JPN Guidelines for the management of acute pancreatitis: medical management of acute pancreatitis

The basic principles of the initial management of acute pancreatitis are adequate monitoring of vital signs, fluid replacement, correction of any electrolyte imbalance, nutritional support, and the prevention of local and systemic complications. Patients with severe acute pancreatitis should be transferred to a medical facility where adequate monitoring and intensive medical care are available. Strict cardiovascular and respiratory monitoring is mandatory for maintaining the cardiopulmonary system in patients with severe acute pancreatitis. Maximum fluid replacement is needed to stabilize the cardiovascular system. Prophylactic antibiotic administration is recommended to prevent infectious complications in patients with necrotizing pancreatitis. Although the efficacy of the intravenous administration of protease inhibitors is still a matter of controversy, there is a consensus in Japan that a large dose of a synthetic protease inhibitor should be given to patients with severe acute pancreatitis in order to prevent organ failure and other complications. Enteral feeding is superior to parenteral nutrition when it comes to the nutritional support of patients with severe acute pancreatitis. The JPN Guidelines recommend, as optional measures, blood purification therapy and continuous regional arterial infusion of a protease inhibitor and antibiotics, depending on the patient’s condition.     

Characterization of MADS-box genes in charophycean green algae and its implication for the evolution of MADS-box genes

The MADS-box genes of land plants are extensively diverged to form a superfamily and are important in various aspects of development including the specification of floral organs as homeotic selector genes. The closest relatives of land plants are the freshwater green algae charophyceans. To study the origin and evolution of land plant MADS-box genes, we characterized these genes in three charophycean green algae: the stonewort Chara globularis, the coleochaete Coleochaete scutata, and the desmid Closterium peracerosum-strigosum-littorale complex. Phylogenetic analyses suggested that MADS-box genes diverged extensively in the land plant lineage after the separation of charophyceans from land plants. The stonewort C. globularis mRNA was specifically detected in the oogonium and antheridium together with the egg and spermatozoid during their differentiation. The expression of the C. peracerosum-strigosum-littorale-complex gene increased when vegetative cells began to differentiate into gametangial cells and decreased after fertilization. These expression patterns suggest that the precursors of land plant MADS-box genes originally functioned in haploid reproductive cell differentiation and that the haploid MADS-box genes were recruited into a diploid generation during the evolution of land plants.     

Emotional intelligence score and performance of dental undergraduates

The purpose of this study was to investigate the relationship between emotional intelligence (EI) and undergraduate dental students’ ability to deal with different situations of communication in a clinical dentistry practical training course of communication skills. Fourth-year students in 2012 and in 2013 at the Nippon Dental University School of Life Dentistry at Niigata participated in the survey. The total number of participating students was 129 (88 males and 41 females). The students were asked to complete the Japanese version of the Mayer–Salovey–Caruso Emotional Intelligence Test in communication skills. Female students tended to have significantly higher EI score than males. The EI score in the group with high-grade academic performers was higher than in the low-grade group. The influence of EI on academic performance appeared to be mainly due to the students’ ability to accurately perceiving emotions and to their ability to understand emotional issues. The importance of EI may also lie in its ability to parse out personality factors from more changeable aspects of a person’s behavior. Although further studies are required, we believe that dental educators need to assume the responsibility to help students develop their emotional competencies that they will need to prosper in their chosen careers. In our conclusion, dental educators should support low achievers to increase their levels of self-confidence instead of concentrating mainly on improving their technical skill and academic performance. This may lead to upgrading their skills for managing emotions and to changing their learning approach.     

Patterns of bilateral agenesis of maxillary third molars and agenesis of other teeth

The purpose of this study was to investigate the patterns of bilateral agenesis of maxillary third molars and other tooth agenesis in Japanese orthodontic patients. A group of 262 subjects with bilateral agenesis of maxillary third molars (group A) was divided into three subgroups: group 1A consisting of 114 subjects without agenesis of mandibular third molars; group 2A, 31 subjects with unilateral agenesis of mandibular third molars; and group 3A, 117 subjects with agenesis of all third molars. As controls, 926 other subjects without third molar agenesis were selected (group C). Panoramic radiographs were mainly used to examine for tooth agenesis. The Chi square test and odds ratio were used to make statistical comparisons. The prevalence rates of agenesis of maxillary lateral incisors, mandibular incisors and maxillary and mandibular second premolars, and bilateral agenesis of maxillary lateral incisors and second premolars were significantly higher in any one of the third molar agenesis groups than in the control group. Characteristically, no significant increase in occurrence of bilateral agenesis of mandibular second premolars was demonstrated by the subjects with bilateral agenesis of maxillary third molars. Irrespective of whether unilateral or bilateral agenesis of mandibular third molars is present or not, the Japanese orthodontic patients with bilateral agenesis of maxillary third molars exhibited a significantly increased occurrence of unilateral or bilateral agenesis of maxillary lateral incisors, mandibular incisors and maxillary and mandibular second premolars, except for bilateral agenesis of mandibular incisors and second premolars.     

Risk‐adjusted assessment of incidence and quantity of blood use in acute‐care hospitals in Japan: an analysis using administrative data

Background and Objectives Continuous monitoring of blood use and feedback on transfusions are effective in decreasing inappropriate blood transfusions. However, traditional methods of monitoring have practical challenges, such as the limited availability of experts and funding. Administrative data including a patient classification system may be employed for risk‐adjusted assessment of hospital‐wide blood use. Materials and Methods We conducted an audit of blood use at two hospitals and determined proportions of appropriate blood use at each hospital. We then used administrative data of 587 045 cases provided by 73 hospitals to develop two mathematical models to calculate risk‐adjusted use of blood products. The first model is a logistic regression model to predict the percentage of transfused patients. Patient demographics, surgery and diagnostic groups were utilized as predictors of transfusion. The second model is a case‐mix adjusted model which predicts hospital‐wide use of units of blood products from the distribution of diagnosis‐related groups. For each model, the observed to expected (O/E) ratio of blood use in each hospital was calculated. We compared resultant ratios with proportions of appropriate blood use in two of the hospitals studied. Results Both models showed good prediction abilities. O/E ratios calculated using the two models were relevant to proportions of appropriate transfusions. Conclusions Risk‐adjusted assessments of blood product use based on administrative data allow hospital‐wide evaluation of transfusion use. Comparing blood use between different hospitals contributes toward establishing appropriate transfusion practices.     

Assessment of severity of acute pancreatitis according to new prognostic factors and CT grading

The assessment of severity at the initial medical examination plays an important role in introducing adequate early treatment and the transfer of patients to a medical facility that can cope with severe acute pancreatitis. Under these circumstances, “criteria for severity assessment” have been prepared in various countries, including Japan, and these criteria are now being evaluated. The criteria for severity assessment of acute pancreatitis in Japan were determined in 1990 (of which a partial revision was made in 1999). In 2008, an overall revision was made and the new Japanese criteria for severity assessment of acute pancreatitis were prepared. In the new criteria for severity assessment, the diagnosis of severe acute pancreatitis can be made according to 9 prognostic factors and/or the computed tomography (CT) grades based on contrast-enhanced CT. Patients with severe acute pancreatitis are expected to be transferred to a specialist medical center or to an intensive care unit to receive adequate treatment there. In Japan, severe acute pancreatitis is recognized as being a specified intractable disease on the basis of these criteria, so medical expenses associated with severe acute pancreatitis are covered by Government payment.     

New diagnostic criteria of acute pancreatitis

Practical guidelines for the diagnosis of acute pancreatitis are presented so that a rapid and adequate diagnosis can be made. When acute pancreatitis is suspected in patients with acute onset of abdominal pain and tenderness mainly in the upper abdomen, the diagnosis of acute pancreatitis is made on the basis of elevated levels of pancreatic enzymes in the blood and/or urine. Furthermore, other acute abdominal diseases are ruled out if local findings associated with pancreatitis are confirmed by diagnostic imaging. According to the diagnostic criteria established in Japan, patients who present with two of the following three manifestations are diagnosed as having acute pancreatitis: characteristic upper abdominal pain, elevated levels of pancreatic enzymes, and findings of ultrasonography (US), CT or MRI suggesting acute pancreatitis. Detection of elevated levels of blood pancreatic enzymes is crucial in the diagnosis of acute pancreatitis. Measurement of blood lipase is recommended, because it is reported to be superior to all other pancreatic enzymes in terms of sensitivity and specificity. For measurements of the blood amylase level widely used in Japan, it should be cautioned that, because of its low specificity, abnormal high values are also often obtained in diseases other than pancreatitis. The cut-off level of blood pancreatic enzymes for the diagnosis of acute pancreatitis is not able to be set because of lack of sufficient evidence and consensus to date. CT study is the most appropriate procedure to confirm image findings of acute pancreatitis. Elucidation of the etiology of acute pancreatitis should be continued after a diagnosis of acute pancreatitis. In the process of the etiologic elucidation of acute pancreatitis, judgment whether it is gallstone-induced or not is most urgent and crucial for deciding treatment policy including the assessment of whether endoscopic papillary treatment should be conducted or not. The diagnosis of gallstone-induced acute pancreatitis can be made by combining detection of elevated levels of bilirubin, transamylase (ALT, AST) and ALP detected by hematological examination and the visualization of gallstones by US.     

Post-ERCP pancreatitis

Pancreatitis remains the most common severe complication of endoscopic retrograde cholangiopancreatography (ERCP). Detailed information about the findings of previous studies concerning post-ERCP pancreatitis has not been utilized sufficiently. The purpose of the present article was to present guidelines for the diagnostic criteria of post-ERCP pancreatitis, and its incidence, risk factors, and prophylactic procedures that are supported by evidence. To achieve this purpose, a critical examination was made of the articles on post-ERCP pancreatitis, based on the data obtained by research studies published up to 2009. At present, there are no standardized diagnostic criteria for post-ERCP pancreatitis. It is appropriate that post-ERCP pancreatitis is defined as acute pancreatitis that has developed following ERCP, and its diagnosis and severity assessment should be made according to the diagnostic criteria and severity assessment of the Japanese Ministry of Health, Labour and Welfare. The incidence of acute pancreatitis associated with diagnostic and therapeutic ERCP is 0.4–1.5 and 1.6–5.4%, respectively. Endoscopic papillary balloon dilation is associated with a high risk of acute pancreatitis compared with endoscopic sphincterotomy. It was made clear that important risk factors include dysfunction of the Oddi sphincter, being of the female sex, past history of post-ERCP pancreatitis, and performance of pancreaticography. Temporary prophylactic placement of pancreatic stents in the high-risk group is useful for the prevention of post-ERCP pancreatitis [odds ratio (OR) 3.2, 95% confidence interval (CI) 1.6–6.4, number needed to treat (NNT) 10]. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with a reduction in the development of post-ERCP pancreatitis (OR 0.46, 95% CI 0.32–0.65). Single rectal administration of NSAIDs is useful for the prevention of post-ERCP pancreatitis [relative risk (RR) 0.36, 95% CI 0.22–0.60, NNT 15] and decreases the development of pancreatitis in both the low-risk group (RR 0.29, 95% CI 0.12–0.71) and the high-risk group (RR 0.40, 95% CI 0.23–0.72) of post-ERCP pancreatitis. As for somatostatin, a bolus injection may be most useful compared with short- or long-term infusion (OR 0.271, 95% CI 0.138–0.536, risk difference 8.2%, 95% CI 4.4–12.0%). The usefulness of gabexate mesilate was not apparent in any of the following conditions: acute pancreatitis (control 5.7 vs. 4.8% for gabexate mesilate), hyperamylasemia (40.6 vs. 36.9%), and abdominal pain (1.7 vs. 8.9%). Formulation of diagnostic criteria for post-ERCP pancreatitis is needed. Temporary prophylactic placement of pancreatic stents in the high-risk group offers the most promise as a means of preventing post-ERCP pancreatitis. As for pharmacological attempts, there are high expectations concerning NSAIDs because they are excellent in terms of cost-effectiveness, ease of use, and safety. There was no evidence of effective prophylaxis with the use of protease inhibitors, especially gabexate mesilate.