Early onset of organ failure is the best predictor of mortality in acute pancreatitis.

BACKGROUND: APACHE II is a multifactorial scoring system for predicting severity in acute pancreatitis (AP). Organ failure (OF) has been correlated with mortality in AP. OBJECTIVE: To evaluate the usefulness of APACHE II as an early predictor of severity in AP, its correlation with OF, and the relevance of an early establishment of OF during the course of AP. PATIENTS AND METHODS: From January 1999 to November 2001, 447 consecutive cases of AP were studied. APACHE II scores and Atlanta criteria were used for defining severity and OF. RESULTS: Twenty-five percent of patients had severe acute pancreatitis (SAP). APACHE II at 24 h after admission showed a sensitivity, specificity, and positive and negative predictive value of 52, 77, 46, and 84%, respectively, for predicting severity. Mortality for SAP was 20.5%. Seventy percent of patients who developed OF did so within the first 24 hours of admission, and their mortality was 52%. Mortality was statistically significant (p< 0.01) if OF was established within the first 24 hours after admission. CONCLUSIONS: APACHE II is not reliable for predicting outcome within the first 24 hours after admission and should therefore be used together with other methods. OF mostly develops within the first days after admission, if ever. The time of onset of OF is the most accurate and reliable method for predicting death risk in AP.

El fracaso orgánico precoz como mejor factor predictivo de mortalidad en la pancreatitis aguda / Early onset of organ failure is the best predictor of mortality in acute pancreatitis

Introducción: el APACHE II se ha utilizado como factor predictivo de gravedad en la pancratitis aguda (PA). La instauración de fracaso orgánico (FO) en la PA se correlaciona con una mayor mortalidad. Objetivos: evaluar la utilidad del APACHE II como factor predictivo precoz de gravedad en la PA, su correlación con el FO y la relevancia del establecimiento precoz del FO en la PA. Pacientes y métodos: desde enero de 1999 hasta noviembre de 2001 se estudiaron 447 pacientes ingresados consecutivamente por PA. Se utilizó el sistema APACHE II y los criterios de Atlanta para evaluar la gravedad. Resultados: el 25 por ciento de los pacientes presentaron una pancreatitis aguda grave (PAG). El APACHE II a las 24 horas del ingreso mostró una sensibilidad, especificidad, valor predictivo positivo y negativo del 52, 77, 46 y 84 por ciento, respectivamente, como marcador de gravedad. La mortalidad global de la PAG fue del 20,5 por ciento. El 70 por ciento de los pacientes que presentaron FO lo hicieron en las primeras 24 horas del ingreso, falleciendo el 52 por ciento de ellos. La mortalidad fue significativamente mayor (p < 0,01) si el FO se estableció en ese periodo. Conclusiones: el APACHE II por si solo no es un sistema fiable de detección precoz de gravedad en las primeras 24 horas del ingreso por lo que debe utilizarse junto con otros métodos. El FO suele establecerse en los primeros días del curso evolutivo de la PA. La precocidad del establecimiento del FO muestra una estrecha relación con la mortalidad en la PA (AU)

[Results of cephalic pancreaticoduodenectomy in patients with chronic pancreatitis]. / Resultados de la duodenopancreatectomía cefálica en los pacientes con pancreatitis crónica.

OBJECTIVE: To analyse the results obtained after cephalic pancreatoduodenectomy in patients with severe chronic pancreatitis. DESIGN: Retrospective study of indications and results of the intervention.Patients. The inclusion criteria were severe anatomic alteration of the head of the pancreas associated with refractory pain. Pancreatoduodenectomy was performed in 19 patients. RESULTS: Four patients had postoperative morbidity, and the mean hospital stay was 15 days. One patient died in the postoperative period. The pain evolution after surgery was: total control in 72% and satisfactory control in the remaining patients. During follow-up, de novo diabetes was detected in two patients, difficulty in maintaining weight in one patient, and de novo steatorrhea in four patients. CONCLUSIONS: Cephalic pancreatoduodenectomy is a good therapeutic alternative for the treatment of patients with chronic pancreatitis, refractory pain, and severe involvement of the pancreas head. Pain control is excellent and sequelae, such as diabetes or steatorrhea, are easily amenable to medical treatment.

Resultados de la duodenopancreatectomía cefálica en los pacientes con pancreatitis crónica / Results of cephalic pancreatoduodenectomy in patients with chronic pancreatitis

Objetivo. Análisis de los resultados obtenidos tras la realización de una duodenopancreatectomía cefálica en pacientes con pancreatitis crónica grave. Diseño. Estudio retrospectivo de las indicaciones y resultados de la intervención. Pacientes. Los criterios de inclusión fueron la alteración anatómica grave de la cabeza pancreática asociada a dolor intratable. Se efectuó duodenopancreatectomía en 19 pacientes. Resultados. Cuatro pacientes presentaron morbilidad postoperatoria, siendo la estancia postoperatoria media de 15 días. Un paciente falleció en el postoperatorio. La evolución del dolor tras la intervención fue: de control total en el 72 por ciento y satisfactorio en el resto. Durante el seguimiento se detectó diabetes de novo en 2 pacientes, dificultad para mantener el peso en un caso y esteatorrea de novo en 4. Conclusiones. La duodenopancreatectomía cefálica es una buena alternativa terapéutica para el tratamiento de los pacientes con pancreatitis crónica, dolor intratable y afectación grave de la cabeza pancreática. El control del dolor es excelente y las secuelas como la diabetes o la esteatorrea son fácilmente controlables con tratamiento médico. (AU)

Mortalidad en el trasplante hepático: causas y período de máxima incidencia / Mortality in liver transplantation. Causes and period of maximum incidence

Objetivos. Describir y cuantificar las causas de muerte de nuestros pacientes e identificar su incidencia en los diversos períodos postrasplante. Pacientes y métodos. Durante el período de estudio, se realizaron 441 trasplantes hepáticos en 381 pacientes. Definimos como causa predisponente de fallecimiento aquella que pone al paciente en situación de riesgo de muerte, y causa inmediata la que precipita el fallecimiento. Definimos 3 períodos: mortalidad postoperatoria, temprana y tardía. Resultados. La mortalidad fue de 112 pacientes (29 por ciento). Los pacientes que fallecieron en período de mortalidad postoperatoria, temprana y tardía fueron 32 (30 por ciento), 13 (12 por ciento) y 65 (58 por ciento), respectivamente. Los tumores de novo (15 por ciento) y la recidiva viral (14 por ciento) fueron las causas predisponentes globales más frecuentes. Las infecciones (24 por ciento) y las complicaciones médicas (12 por ciento) fueron las causas inmediatas principales. En el período postoperatorio y temprano las causas más frecuentes fueron las complicaciones médicas y el rechazo ductopénico (4 por ciento), respectivamente; en cambio, en el período de mortalidad tardía lo fueron los tumores de novo (13 por ciento) y la recurrencia de hepatopatía por virus de la hepatitis C (13 por ciento). Conclusiones. La diferenciación entre causa predisponente e inmediata define con precisión la frecuencia de cada una de ellas. Los tumores de novo y la recurrencia de hepatopatía por virus de la hepatitis C son las causas más frecuentes de muerte global y tardía (AU)

[The COMBELL project. Analysis of the medical clinical competence]. / El proyecto COMBELL. Un análisis de la competencia clínica médica.

BACKGROUND: The most frequent tests for evaluate medical education in Spain, do not analyze clinical competence. The aims of this project was to introduce a method for the assessment of clinical skills using the simulation methodology with standardized patients. METHODS: All 83 first-year medical residents were evaluated. Three evaluation exercises were used in all study. The first was 10 standardized patients encounters, the second was 100 multiple choice questions, and the third 60 clinical images. Sixty-four last year medical students were evaluated using the same 10 standardized patients. RESULTS: The global mean score for the residents was 56.7% for all the encounters, and was lower in physical examination and patients notes. The global mean score for the students was 57.1% and was also lower in physical examination. We did not find correlations between clinical competence assessment, multiple choice-questions, MIR exam and clinical images. CONCLUSIONS: Our results show that: this assessment method was successful; the clinical competence levels of our residents and students, and the lack of statistical correlation between this method and other methods, which, basically analyze cognitive capacities.

A randomized trial on the effect of isotonic amino acid infusion on postoperative complications and short life plasma protein concentrations.

In a randomized clinical study 30 patients with high risk surgical procedures were distributed to receive either standard fluid-therapy (n = 14) or an isotonic amino acid solution (n = 16) during five days. The patients were evaluated pre- and postoperatively using: anthropometric parameters: body weight, biceps and triceps skinfold thickness, and mid arm circumference; biochemical parameters: albumin, prealbumin, transferrin, retinol-binding protein, total iron-binding capacity, and cholesterol; and delayed cutaneous hypersensitivity. Clinical outcome and complications were also recorded. Positive ketonuria was obtained soon in the treatment group after 24 h. Mean daily nitrogen balance was better in the protein sparing group (-3.8 g vs -9.3 g) p less than 0.02. No differences were observed between both groups in the postoperative plasma protein levels. There were no significant differences in delayed cutaneous reactivity nor anthropometric parameters between both groups; and mortality and morbidity were similar. The present study lends little support for substituting the routine D5W and saline postoperative fluid regime. No clinical advantage of amino acids over standard fluids could be appreciated indicating that the much less expensive conventional solutions should not be replaced by amino acids, at least in routine postoperative cases.

Successful diagnosis and treatment of cardiac perforation due to subclavian catheter during total parenteral nutrition.

A case of atrial perforation by a subclavian vein catheter, which was inserted for total parenteral nutrition (TPN) is reported. Acute thoracic symptoms developed 3 days after the infusion was started. The diagnosis was correctly made by demonstrating contrast medium within the pericardial sac. The catheter was withdrawn and the patient recovered satisfactorily. The clinical picture and the differential diagnosis of this complication are discussed.