Diagnostic assessment and outcome of acute pancreatitis in Italy: Results of a prospective multicentre study: ProInf-AISP: Progetto informatizzato pancreatite acuta, Associazione Italiana Studio Pancreas, phase II

BACKGROUND AND AIM: Up till now, only one study providing practically complete information on acute pancreatitis in Italy has been published. The aim of this prospective study was to evaluate the clinical characteristics, in terms of diagnostic assessment and outcome, of a large series of patients affected by acute pancreatitis in Italy. MATERIALS AND METHODS: The study involved 56 Italian centres, homogeneously distributed throughout the entire national territory. Each participating centre was furnished with an ad hoc software including 530 items along with subsequent collection, tabulation and quality control of the data. RESULTS: One thousand five hundred and forty case report forms of patients affected by acute pancreatitis were collected but 367 of them (24%) were subsequently eliminated from the final analysis. Therefore, 1173 patients (581 females and 592 males) were recruited. Mean age of patients was 62.0+/-18.2 years (95% confidence interval, 60.9-63.0). On the basis of Atlanta classification, 1006 patients (85.8%) were defined as mild and 167 (14.2%) as severe pancreatitis. Biliary forms represented the most frequent aetiological category (813 cases, 69.3%) while alcoholic forms only 6.6% (77 cases); the remaining aetiologies accounted for 7.1% (83 cases) while 200 cases (17.1%) remained without a definite aetiological factor. Complete recovery was achieved in 1016 patients (86.6%) whereas morphological sequelae were found in 121 patients (10.3%) and mortality in 36 patients (3.1%; 0.4% in mild and 19.2% in severe acute pancreatitis). Ultrasonography was largely utilised as a first line diagnostic tool in all patients, with valuable visualisation of the pancreas in 85% of patients. Computer tomography scan was also widely used, with 66.7% of exams in mild and 33.3% in severe pancreatitis. Patients affected by biliary pancreatitis presented more severe (p=0.004) and necrotizing forms (p=0.021). Mortality was significantly related (p<0.001) with the extension of pancreatic necrosis and with an age of over 70 years. Body mass index presented significantly greater values in severe than in mild forms (p<0.001). CONCLUSIONS: Association of creatinine serum level over 2mg/dl with an abnormal chest X-ray showed a high significant correlation with a more severe outcome in terms of morphological sequelae and mortality (p=0.0001). Acute pancreatitis in Italy more commonly presents biliary aetiology and favourable outcome with low rate of complications and mortality. From a cost-effectiveness standpoint, diagnostic approach to this disease needs to be better standardised.     

CAGS and ACS Evidence-based Reviews in Surgery. 28: Comparison of on-demand and planned relaparotomy for secondary peritonitis

Objective: To compare patient outcomes, healthcare utilization and costs of on-demand and planned relaparotomy in patients with severe secondary peritonitis. Design: Randomized, nonblinded controlled trial. Setting: Two academic and 5 regional teaching hospitals in The Netherlands. Patients: A total of 232 patients with a diagnosis of peritonitis, confirmed during an index laparotomy, and an acute physiology and chronic health evaluation (APACHE II) score of greater than 11. Intervention: The planned relaparotomy (n = 116) was performed every 36–48 hours after the index laparotomy to inspect, drain, lavage and perform other necessary abdominal interventions for residual peritonits or new infections. The sequence of planned relaparotomy was terminated when negative findings were found macroscopically. On-demand relaparotomy (n = 116) was only performed in patients with clinical deterioration or lack of improvement with a likely intra-abdominal cause. Deterioration was considered if there was an increase of more than 4 points in the multiple organ dysfunction score or a prespecified surgical emergency (e.g., abdominal compartment syndrome, intra-abdominal bleeding with decrease in hemoglobin despite replacement and hemodynamic instability, burst abdomen, perforation of visceral organ, anastomotic leak, intra-abdominal abscess that cannot be drained percutaneously, ischemia/necrosis of a visceral organ). Primary outcome: A combination of all-cause mortality and major disease-related morbidity in surviving patients within the 12 month follow-up period after the index laparotomy. Secondary outcomes included health care utilization and direct medical costs during the follow-up period. Results: Comparing on-demand with planned relaparotomy, there was no significant difference in the primary outcome (57% v. 65%, p = 0.25), in mortality alone (29% v. 36%, p = 0.22), or in morbidity alone (40% v. 44%, p = 0.58). A total of 42% of patients in the on-demand group had a relaparotomy compared with 94% of patients in the planned relaparotomy group. Thirty-one percent of first relaparotomies were negative in the on-demand group compared with 66% in the planned relaparotomy group (p < 0.001). Patients in the on-demand group had shorter stays in the intensive care unit than those in the planned relaparotomy group (median 7 v. 11 d, p = 0.001) in addition to shorter stays in hospital (median 27 v. 35 d, p = 0.008). The medical costs for patients in the on-demand group were 23% lower than those for patients in the planned relaparotomy group. Conclusion: Patients in the on-demand group did not have significantly lower mortality or major peritonitis-related morbidity than those in the planned relaparotomy group, but did have fewer relaparotomies and a substantial reduction in health care utilization and medical costs.     

The population-specific distribution and frequencies of genomic variants in the<Emphasis Type="Italic"> SLC3A1</Emphasis> and<Emphasis Type="Italic"> SLC7A9</Emphasis> genes and their application in molecular genetic testing of cystinuria

Cystinuria is a common inherited aminoaciduria resulting in nephrolithiasis. Mutations in two genes, SLC3A1 and SLC7A9, have been identified in cystinuric patients. Considering the population-specific distribution of genetic variants in the SLC3A1 gene, we focused our study on mutations in SLC3A1 and SLC7A9 described more than once in the literature. We evaluated the usefulness of this restricted analysis as a diagnostic approach. Furthermore, the data obtained were used to estimate the frequency of heterozygote carriers of SLC3A1 mutations in the general European population. A total of 22 unclassified cystinuric patients were screened for genetic variants in four exons of both SLC3A1 and SLC7A9 in which the most common mutations have been identified. For screening, we used single strand conformation polymorphism analysis (SSCP), restriction assays, real-time PCR and direct sequencing. In total, we identified mutations in 17 of our 22 patients, including a new mutation (R365Q) as well as a novel polymorphism (c.1035G/A) within the SLC3A1 gene. An ethnic influence on the distribution of mutations was confirmed: T216M in SLC3A1 is the major mutation in south-eastern Europe, whereas M467T in SLC3A1 is mainly found in western Europe. A complex duplication in SLC3A1 is restricted to German patients. Generally, we could show that a stepwise analysis directed to the most common mutations in the two cystinuria genes is sufficient to detect variants in more than 75% of patients of European origin. The test consists of nine different PCR-based approaches and therefore represents a low-cost, reliable and timesaving diagnostic tool.     

Probiotic prophylaxis in patients with predicted severe acute pancreatitis (PROPATRIA): design and rationale of a double-blind,placebo-controlled randomised multicenter trial [ISRCTN38327949]

Background  

Infectious complications are the major cause of death in acute pancreatitis. Small bowel bacterial overgrowth and subsequent bacterial translocation are held responsible for the vast majority of these infections. Goal of this study is to determine whether selected probiotics are capable of preventing infectious complications without the disadvantages of antibiotic prophylaxis; antibiotic resistance and fungal overgrowth.     

Consensus on drug treatment, definition and diagnosis for insomnia

Thirty-four experts and a literature supervisor got together in order to reach a 'consensus' regarding the definition, diagnosis and pharmacological treatment of insomnia. Insomnia is a subjective perception of dissatisfaction with the amount and/or quality of sleep. It includes difficulty in initiating or maintaining sleep or early awakening with inability to fall asleep again. It is associated with complaints of non-restorative sleep and dysfunction of diurnal alertness, energy, cognitive function, behaviour or emotional state, with a decrease in quality of life. The diagnosis is based on clinical and sleep history, physical examination and additional tests, although polysomnography is not routinely indicated. Therapy should include treatment of the underlying causes, cognitive and behavioural measures and drug treatment. Hypnotic therapy can be prescribed from the onset of insomnia and non-benzodiazepine selective agonists of the GABA-A receptor complex are the drugs of first choice. It is recommended that hypnotic treatment be maintained in cases where withdrawal impairs the patient's quality of life and when all other therapeutic measures have failed. Experience suggests that intermittent treatment is better than continuous therapy. The available data do not confirm safety of hypnotics in pregnancy, lactation and childhood insomnia. Benzodiazepines are not indicated in decompensated chronic pulmonary disease but no significant adverse effects on respiratory function have been reported with zolpidem and zopiclone in stable mild to moderate chronic obstructive pulmonary disease and in treated obstructive sleep apnoea syndrome. Data for zaleplon are inconclusive. If the patient recovers subjective control over the sleep process, gradual discontinuation of hypnotic treatment can be considered.