Does mortality occur early or late in acute pancreatitis?

UNLABELLED: Several prior studies have suggested that 80% of deaths in acute pancreatitis occur late as a result of pan-creatic infection. Others have suggested that approx half of deaths occur early as a result of multisystem organ failure. The aim of the present study was to determine the timing of mortality of acute pancreatitis at a large tertiary-care hospital in the United States. METHODS: Patients with a diagnosis of acute pancreatitis (ICD-9 code 577.0) admitted to Brigham and Women's Hospital from October 1, 1982 to June 30, 1995 were retrospectively studied to determine total mortality, frequency of early vs late deaths, and clinical features of patients with early (< or = 14 d after admission) or late deaths (> 14 d after admission). RESULTS: The overall mortality of acute pancreatitis was 2.1% (17 deaths among 805 patients). Eight deaths (47%) occurred within the first 14 d of hospitalization (median d 8, range 1-11 d), whereas 9 occurred after 14 d (median d 56, range 19-81). Early deaths resulted primarily from organ failure. Late deaths occurred postoperatively in 8 patients with infected or sterile necrosis and 1 patient with infected necrosis treated medically. CONCLUSION: Approximately half of deaths in acute pancreatitis occur within the first 14 d owing to organ failure and the remainder of deaths occur later because of complications associated with necrotizing pancreatitis. Improvement in mortality in the future will require innovative approaches to counteract early organ failure and late complications of necrotizing pancreatitis.

Emergency medical services (EMS) vs non-EMS transport of critically injured patients: a prospective evaluation.

BACKGROUND: A previous report of 5,782 trauma patients demonstrated higher mortality among those transported by emergency medical services (EMS) than among their non-EMS-transported counterparts. HYPOTHESIS: Trauma patients who are transported by EMS and those who are not differ in the injury-to-hospital arrival time interval. DESIGN: Prospective cohort-matched observation study. SETTING: Level I trauma center, multidisciplinary study group. PATIENTS: All non-EMS patients were matched with the next appropriate EMS patient by an investigator who was unaware of the outcome and mode of transport. Every 10th EMS patient with an Injury Severity Score (ISS) of 13 or greater was also randomly enrolled. Matching characteristics included age, ISS, mechanism of injury, head Abbreviated Injury Score, and presence of hypotension. An interview protocol was developed to determine the time of injury. Interview responses from patients, witnesses, and friends were combined with data obtained from police, sheriff, and medical examiner reports. MAIN OUTCOME MEASURES: Time to the hospital, mortality, morbidity, and length of stay. RESULTS: A total of 103 patients were enrolled (38 non-EMS, 38 EMS matched, 27 random EMS). Injury time was estimated using all available data made on 100 patients (97%). Independent raters agreed in 81% of cases. Deaths, complications, and length of hospital stay were similar between the EMS- and non-EMS-transported groups. Although time intervals were similar among the groups overall, more critically injured non-EMS patients (ISS > or = 13) got themselves to the trauma center in less time than their EMS counterparts (15 minutes vs 28 minutes; P<.05). CONCLUSIONS: A multidisciplinary approach can be utilized, and an interview protocol created to determine actual time of injury. Critically injured non-EMS-transported patients (ISS > or =13) arrived at the hospital earlier after their injuries.

Tumor necrosis factor-alpha decreases hepatocyte bile salt uptake and mediates endotoxin-induced cholestasis.

Tumor necrosis factor-alpha (TNF alpha), a cytokine that is produced in a variety of inflammatory diseases associated with cholestasis, is believed to be the primary mediator of the systemic effects of endotoxin. Thus, we have investigated the role of TNF alpha in the pathogenesis of endotoxin-induced cholestasis in intact animals, and in the uptake of taurocholate by cultured hepatocytes. Male Sprague-Dawley rats received either intravenous (IV) endotoxin (7.5 mg/kg) or monoclonal anti-TNF alpha antibody followed by endotoxin. Basal bile flow and bile salt excretion were measured for a 2-hour period, after which all animals received an IV bolus of taurocholate (10 mumol/100 g body weight). Endotoxin decreased basal bile flow by 41% and bile salt stimulated bile flow by 38% (n = 12; P < .01). Basal bile salt excretion was decreased 86% after endotoxin administration. Passive immunization with anti-TNF alpha antibody blocked this endotoxin-associated cholestasis. In addition, rat hepatocytes were isolated and cultured in the presence of either endotoxin (10 micrograms/mL) or TNF alpha (100 ng/mL) for 24 hours. These primary hepatocyte cultures exhibited a dose- and time-dependent, noncompetitive, inhibition of taurocholate uptake. We postulate that TNF alpha is an important mediator of the cholestasis of sepsis.

Interleukin-6 inhibits hepatocyte taurocholate uptake and sodium-potassium-adenosinetriphosphatase activity.

The potential effects of cytokines on hepatocellular transport functions remain undefined. Interleukin-6 (IL-6) is a cytokine that is produced in sepsis, hepatitis, and other inflammatory conditions often associated with cholestasis. Using cultured rat hepatocytes, we have investigated the effects of IL-6 on hepatocellular bile salt uptake. Because hepatocyte Na(+)-K(+)-adenosinetriphosphatase (ATPase) produces the electrochemical gradient that drives sodium-dependent bile salt contransport, we also examined the effects of IL-6 on Na(+)-K(+)-ATPase activity. Hepatocytes cultured for 20 h in media containing IL-6 exhibited a dose-dependent noncompetitive inhibition of [3H]taurocholate uptake, which was maximal at an IL-6 dose of 100 U/ml. IL-6 treatment had no effect on hepatocyte sodium-independent taurocholate uptake. Northern blotting of RNA from cultured hepatocytes revealed that IL-6 had no effect on steady-state RNA levels of the Na(+)-taurocholate transporter (Ntcp). Hepatocytes incubated with IL-6 for 20 h, however, exhibited a 55% decrease in hepatocyte Na(+)-K(+)-ATPase activity. This effect also was dose dependent, with maximal inhibition occurring at an IL-6 dose of 100 U/ml. Similar treatment with IL-6 did not influence hepatocyte Mg(2+)-ATPase activity. The inhibition of Na(+)-K(+)-ATPase activity induced by IL-6 provides a putative mechanism for the observed inhibition of sodium-dependent taurocholate uptake. Since modulation of bile salt transport and Na(+)-K(+)-ATPase activity occurred at IL-6 concentrations comparable to the serum levels observed in patients with severe inflammatory states, these findings have potential pathophysiological relevance for the cholestasis of sepsis and other inflammatory disorders.

Evaluation of highly corrected optics by measurement of the Strehl ratio.

The Strehl ratio (SR) is a measure of image quality that is especially relevant to recording media of finite contrast, such as photoresist, film, and the human retina. The SR is accessible experimentally from the total power and maximum irradiance in the point spread function (PSF). Measurement error is introduced by the finite dimension of the pinhole aperture that is used to generate a detectable image. This systematic error can be related parametrically to the object geometry and illumination system, and the SR can be corrected to within a few percent. Systematic corrections also compensate for the portion of the PSF irradiance that falls outside the data integration window in the image plane. An optical test bench is constructed to measure the SR over the lens field and azimuth to an accuracy of 5% and a repeatability of 1%.

Scanning differential interferometer to measure index heterogeneity.

The index heterogeneity of rectangular glass samples is measured to a repeatability of 2 x 10(-8) by a scanning differential interferometer. The noise-limited instrument resolution is 2 nm of optical path length. The surface figure is decoupled from bulk inhomogeneity by a thin film of index-matching liquid, which is located by surface tension between the interferometer cavity and the test sample. An algorithm based on Poisson's equation reconstructs the integrated optical path length profile from data in differential form with a minimal integration of noise.

Left main coronary bypass for aberrant (aortic) intramural left coronary artery.

This report describes the first saphenous vein bypass graft from the aorta to the left main coronary artery for an aberrant left main coronary artery arising from the anterior sinus of Valsalva. A 20-year-old college student had a cardiac arrest and documented ventricular fibrillation while jogging. He was resuscitated. An anomalous left main coronary artery, arising anteriorly from the right coronary sinus, was demonstrated at operation to be within the wall of the aorta. Following aorta--left main coronary artery bypass with the saphenous vein, results of a stress test were normal, and cardiac catheterization revealed the left coronary system to be entirely supplied by the graft.