性糖蛋白和超敏C-反应蛋白动态检测可作为AP患者病情变化的指标,对AP早期严重度具有良好的预测作用.     

Applying Ockham's razor to pancreatitis prognostication: a four-variable predictive model

OBJECTIVE: We sought to develop a simple yet accurate prognostic scoring system to determine the severity of acute pancreatitis at admission. SUMMARY BACKGROUND DATA: Because acute pancreatitis has a variable and frequently unpredictable course, identifying individuals at greatest risk for significant, life-threatening complications and stratifying their care appropriately remain a concern. Previous prognostic scoring systems predict severity reasonably well but are limited by time constraints, are unwieldy to use, or both. METHODS: Data from the international phase III trial of the platelet-activating factor receptor-antagonist Lexipafant were used to develop a 4-variable prognostic model. We then compared the model's ability to predict the severity of acute pancreatitis with the Ranson, Glasgow, and APACHE II systems. RESULTS: The model (BALI), which included BUN >or=25 mg/dL, Age >or=65 years, LDH >or=300 IU/L, and IL-6 >or=300 pg/mL, measured at admission, was similar to the Ranson, Glasgow, and APACHE II systems in its ability to identify increased mortality from acute pancreatitis. The receiver operating characteristic curve area for the BALI model was >or=0.82 +/- 0.03 (mean +/- SD) versus 0.75 +/- 0.04 (Ranson), 0.80 +/- 0.03 (Glasgow), and 0.79 +/- 0.03 (APACHE II). Furthermore, at a prevalence of 15%, the positive and negative predictive values for increased mortality were similar for all systems. CONCLUSION: The prognostic ability of the BALI 4-variable model was similar to the Ranson, Glasgow, and APACHE II systems but is unique in its simplicity and ability to accurately predict disease severity when used at admission or anytime during the first 48 hours of hospitalization.     

Early physiological response to intensive care as a clinically relevant approach to predicting the outcome in severe acute pancreatitis

HYPOTHESIS: The physiological response to treatment is a better predictor of outcome in acute pancreatitis than are traditional static measures. DESIGN: Retrospective diagnostic test study. The criterion standard was Organ Failure Score (OFS) and Acute Physiology and Chronic Health Evaluation II (APACHE II) score at the time of hospital admission. SETTING: Intensive care unit of a tertiary referral center, Auckland City Hospital, Auckland, New Zealand. PATIENTS: Consecutive sample of 92 patients (60 male, 32 female; median age, 61 years; range, 24-79 years) with severe acute pancreatitis. Twenty patients were not included because of incomplete data. The cause of pancreatitis was gallstones (42%), alcohol use (27%), or other (31%). At hospital admission, the mean +/- SD OFS was 8.1 +/- 6.1, and the mean +/- SD APACHE II score was 19.9 +/- 8.2. INTERVENTIONS: All cases were managed according to a standardized protocol. There was no randomization or testing of any individual interventions. MAIN OUTCOME MEASURES: Survival and death. RESULTS: There were 32 deaths (pretest probability of dying was 35%). The physiological response to treatment was more accurate in predicting the outcome than was OFS or APACHE II score at hospital admission. For example, 17 patients had an initial OFS of 7-8 (posttest probability of dying was 58%); after 48 hours, 7 had responded to treatment (posttest probability of dying was 28%), and 10 did not respond (posttest probability of dying was 82%). The effect of the change in OFS and APACHE II score was graphically depicted by using a series of logistic regression equations. The resultant sigmoid curve suggests that there is a midrange of scores (the steep portion of the graph) within which the probability of death is most affected by the response to intensive care treatment. CONCLUSION: Measuring the initial severity of pancreatitis combined with the physiological response to intensive care treatment is a practical and clinically relevant approach to predicting death in patients with severe acute pancreatitis.     

Significance of endothelial molecular markers in the evaluation of the severity of acute pancreatitis

Purpose  In acute pancreatitis, neutrophil elastase is secreted which damages the endothelial cells. This study was designed to demonstrate that the plasma levels of soluble E-selectin (sES) and soluble thrombomodulin (sTM) serve as endothelial molecular markers; the former is used as an endothelial activation marker, while the latter, as an endothelial injury marker. Methods  A total of 27 acute pancreatitis patients were enrolled. The plasma sES and sTM levels were assessed for 10 days after admission. Results  The plasma sES levels of all the patients in different disease stages were elevated at the time of admission day (day 1). The plasma sTM levels correlated with the severity and prognosis of acute pancreatitis. The required cutoff to predict a fatal outcome was set as 32 Teijin Units (TU)/ml (sensitivity, 80%; specificity, 91%). On day 1, the mortality rate of patients with the sTM levels of ≥32 TU/ml (67%, 4/6) was significantly higher than of those with the sTM levels of <32 TU/ml (5%, 1/21). Conclusion  These results indicated that (1) the activation of the vascular endothelial cells and the resultant increase in the plasma sES levels might be evoked in all disease stages, and (2) an elevation of the plasma sTM level, which indicates the presence of vascular endothelial injury, might therefore result in a poor prognosis. S. Ida and Y. Fujimura have contributed equally to this work.     

Simple scoring system for the prediction of the prognosis of severe acute pancreatitis

BACKGROUND: In severe acute pancreatitis (SAP), it is important clinically to predict the prognosis at the time of admission. Most scoring systems for severity of acute pancreatitis consist of multiple factors and are complicated. This investigation aimed to propose a simple scoring system for the prediction of the prognosis of SAP. METHODS: Prognostic factors were evaluated by receiver operator characteristic curve analyses and multivariate analysis from data that were obtained on admission of 137 patients with SAP. A simple scoring system with 3 most useful factors was made, and its usefulness was investigated in comparison with conventional scoring systems. RESULTS: Three prognostic factors were selected: serum blood urea nitrogen > or = 25 mg/dL, serum lactate dehydrogenase > or = 900 IU/L, and contrast-enhanced computed tomography finding with pancreatic necrosis. On admission, 137 patients were classified from 0 to 3 by the number of positive items (simple prognostic score [SPS]). Mortality rates for patients whose SPS was 0, 1, 2, and 3 were 2% (1/42 patients), 18% (7/40 patients), 48% (12/25 patients), and 67% (20/30 patients), respectively. Furthermore, when usefulness of SPS was compared with conventional scoring systems, the area under the curve by receiver operator characteristic curve analyses in SPS was 0.83; the Ranson score was 0.83; the Japanese severity score was 0.83; the Acute Physiology and Chronic Health Evaluation II score was 0.81, and the Glasgow score was 0.75. After onset, SPS kept almost same levels from day 2 to day 6, and a significant difference was observed between survivors and nonsurvivors from day 1 to day 6. CONCLUSION: This scoring system that comprised 3 items is simple, is feasible for the prediction of prognosis and conventional scoring systems, and is useful for the selection of the extremely severe patients with SAP on admission.     

An audit of the management of patients with acute pancreatitis against national standards of practice

BACKGROUND: The aim of this study was to audit the management of patients with acute pancreatitis against the standards of practice in the British Society of Gastroenterology guidelines. METHODS: The study assessed consecutive patients with acute pancreatitis over 5 years. Audit targets were overall mortality below 10 per cent, mortality for severe acute pancreatitis below 30 per cent, correct diagnosis and severity stratification within 48 h, aetiology determined in more than 80 per cent, availability of computed tomography and high-dependency or intensive therapy units when indicated and definitive treatment of gallstone pancreatitis within 2 weeks. RESULTS: Of 759 patients with acute pancreatitis, 219 (28.9 per cent) had severe acute pancreatitis (SAP). Overall mortality was 5.9 per cent, and 19.6 per cent in those with SAP. Acute pancreatitis was diagnosed within 48 h of presentation in 96.3 per cent of patients. The definitive aetiology was classified in 87.5 per cent. Of patients with SAP, 95.9 per cent underwent computed tomography within 6-10 days of admission. Of 93 patients with severe gallstone pancreatitis, 48 per cent had urgent endoscopic retrograde cholangiopancreatography, and 89.6 per cent of 359 patients with acute gallstone pancreatitis underwent definitive management within 2 weeks of admission. CONCLUSION: Patients with acute pancreatitis can be managed according to revised guidelines with a low associated mortality.     

Late mortality in patients with severe acute pancreatitis.

BACKGROUND: Mortality due to severe or necrotizing acute pancreatitis most often results from multiorgan dysfunction syndrome (MODS) occurring either early (within the first 14 days) or 2 weeks or more after the onset of symptoms due to septic complications. The aim of this study was to analyse the course of the disease in patients who died from severe acute pancreatitis. METHODS: Between January 1994 and August 2000 details of 263 consecutive patients with acute pancreatitis were entered prospectively into a database. All patients were treated in an intermediate or intensive care unit. RESULTS: The overall mortality rate was 4 per cent (ten of 263 patients). The mortality rate was 9 per cent (ten of 106) in patients with necrotizing disease. No patient died within the first 2 weeks of disease onset. The median day of death was 91 (range 15-209). Six patients died from septic MODS. Ranson score, Acute Physiology and Chronic Health Evaluation (APACHE) II score during the first week of disease, pre-existing co-morbidity, body mass index, infection and extent of necrosis were significantly associated with death (P < 0.01 for all parameters). However, only infection of the necrotic pancreas was an independent risk factor in the multivariate analysis. CONCLUSION: Early deaths in patients with severe acute pancreatitis are rare, mainly as a result of modern intensive care treatment. Nine of the ten deaths occurred more than 3 weeks after disease onset. Infection of pancreatic necrosis was the main risk factor for death.