|
1
|
Thiruvengadam N, Anderson KL, Sheth SG. Significant projected savings with expansion of an emergency department observation protocol for mild acute pancreatitis. Pancreatology 2025; 25:35-38. [PMID: 39721870 DOI: 10.1016/j.pan.2024.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2024] [Revised: 11/26/2024] [Accepted: 12/17/2024] [Indexed: 12/28/2024]
Abstract
BACKGROUND Acute pancreatitis (AP) significantly contributes to healthcare costs, but not all patients require hospitalization. A novel, validated Emergency Department (ED) pathway for mild AP (MAP) at our tertiary care center reduced hospitalizations and resource utilization, without affecting outcomes. METHODS A decision-analytic model was constructed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist and methodologic recommendations by the Second Panel on Cost-Effectiveness in Health and Medicine to predict healthcare costs based on whether an ED discharge protocol for MAP was utilized. RESULTS Average savings for one MAP discharged from the ED were $1720.5 compared to the standard of care hospitalization. Assuming that 67.7 % of cases are mild and that there are 288,820 hospitalizations for AP annually, the ED discharge pathway would result in $98.6 million direct healthcare savings. CONCLUSIONS Implementation of an evidence-based, protocoled ED pathway for MAP could result in over $100 million in direct healthcare savings.
Collapse
Affiliation(s)
- Nikhil Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, CA, USA
| | - Kelsey L Anderson
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
|
2
|
Kant N, Beij A, Verdonk RC, van Hooft JE, Voermans RP, Spanier MBW, Doggen CJM. Early discharge of patients with mild acute pancreatitis - A scoping review. Pancreatology 2024; 24:847-855. [PMID: 39155165 DOI: 10.1016/j.pan.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 07/05/2024] [Accepted: 08/09/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Acute pancreatitis is a common disease that is usually mild and self-limiting. Early discharge of patients with mild acute pancreatitis, with the use of supporting outpatient services including remote monitoring or smartphone applications, might be safe and could reduce the healthcare demand. The objective of this review was to provide a comprehensive overview of existing strategies aimed at facilitating early discharge of patients diagnosed with mild acute pancreatitis and to assess clinical outcomes, feasibility and costs associated with these strategies. METHODS PubMed, Cochrane, Embase, and Web of Science were systematically searched, to identify studies that evaluated strategies to reduce the length of hospital stay in patients with mild acute pancreatitis. RESULTS Five studies, including 84 to 419 patients each, were identified and described three different early discharge protocols. The early discharge strategies resulted in a median length of hospital stay of a minimum of 6 to a maximum of 23 h in these studies. Early discharge compared to usual care did not result in increased 30-day readmissions. Additionally, no occurrences of complications or mortality were observed in either group. A significant reduction in overall costs was reported ranging from 43.1 % to 85.4 %. CONCLUSIONS Early discharge of patients with mild acute pancreatitis seems both feasible and safe. Further studies are warranted, since focus on safe early discharge could significantly reduce inpatient healthcare utilization and associated costs.
Collapse
Affiliation(s)
- Niels Kant
- Clinical Research Center, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, the Netherlands; Department of Health Technology and Services Research, Technical Medical Centre, Faculty of Behavioral, Management and Social Sciences, University of Twente, Hallenweg 5, 7522 NH, Enschede, the Netherlands
| | - Astrid Beij
- Department of Gastroenterology and Hepatology, Amsterdam UMC Location University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, De Boelelaan 1117, 1081HV, Amsterdam, the Netherlands; Department of Research & Development, St. Antonius Hospital, Koekoekslaan 1, 3435CM, Nieuwegein, the Netherlands.
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Koekoekslaan 1, 3435CM, Nieuwegein, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, the Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam UMC Location University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, De Boelelaan 1117, 1081HV, Amsterdam, the Netherlands
| | - Marcel B W Spanier
- Department of Gastroenterology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, the Netherlands
| | - Carine J M Doggen
- Clinical Research Center, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, the Netherlands; Department of Health Technology and Services Research, Technical Medical Centre, Faculty of Behavioral, Management and Social Sciences, University of Twente, Hallenweg 5, 7522 NH, Enschede, the Netherlands
| |
Collapse
|
|
3
|
Zhang J, Lu X, Ge Y. Nurse-Led Care at Home Visit Versus Standard Care in Patients with Mild Acute Pancreatitis: A Retrospective Analysis. Dig Dis Sci 2024; 69:2775-2783. [PMID: 38850507 DOI: 10.1007/s10620-024-08496-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 05/09/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUNDS Frequent hospitalization and the costs of hospitalization are the main burdens in China for patients with acute pancreatitis. Most admitted patients have mild disease conditions that do not require hospitalization. AIMS Here, we compare some health and economic aspects of patients with mild acute pancreatitis who received nurse-led care at home visits against those who were hospitalized on follow-up. METHODS Patients discharged from the hospital after treatment for mild acute pancreatitis received (NC cohort, n = 104) or did not receive (HN cohort, n = 141) regular home visits by nurses for treatment and care. Patients were rehospitalized by caregivers with or without help of nurse. RESULTS Hospital readmission events occurred in both cohorts at a follow-up care time of 2 months. Compared with the time of discharge from the hospital, unwanted effects were higher in follow-up care in all patients (p < 0.001 for all). Patients in the NC cohort had less time to resolution of pain, less time to resumption of oral solid food intake, smaller number of patients with hospital readmissions, less average time of hospitalization, lower cost of care, and lower occurrence of unwanted effects than those of patients in the HN cohort during 2 months of follow-up care (p < 0.05 for all). CONCLUSIONS Patients with mild acute pancreatitis who undergo treatment require nurse-led nontreatment intervention(s) for rehabilitation in follow-up. Nurse-led follow-up care at-home visits increase recovery, are beneficial and cost-effective, and decrease unwanted adverse effects in patients receiving treatment for mild acute pancreatitis. LEVEL OF EVIDENCE IV. TECHNICAL EFFICACY Stage 5.
Collapse
Affiliation(s)
- Jiayan Zhang
- Department of Emergency, Affiliated Hospital of Jiangnan University, No 1000 Hefeng Road, Binhu District, Wuxi City, 214000, Jiangsu Province, China
| | - Xing Lu
- Department of Emergency, Affiliated Hospital of Jiangnan University, No 1000 Hefeng Road, Binhu District, Wuxi City, 214000, Jiangsu Province, China
| | - Yanqian Ge
- Department of Emergency, Affiliated Hospital of Jiangnan University, No 1000 Hefeng Road, Binhu District, Wuxi City, 214000, Jiangsu Province, China.
| |
Collapse
|
|
4
|
Vahapoğlu A, Çalik M. A comparison of scoring systems and biomarkers to predict the severity of acute pancreatitis in patients referring to the emergency clinic. Medicine (Baltimore) 2024; 103:e37964. [PMID: 38669403 PMCID: PMC11049751 DOI: 10.1097/md.0000000000037964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
To investigate scoring systems and biomarkers for determining the severity and prognosis of acute pancreatitis (AP). Between January and July 2023, 100 patients with AP diagnosed and treated in the emergency department were included. AP was divided into 2 groups according to severity: mild AP and moderately severe AP (MSAP-SAP), according to the revised Atlanta Classification in 2012. Demographic characteristics, severity, intensive care unit (ICU) admission, white blood cell count (WBC), hematocrit, red cell distribution width from whole blood taken at admission and 48 hours later, C-reactive protein (CRP) and biochemistry values, Bedside Index for Severity in Acute Pancreatitis (BISAP), Pancreatitis Activity Scoring System (PASS), and harmless AP score scores were recorded retrospectively. Our variables, which were found to be significant in multiple logistic regression results, were found to increase MSAP-SAP expectation by 4.36-, 7.85-, 6.63 and 5.80 times in the presence of CRP > 47.10, WBC > 13.10, PASS > 0, and necrotizing computed tomography findings, respectively. It was detected that the risk factor which was found significant as a single variable affecting the ICU admission increased the risk of ICU requirement by 28.88 when PASS > 0, by 3.96 when BISAP > 1, and it increased the Atlanta score by 9.93-fold. We found that WBC and CRP values at the time of hospital admission and WBC, CRP, and red cell distribution width values after 48 had the highest accuracy in determining AP disease severity. BISAP, which was found to be significant in determining MSAP-SAP expectations, lost its significance in multiple logistic regression results, and PASS was found to be effective. The PASS is an important score in the clinical evaluation of patients with AP and in determining the need for ICU hospitalization.
Collapse
Affiliation(s)
- Ayşe Vahapoğlu
- Department of Anesthesiology and Reanimation, University of Health Sciences Turkey, Gaziosmanpaşa Training Research Hospital, İstanbul, Turkey
| | - Mustafa Çalik
- Department of Emergency Medicine, University of Health Sciences Turkey, Gaziosmanpaşa Training Research Hospital, İstanbul, Turkey
| |
Collapse
|
|
5
|
Shi C, Dumville J, Rubinstein F, Norman G, Ullah A, Bashir S, Bower P, Vardy ERLC. Inpatient-level care at home delivered by virtual wards and hospital at home: a systematic review and meta-analysis of complex interventions and their components. BMC Med 2024; 22:145. [PMID: 38561754 PMCID: PMC10986022 DOI: 10.1186/s12916-024-03312-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/22/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Technology-enabled inpatient-level care at home services, such as virtual wards and hospital at home, are being rapidly implemented. This is the first systematic review to link the components of these service delivery innovations to evidence of effectiveness to explore implications for practice and research. METHODS For this review (registered here https://osf.io/je39y ), we searched Cochrane-recommended multiple databases up to 30 November 2022 and additional resources for randomised and non-randomised studies that compared technology-enabled inpatient-level care at home with hospital-based inpatient care. We classified interventions into care model groups using three key components: clinical activities, workforce, and technology. We synthesised evidence by these groups quantitatively or narratively for mortality, hospital readmissions, cost-effectiveness and length of stay. RESULTS We include 69 studies: 38 randomised studies (6413 participants; largely judged as low or unclear risk of bias) and 31 non-randomised studies (31,950 participants; largely judged at serious or critical risk of bias). The 69 studies described 63 interventions which formed eight model groups. Most models, regardless of using low- or high-intensity technology, may have similar or reduced hospital readmission risk compared with hospital-based inpatient care (low-certainty evidence from randomised trials). For mortality, most models had uncertain or unavailable evidence. Two exceptions were low technology-enabled models that involve hospital- and community-based professionals, they may have similar mortality risk compared with hospital-based inpatient care (low- or moderate-certainty evidence from randomised trials). Cost-effectiveness evidence is unavailable for high technology-enabled models, but sparse evidence suggests the low technology-enabled multidisciplinary care delivered by hospital-based teams appears more cost-effective than hospital-based care for those with chronic obstructive pulmonary disease (COPD) exacerbations. CONCLUSIONS Low-certainty evidence suggests that none of technology-enabled care at home models we explored put people at higher risk of readmission compared with hospital-based care. Where limited evidence on mortality is available, there appears to be no additional risk of mortality due to use of technology-enabled at home models. It is unclear whether inpatient-level care at home using higher levels of technology confers additional benefits. Further research should focus on clearly defined interventions in high-priority populations and include comparative cost-effectiveness evaluation. TRIAL REGISTRATION https://osf.io/je39y .
Collapse
Affiliation(s)
- Chunhu Shi
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK.
| | - Jo Dumville
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
| | - Fernando Rubinstein
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Gill Norman
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Evidence Synthesis Group, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Akbar Ullah
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Manchester Centre for Health Economics, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Saima Bashir
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Manchester Centre for Health Economics, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Peter Bower
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Emma R L C Vardy
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Oldham Care Organisation, Northern Care Alliance NHS Foundation Trust, Oldham, UK
| |
Collapse
|
|
6
|
Kothari DJ, Sheth SG. Innovative pathways allow safe discharge of mild acute pancreatitis from the emergency room. World J Gastroenterol 2024; 30:1475-1479. [PMID: 38617458 PMCID: PMC11008414 DOI: 10.3748/wjg.v30.i11.1475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/22/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024] Open
Abstract
Acute pancreatitis (AP) is a leading cause of gastrointestinal-related hospitalizations in the United States, resulting in 300000 admissions per year with an estimated cost of over $2.6 billion annually. The severity of AP is determined by the presence of pancreatic complications and end-organ damage. While moderate/severe pancreatitis can be associated with significant morbidity and mortality, the majority of patients have a mild presentation with an uncomplicated course and mortality rate of less than 2%. Despite favorable outcomes, the majority of mild AP patients are admitted, contributing to healthcare cost and burden. In this Editorial we review the performance of an emergency department (ED) pathway for patients with mild AP at a tertiary care center with the goal of reducing hospitalizations, resource utilization, and costs after several years of implementation of the pathway. We discuss the clinical course and outcomes of mild AP patients enrolled in the pathway who were successfully discharged from the ED compared to those who were admitted to the hospital, and identify predictors of successful ED discharge to select patients who can potentially be triaged to the pathway. We conclude that by implementing innovative clinical pathways which are established and reproducible, selected AP patients can be safely discharged from the ED, reducing hospitalizations and healthcare costs, without compromising clinical outcomes. We also identify a subset of patients most likely to succeed in this pathway.
Collapse
Affiliation(s)
- Darshan J Kothari
- Division of Gastroenterology, Duke University Medical Center, Durham, NC 27710, United States
| | - Sunil G Sheth
- Division of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| |
Collapse
|
|
7
|
Ramírez-Maldonado E, Rodrigo-Rodrigo M, Lopez Gordo S, Sanchez A, Coronado Llanos D, Sanchez R, Vaz J, Fondevila C, Jorba-Martin R. Home care/outpatient versus hospital admission in mild acute pancreatitis: protocol of a multicentre, randomised controlled trial (PADI_2 trial). BMJ Open 2023; 13:e071265. [PMID: 37380212 PMCID: PMC10410805 DOI: 10.1136/bmjopen-2022-071265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 05/16/2023] [Indexed: 06/30/2023] Open
Abstract
INTRODUCTION Acute pancreatitis (AP) is the third most common gastrointestinal disease resulting in hospital admission, with over 70% of AP admissions being mild cases. In the USA, it costs 2.5 billion dollars annually. The most common standard management of mild AP (MAP) still is hospital admission. Patients with MAP usually achieve complete recovery in less than a week and the severity predictor scales are reliable. The aim of this study will be to compare three different strategies for the management of MAP. METHODS/DESIGN This is a randomised, controlled, three-arm multicentre trial. Patients with MAP will be randomly assigned to group A (outpatient), B (home care) or C (hospital admission). The primary endpoint of the trial will be the treatment failure rate of the outpatient/home care management for patients with MAP compared with that of hospitalised patients. The secondary endpoints will be pain relapse, diet intolerance, hospital readmission, hospital length of stay, need for intensive care unit admission, organ failure, complications, costs and patient satisfaction. The general feasibility, safety and quality checks required for high-quality evidence will be adhered to. ETHICS AND DISSEMINATION The study (version 3.0, 10/2022) has been approved by the Scientific and Research Ethics Committee of the 'Institut d'Investigació Sanitaria Pere Virgili-IISPV' (093/2022). This study will provide evidence as to whether outpatient/home care is similar to usual management of AP. The conclusions of this study will be published in an open-access journal. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT05360797).
Collapse
Affiliation(s)
- Elena Ramírez-Maldonado
- General and Digestive Surgery Department, Joan XXIII University Hospital in Tarragona, Tarragona, Spain
- Biomedicine Department, Rovira i Virgili University, Tarragona, Spain
| | - Marta Rodrigo-Rodrigo
- General and Digestive Surgery Department, Joan XXIII University Hospital in Tarragona, Tarragona, Spain
| | - Sandra Lopez Gordo
- General and Digestive Surgery Department, Maresme Health Consortium, Mataro, Spain
| | - Ariadna Sanchez
- Gastroenterology Department, Clinic Barcelona Hospital University, Barcelona, Spain
| | - Daniel Coronado Llanos
- General and Digestive Surgery Department, Hospital de Sant Joan Despí Moisès Broggi, Sant Joan Despi, Spain
| | - Raquel Sanchez
- General and Digestive Surgery Department, Manresa Public Health Fundation, Manresa, Spain
| | - Joao Vaz
- General and Digestive Surgery, Hospital Garcia de Orta EPE, Almada, Portugal
| | | | - Rosa Jorba-Martin
- General and Digestive Surgery Department, Joan XXIII University Hospital in Tarragona, Tarragona, Spain
- Biomedicine Department, Rovira i Virgili University, Tarragona, Spain
| |
Collapse
|
|
8
|
Sorribas M, Carnaval T, Peláez N, Secanella L, Salord S, Sarret S, Videla S, Busquets J. Home monitoring vs hospitalization for mild acute pancreatitis. A pilot randomized controlled clinical trials. Medicine (Baltimore) 2023; 102:e33853. [PMID: 37335696 PMCID: PMC10194650 DOI: 10.1097/md.0000000000033853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 06/21/2023] Open
Abstract
INTRODUCTION Acute pancreatitis is a high-incidence benign disease. In 2009, it was the second highest cause of total hospital stays, the largest contributor to aggregate costs (approximately US$ 7000.00 per hospitalization), and the fifth leading cause of in-hospital deaths in the United States. Although almost 80% of acute pancreatitis cases are mild (usually requiring short-term hospitalization and without further complications), severe cases can be quite challenging.Classifications, scores, and radiological criteria have been developed to predict disease severity and outcome accurately; however, in-hospital care remains of widespread use, regardless of disease severity. A recent Turkish study reported that mild acute pancreatitis can be effectively and safely managed with home monitoring. Although the optimal timing for oral refeeding remains controversial and could cast some doubt on the feasibility of home monitoring, some guidelines already advocate for starting it within 24 hours.The present clinical trial aims to assess whether home monitoring is effective, safe and non-inferior to hospitalization for managing mild acute pancreatitis. METHODS This will be a multicenter open-label randomized (1:1) controlled clinical trial to assess the efficacy and safety of home monitoring compared to in-hospital care for mild acute pancreatitis. All patients coming to the emergency department with suspected acute pancreatitis will be screened for enrollment. The main variable will be treatment failure (Yes/No) within the first 7 days after randomization. DISCUSSION Acute pancreatitis implies a high economic burden in healthcare systems worldwide. Recent evidence suggests that mild disease can be safely and effectively treated with home monitoring. This approach may produce considerable cost savings and positively impact patients' quality of life. We expect the results to show that home monitoring is effective and not inferior to hospitalization for managing mild acute pancreatitis and that the economic costs are lower, kickstarting similar trials throughout the world, optimizing the use of limited healthcare budgets, and improving patients' quality of life.
Collapse
Affiliation(s)
- Maria Sorribas
- Digestive and General Surgery Department, Bellvitge University Hospital, L’Hospitalet DE Llobregat, Barcelona, Spain
- Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d’Investigació Biomèdica de Bellvitge – IDIBELL, University of Barcelona, L’Hospitalet DE Llobregat, Barcelona, Spain
| | - Thiago Carnaval
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, IDIBELL, University of Barcelona, L’Hospitalet DE Llobregat, Barcelona, Spain
| | - Núria Peláez
- Digestive and General Surgery Department, Bellvitge University Hospital, L’Hospitalet DE Llobregat, Barcelona, Spain
- Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d’Investigació Biomèdica de Bellvitge – IDIBELL, University of Barcelona, L’Hospitalet DE Llobregat, Barcelona, Spain
| | - Luis Secanella
- Digestive and General Surgery Department, Bellvitge University Hospital, L’Hospitalet DE Llobregat, Barcelona, Spain
- Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d’Investigació Biomèdica de Bellvitge – IDIBELL, University of Barcelona, L’Hospitalet DE Llobregat, Barcelona, Spain
| | - Silvia Salord
- Gastroenterology Department, Bellvitge University Hospital, L’Hospitalet DE Llobregat, Barcelona, Spain
| | - Sònia Sarret
- Home Hospitalization Unit, Bellvitge University Hospital, L’Hospitalet DE Llobregat, Barcelona, Spain
| | - Sebastián Videla
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, IDIBELL, University of Barcelona, L’Hospitalet DE Llobregat, Barcelona, Spain
- Clinical Research Support Unit (HUB·IDIBELL), Clinical Pharmacology Department, Bellvitge University Hospital, L´Hospitalet DE Llobregat, Barcelona, Spain
| | - Juli Busquets
- Digestive and General Surgery Department, Bellvitge University Hospital, L’Hospitalet DE Llobregat, Barcelona, Spain
- Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d’Investigació Biomèdica de Bellvitge – IDIBELL, University of Barcelona, L’Hospitalet DE Llobregat, Barcelona, Spain
- Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain
| |
Collapse
|
|
9
|
Anderson K, Shah I, Yakah W, Cartelle AL, Zuberi SA, McHenry N, Horton L, Ahmed A, Freedman SD, Kothari DJ, Sheth SG. Prospective evaluation of an emergency department protocol to prevent hospitalization in mild acute pancreatitis: Outcomes and predictors of discharge. Pancreatology 2023; 23:299-305. [PMID: 36870814 DOI: 10.1016/j.pan.2023.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/27/2023] [Accepted: 02/21/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND While acute pancreatitis (AP) contributes significantly to hospitalizations and costs, most cases are mild with minimal complications. In 2016, we piloted an observation pathway in the emergency department (ED) for mild AP and showed reduced admissions and length of stay (LOS) without increased readmissions or mortality. After 5 years of implementation, we evaluated outcomes of the ED pathway and identified predictors of successful discharge. METHODS We reviewed a prospectively enrolled cohort of patients with mild AP presenting to a tertiary care center ED between 10/2016 and 9/2021, evaluating LOS, charges, imaging, and 30-day readmission, and assessed predictors of successful ED discharge. Patients were divided into two main groups: successfully discharged via the ED pathway ("ED cohort") and admitted to the hospital ("admission cohort"), with subgroups to compare outcomes, and multivariate analysis to determine predictors of discharge. RESULTS Of 619 AP patients, 419 had mild AP (109 ED cohort, 310 admission cohort). The ED cohort was younger (age 49.3 vs 56.3,p < 0.001), had lower Charlson Comorbidity Index (CCI) (1.30 vs 2.43, p < 0.001), shorter LOS (12.3 h vs 116 h, p < 0.001), lower charges (mean $6768 vs $19886, p < 0.001) and less imaging, without differences in 30-day readmissions. Increasing age (OR: 0.97; p < 0.001), increasing CCI (OR: 0.75; p < 0.001) and biliary AP (OR: 0.10; p < 0.001) were associated with decreased ED discharge, while idiopathic AP had increased ED discharge (OR: 7.8; p < 0.001). CONCLUSIONS After appropriate triage, patients with mild AP (age <50, CCI <2, idiopathic AP) can safely discharge from the ED with improved outcomes and cost savings.
Collapse
Affiliation(s)
- Kelsey Anderson
- Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Ishani Shah
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - William Yakah
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Anabel Liyen Cartelle
- Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Shaharyar A Zuberi
- Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Nicole McHenry
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Laura Horton
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Awais Ahmed
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Steven D Freedman
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Darshan J Kothari
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Duke University Medical Center, Durham, NC, USA
| | - Sunil G Sheth
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
|
10
|
Lai Q, Wei W, He Y, Cheng T, Han T, Cao Y. A Rapid Prognostic Score Based on Bedside Arterial Blood Gas Analysis (ABG) Established for Predicting 60-Day Adverse Outcomes in Patients with Acute Pancreatitis in the Emergency Department. J Inflamm Res 2022; 15:5337-5346. [PMID: 36131781 PMCID: PMC9484575 DOI: 10.2147/jir.s381438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/29/2022] [Indexed: 12/02/2022] Open
Abstract
Objective To establish a rapid and concise prognosis scoring system for pancreatitis in the emergency department based on bedside arterial blood gas analysis (ABG). Methods A single-center, retrospective cohort study was used to establish the new scoring system, and a validation group was used to verify it. The primary endpoint was 60-day death, and secondary endpoints were 28-day death, admission to the intensive care unit (AICU), requirement for mechanical ventilation (MV) and persistent organ failure (POF). Receiver operating characteristic (ROC) curves was drawn to validate the predictive value of the new scoring system. The performance of the new scoring system was compared with that of conventional predictive scoring. Results 443 patients were in the derivation group and 217 patients in the validation group, of which 27 and 25 died during follow-up. A total of 443 patients in the derivation group, 27 of whom died during the follow-up period. Multivariate regression analysis showed that mental status, hematocrit (HCT), base excess (BE) and Serum ionic calcium (Ca2+) were independent risk factors for 60-day mortality of pancreatitis, and they were used to create a new scoring system (MHBC). In the derivation and validation, the ability of MHBC (AUC= 0.922, 0.773, respectively) to predict 60-day mortality from pancreatitis was no less than that of APACHE II (AUC= 0.838, 0.748, respectively) and BISAP (AUC= 0.791, 0.750, respectively), while, MHBC is more quickly and concisely than APACHE II and BISAP. Compared with MHBC less than or equal to 2, when MHBC is greater than 2, the 28-day mortality, 60-day mortality and the incidence of AICU, MV and POF increased significantly (P <0.001). Conclusion The MHBC can quickly and concisely evaluate the 60-day mortality, 28-day mortality, and the incidence of AICU, MV and POF of patients with acute pancreatitis in the emergency department.
Collapse
Affiliation(s)
- Qiang Lai
- Emergency Department, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.,Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.,Disaster Medical Center, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Wei Wei
- Emergency Department, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.,Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.,Disaster Medical Center, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Yarong He
- Emergency Department, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.,Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.,Disaster Medical Center, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Tao Cheng
- Emergency Department, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.,Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.,Disaster Medical Center, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Tianyong Han
- Emergency Department, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.,Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.,Disaster Medical Center, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Yu Cao
- Emergency Department, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.,Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.,Disaster Medical Center, Sichuan University, Chengdu, Sichuan, People's Republic of China
| |
Collapse
|
|
11
|
Ashok A, Faghih M, Azadi JR, Parsa N, Fan C, Bhullar F, Gonzalez FG, Jalaly NY, Boortalary T, Khashab MA, Kamal A, Akshintala VS, Zaheer A, Afghani E, Singh VK. Morphologic Severity of Acute Pancreatitis on Imaging Is Independently Associated with Opioid Dose Requirements in Hospitalized Patients. Dig Dis Sci 2022; 67:1362-1370. [PMID: 33835374 PMCID: PMC9225947 DOI: 10.1007/s10620-021-06944-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 03/06/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prior studies have evaluated clinical characteristics associated with opioid dose requirements in hospitalized patients with acute pancreatitis (AP) but did not incorporate morphologic findings on CT imaging. AIMS We sought to determine whether morphologic severity on imaging is independently associated with opioid dose requirements in AP. METHODS Adult inpatients with a diagnosis of AP from 2006 to 2017 were reviewed. The highest modified CT severity index (MCTSI) score and the daily oral morphine equivalent (OME) for each patient over the first 7 days of hospitalization were used to grade the morphologic severity of AP and calculate mean OME per day(s) of treatment (MOME), respectively. Multiple regression analysis was used to evaluate the association of MOME with MCSTI. RESULTS There were 249 patients with AP, of whom 196 underwent contrast-enhanced CT. The mean age was 46 ± 13.6 years, 57.9% were male, and 60% were black. The mean MOME for the patient cohort was 60 ± 52.8 mg/day. MCTSI (β = 3.5 [95% CI 0.3, 6.7], p = 0.03), early hemoconcentration (β = 21 [95% CI 4.6, 39], p = 0.01) and first episode of AP (β = - 17 [95% CI - 32, - 2.7], p = 0.027) were independently associated with MOME. Among the 19 patients undergoing ≥ 2 CT scans, no significant differences in MOME were seen between those whose MCTSI score increased (n = 12) versus decreased/remained the same (n = 7). CONCLUSION The morphologic severity of AP positively correlated with opioid dose requirements. No difference in opioid dose requirements were seen between those who did versus those who did not experience changes in their morphologic severity.
Collapse
Affiliation(s)
- Aditya Ashok
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mahya Faghih
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Javad R Azadi
- Division of Abdominal Imaging, Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Nasim Parsa
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Christopher Fan
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Furqan Bhullar
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Francisco G Gonzalez
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Niloofar Y Jalaly
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Tina Boortalary
- Division of General Internal Medicine, Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ayesha Kamal
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Venkata S Akshintala
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Atif Zaheer
- Division of Abdominal Imaging, Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
- Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Elham Afghani
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
- Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
- Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| |
Collapse
|
|
12
|
Cheng T, Han TY, Liu BF, Pan P, Lai Q, Yu H, Cao Y. Use of Modified Balthazar Grades for the Early Prediction of Acute Pancreatitis Severity in the Emergency Department. Int J Gen Med 2022; 15:1111-1119. [PMID: 35153503 PMCID: PMC8824293 DOI: 10.2147/ijgm.s350383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 01/19/2022] [Indexed: 11/23/2022] Open
Abstract
Objective To develop a new approach based on Balthazar grades of acute pancreatitis (AP) and to assess this modified method as a tool for the early prediction of AP severity in the emergency department (ED). Methods Data pertaining to AP patients ≥18 years old that had undergone computed tomography (CT) scanning within 24 h following ED admission between January 1, 2017 and September 30, 2017 were retrospectively analyzed. Patients were separated into two groups based on the length of time between the onset of their AP symptoms and the completion of CT scanning (Group 1: <72 h; Group 2: ≥72 h). Modified Balthazar grades for these patients were then assessed, with the concordance between these modified grades and the 2012 revised Atlanta classification being assessed using the Kappa (κ) statistic. The modified grade with the largest κ value was evaluated based on performance traits including Harrell’s concordance index (C-index), area under the receiver operating characteristic curve (AUC) analyses, calibration curves, and decision curve analyses (DCA) in comparison with bedside index for severity in AP (BISAP) scores. Results In total, 372 patients were included in the present analysis. These patients were regraded according to six methods, with the method yielding the largest κ value consisting of regraded Balthazar grades A–C, D, and E, respectively, corresponding to mild, moderate, and severe AP. The κ values for this method were 0.786 (95% CI, 0.706–0.853) in Group 1 and 0.907 (95% CI, 0.842–0.955) in Group 2, exhibiting nearly complete agreement with the latest Atlanta classification of AP. AUROC values for these modified Balthazar grades when used to predict SAP were significantly higher than those for BISAP scores in Group 1, Group 2, and the overall cohort (P < 0.05). The DCA curves for Group 1, Group 2, and the overall patient cohort exhibited substantial net benefits when using these modified grades across a range of POFs relative to BISAP scores. The calibration curve for this modified approach to predicting POF in AP patients revealed good agreement in this cohort. Conclusion Modified Balthazar grades exhibited substantial to near-total agreement with the 2012 revised Atlanta classification of AP patients, and this modified method can thus be used for the early prediction of AP severity in the ED.
Collapse
Affiliation(s)
- Tao Cheng
- Emergency Department, West China Hospital of Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Laboratory of Emergency Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Tian-Yong Han
- Emergency Department, West China Hospital of Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Laboratory of Emergency Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Bo-Fu Liu
- Emergency Department, West China Hospital of Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Laboratory of Emergency Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Pan Pan
- Emergency Department, West China Hospital of Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Laboratory of Emergency Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Qiang Lai
- Emergency Department, West China Hospital of Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Laboratory of Emergency Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Haifang Yu
- Emergency Department, West China Hospital of Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Laboratory of Emergency Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Yu Cao
- Emergency Department, West China Hospital of Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Laboratory of Emergency Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Correspondence: Yu Cao, Emergency Department of West China Hospital and Laboratory of Emergency Medicine of West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, 610041, Sichuan, People’s Republic of China, Tel +86-28-85422288, Email
| |
Collapse
|
|
13
|
Maisonneuve P, Lowenfels AB, Lankisch PG. The harmless acute pancreatitis score (HAPS) identifies non-severe patients: A systematic review and meta-analysis. Pancreatology 2021; 21:1419-1427. [PMID: 34629293 DOI: 10.1016/j.pan.2021.09.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION We previously described a scoring system to identify patients with harmless acute pancreatitis as defined by absence of pancreatic necrosis, no need for artificial ventilation or dialysis, and non-fatal course. This scoring system, the Harmless Acute Pancreatitis Score (HAPS), can be quickly calculated from three parameters: absence of abdominal tenderness or rebound, normal hematocrit and normal creatinine level. We aim to assess the positive predictive value (PPV) of the HAPS by performing a meta-analysis of subsequently published studies. METHODS We performed a literature search using Pubmed, Web of ScienceTM and Google Scholar. We used random effects models, with maximum likelihood estimates, to estimate the PPV of HAPS. We produced forest plots and used the I2 statistic to quantify heterogeneity. RESULTS Twenty reports covering 6374 patients were identified. The overall PPV based on 16 studies that closely followed the original description of the HAPS system was 97% (95%CI 95-99%) with significant heterogeneity (I2 = 76%; P < 0.01). For 11 studies in which HAPS was used to identify patients with mild AP, the overall PPV dropped to 83% (74-91%). For 8 studies in which HAPS was used to predict non-fatal course the overall PPV was 98% (97-100%). CONCLUSION The HAPS, if used as originally defined, accurately identifies patients with non-severe AP who will not require ICU care and facilitate selection of patients who can be discharged after a short stay on a general ward or can even be cared for at home. This could free hospital beds for other purposes and decrease healthcare costs.
Collapse
Affiliation(s)
- Patrick Maisonneuve
- Chief, Unit of Clinical Epidemiology, Division of Epidemiology and Biostatistics, IEO, European Institute of Oncology IRCCS, Milan, Italy.
| | - Albert B Lowenfels
- Emeritus Professor of Surgery and Professor of Family Medicine New York Medical College, Valhalla, NY, USA.
| | - Paul G Lankisch
- Retired Chief of Department of General Internal Medicine and Gastroenterology, Clinical Centre of Lüneburg, Lüneburg, Germany.
| |
Collapse
|
|
14
|
Andersson R, Ansari D, Sternby H, Valdimarsson V. Acute pancreatitis - can evidence-based guidelines be transferred to an optimized comprehensive treatment program? Scand J Gastroenterol 2021; 56:1220-1221. [PMID: 34329565 DOI: 10.1080/00365521.2021.1953577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/08/2021] [Accepted: 07/05/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Roland Andersson
- Surgery, Department of Clinical Sciences Lund, Lund University and Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Daniel Ansari
- Surgery, Department of Clinical Sciences Lund, Lund University and Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Hanna Sternby
- Surgery, Department of Clinical Sciences Lund, Lund University and Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Valentinus Valdimarsson
- Surgery, Department of Clinical Sciences Lund, Lund University and Department of Surgery, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
|
15
|
Alves JR, Ferrazza GH, Nunes Junior IN, Teive MB. THE ACCEPTANCE OF CHANGES IN THE MANAGEMENT OF PATIENTS WITH ACUTE PANCREATITIS AFTER THE REVISED ATLANTA CLASSIFICATION. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:17-25. [PMID: 33909792 DOI: 10.1590/s0004-2803.202100000-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/21/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND New recommendations for the management of patients with acute pancreatitis were set after the Atlanta Classification was revised in 2012. OBJECTIVE The aim of the present systematic review is to assess whether these recommendations have already been accepted and implemented in daily medical practices. METHODS A systematic literature review was carried out in studies conducted with humans and published in English and Portuguese language from 10/25/2012 to 11/30/2018. The search was conducted in databases such as PubMed/Medline, Cochrane and SciELO, based on the following descriptors/Boolean operator: "Acute pancreatitis" AND "Atlanta". Only Randomized Clinical Trials comprising some recommendations released after the revised Atlanta Classification in 2012 were included in the study. RESULTS Eighty-nine studies were selected and considered valid after inclusion, exclusion and qualitative evaluation criteria application. These studies were stratified as to whether, or not, they applied the recommendations suggested after the Atlanta Classification revision. Based on the results, 68.5% of the studies applied the recommendations, with emphasis on the application of severity classification (mild, moderately severe, severe); 16.4% of them were North-American and 14.7% were Chinese. The remaining 31.5% just focused on comparing or validating the severity classification. CONCLUSION Few studies have disclosed any form of acceptance or practice of these recommendations, despite the US and Chinese efforts. The lack of incorporation of these recommendations didn't enable harnessing the benefits of their application in the clinical practice (particularly the improvement of the communication among health professionals and directly association with the worst prognoses); thus, it is necessary mobilizing the international medical community in order to change this scenario.
Collapse
Affiliation(s)
- José Roberto Alves
- Universidade Federal de Santa Catarina, Departamento de Cirurgia, Florianópolis, SC, Brasil
| | | | | | | |
Collapse
|
|
16
|
Kothari D, Sheth SG. Treating Acute Medical Conditions Outside the Hospital: Streamlining Care During a Pandemic. J Clin Gastroenterol 2020; 54:912-913. [PMID: 32925301 DOI: 10.1097/mcg.0000000000001427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Darshan Kothari
- Department of Medicine, Division of Gastroenterology, Duke University
- Durham VA Medical Center, Durham, NC
| | - Sunil G Sheth
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, MA
| |
Collapse
|
|
17
|
Kayar Y, Senturk H, Tozlu M, Baysal B, Atay M, Ince AT. Prediction of Self-Limited Acute Pancreatitis Cases at Admission to Emergency Unit. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:251-259. [PMID: 31328139 DOI: 10.1159/000493762] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 09/14/2018] [Indexed: 12/15/2022]
Abstract
Background While acute pancreatitis (AP) resolves spontaneously with supportive treatment in most patients, it may be life-threatening. Predicting the disease severity at onset dictates the management strategy. We aimed to define the patients with mild pancreatitis who may be considered for outpatient management with significant cost-savings. Materials and Methods This prospective observational study included 180 patients with mild AP according to the harmless acute pancreatitis score (HAPS) and Imrie score. The relationships of biochemical parameters with the changes in the Balthazar score and clinical course were examined. Results The study included 180 patients (111 females, 69 males; mean age: 53.9 ± 17.2 years; range: 17-92 years). The etiology was biliary in 118 (65%) patients and remained undetermined in 38 (21.1%) patients. Computed tomography (CT) performed within the first 12 h revealed mild and moderate AP in 159 (88.3%) and 21 (11.7%) patients, respectively. CT repeated at 72 h revealed mild, moderate, and severe AP in 155 (86.1%), 24 (13.3%), and 1 (0.6%) patients, respectively. Comparisons between stages A + B + C and D + E showed significant differences in the amylase levels on day 1 and 3, and in C-reactive protein on day 3. Also, in stage D and E disease, narcotic analgesic intake, oral intake onset time, and pain were significantly higher. Conclusion There were no significant changes in the CT findings of patients with mild AP at 12 and 72 h. Most patients (n = 179; 99.4%) recovered uneventfully. Patients with mild pancreatitis according to the HAPS and Imrie scores can be considered for outpatient management. The recovery is longer in stage D and E disease.
Collapse
Affiliation(s)
- Yusuf Kayar
- Department of Internal Medicine, Division of Gastroenterology, Bezmialem Vakıf University, Istanbul, Turkey
| | - Hakan Senturk
- Department of Internal Medicine, Division of Gastroenterology, Bezmialem Vakıf University, Istanbul, Turkey
| | - Mukaddes Tozlu
- Department of Internal Medicine, Division of Gastroenterology, Bezmialem Vakıf University, Istanbul, Turkey
| | - Birol Baysal
- Department of Internal Medicine, Division of Gastroenterology, Bezmialem Vakıf University, Istanbul, Turkey
| | - Musa Atay
- Department of Radiology, Bezmialem Vakıf University, Istanbul, Turkey
| | - Ali Tuzun Ince
- Department of Internal Medicine, Division of Gastroenterology, Bezmialem Vakıf University, Istanbul, Turkey
| |
Collapse
|
|
18
|
Detection of Common Bile Duct Stones in Mild Acute Biliary Pancreatitis Using Magnetic Resonance Cholangiopancreatography. Surg Res Pract 2018; 2018:5216089. [PMID: 30426071 PMCID: PMC6217739 DOI: 10.1155/2018/5216089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 09/19/2018] [Accepted: 10/04/2018] [Indexed: 11/17/2022] Open
Abstract
Background All patients with mild acute biliary pancreatitis should undergo early cholecystectomy. Whether routine common bile duct (CBD) imaging should be employed before the surgical procedure in these patients is a matter of current controversy. The aim of this study was to investigate the rate of detection of CBD stones using magnetic resonance cholangiopancreatography (MRCP) at different time intervals from admission. Methods From January 1, 2011, through December 31, 2016, 72 patients with acute biliary pancreatitis underwent MRCP. Fifty-six (n=56) of them with mild biliary pancreatitis met the study criteria. The patients were divided into two groups. Group A did not have stones in the CBD (n=45), and Group B had stones in the CBD (n=11). The time from admission to MRCP was divided into several periods (day 1 through day 180), and the presence of the CBD stones on MRCP was weighted against remoteness from admission. Liver chemistry profiles were compared between the groups on admission and before the MRCP. Results The cumulative rate of choledocholithiasis was 19.7% (Group B, n=11). Forty-five patients (Group A, n=45, 80.3%) did not have gallstones in the CBD. Eight patients with choledocholithiasis (8/56, 14.2%) were detected during the first 10 days from admission out of 27 patients. In patients who underwent MRCP between days 11 and 20, choledocholithiasis was found in two patients (2/56, 3.5%) and in one patient between days 21 and 30 (1/56, 1.8%). No stones were found in patients who underwent MRCP beyond 30 days from admission. Liver chemistry profiles did not show a significant difference in both groups. CBD dilatation was observed at presentation in 11 patients (n=11/56), 6 in Group A (6/45, 13.3%) and 5 in Group B (5/11, 45.5%) (p=0.016). Conclusions Routine CBD evaluation should be encouraged after mild acute biliary pancreatitis. Early performance of MRCP gives high yield in selecting the patients for endoscopic retrograde cholangiopancreatography (ERCP) before cholecystectomy. A liver chemistry profile either on admission or before MRCP cannot predict the presence of CBD stones.
Collapse
|
|
19
|
Kothari D, Babineau M, Hall M, Freedman SD, Shapiro NI, Sheth SG. Preventing Hospitalization in Mild Acute Pancreatitis Using a Clinical Pathway in the Emergency Department. J Clin Gastroenterol 2018; 52:734-741. [PMID: 29095424 DOI: 10.1097/mcg.0000000000000954] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
GOALS We created an observation pathway with close outpatient follow-up for patients with mild acute pancreatitis (AP) to determine its effect on admission rates, length of stay (LOS), and costs. BACKGROUND AP is a common reason for hospitalization costing $2.6 billion annually. Majority have mild disease and improve quickly but have unnecessarily long hospital stays. STUDY We performed a pilot prospective cohort study in patients with AP at a tertiary-care center. In total, 90 patients with AP were divided into 2 groups: observation cohort and admitted cohort. Exclusion criteria from observation included end-organ damage, pancreatic complications, and/or severe cardiac, liver, and renal disease. Patients in observation received protocolized hydration and periodic reassessment in the emergency department and were discharged with outpatient follow-up. Using similar exclusion criteria, we compared outcomes with a preintervention cohort composed of 184 patients admitted for mild AP in 2015. Our primary outcome was admission rate, and secondary outcomes were LOS, patient charges, and 30-day readmission. RESULTS Admitted and preintervention cohorts had longer LOS compared with the observation cohort (89.7 vs. 22.6 h, P<0.01 and 72.0 vs. 22.6 h, P<0.01). The observation cohort admission rate was 22.2% lower than the preintervention cohort (P<0.01) and had 43% lower patient charges ($5281 vs. $9279, P<0.01). Moreover there were significantly fewer imaging studies performed (25 vs. 49 images, P=0.03) in the observation cohort. There were no differences in readmission rates and mortality. CONCLUSIONS In this feasibility study, we demonstrate that a robust pathway can prevent hospitalization in those with AP and may reduce resource utilization without a detrimental impact on safety.
Collapse
Affiliation(s)
| | - Matthew Babineau
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Dartmouth Medical School, Lebanon, NH
| | - Matthew Hall
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sunil G Sheth
- Department of Medicine, Division of Gastroenterology
| |
Collapse
|
|
20
|
Kumar VV, Treacy PJ, Li M, Dharmawardane A. Early discharge of patients with acute pancreatitis to enhanced outpatient care. ANZ J Surg 2018; 88:1333-1336. [DOI: 10.1111/ans.14710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/29/2018] [Accepted: 04/30/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Vineeth V. Kumar
- Department of Surgery; Royal Darwin Hospital; Darwin Northern Territory Australia
| | - P. John Treacy
- Department of Surgery; Royal Darwin Hospital; Darwin Northern Territory Australia
- Northern Territory Medical School; Flinders University; Darwin Northern Territory Australia
| | - Minghao Li
- Department of Surgery; Royal Darwin Hospital; Darwin Northern Territory Australia
| | - Anoj Dharmawardane
- Department of Surgery; Royal Darwin Hospital; Darwin Northern Territory Australia
| |
Collapse
|
|
21
|
Serra Pla S, Garcia Monforte N, García Borobia FJ, Rebasa Cladera P, García Pacheco JC, Romaguera Monzonís A, Bejarano González N, Navarro Soto S. Early discharge in Mild Acute Pancreatitis. Is it possible? Observational prospective study in a tertiary-level hospital. Pancreatology 2017; 17:669-674. [PMID: 28851510 DOI: 10.1016/j.pan.2017.07.193] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/21/2017] [Accepted: 07/30/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS In acute pancreatitis (AP), first 24 h are crucial as this is the period in which the greatest amount of patients presents an organ failure. This suggests patients with Mild AP (MAP) could be early identified and discharged. This is an observational prospective trial with the aim to demonstrate the safety of early discharge in Mild Acute Pancreatitis (MAP). METHODS Observational prospective study in a third level single centre. Consecutive patients with AP from March 2012 to March 2014 were collected. INCLUSION CRITERIA MAP, tolerance to oral intake, control of pain, C Reactive Protein <150 mg/dL and blood ureic nitrogen < 5 mg/dL in two samples. EXCLUSION CRITERIA pregnant, lack of family support, active comorbidities, temperature and serum bilirubin elevation. Patients with MAP, who met the inclusion criteria, were discharged within the first 48 h. Readmissions within first week and first 30 days were recorded. Adverse effects related to readmissions were also collected. RESULTS Three hundred and seventeen episodes were collected of whom 250 patients were diagnosed with MAP. From these, 105 were early discharged. Early discharged patients presented a 30-day readmission rate of 15.2% (16 patients out of 105) corresponding to the readmission rates in Acute Pancreatitis published to date. Any patient presented adverse effects related to readmissions. CONCLUSION Early discharge in accurately selected patients with MAP is feasible, safe and efficient and leads to a decrease in median stay with the ensuing savings per process and with no increase in readmissions or inmorbi-mortality.
Collapse
Affiliation(s)
- Sheila Serra Pla
- Hospital Universitari Parc Taulí, General and Digestive Surgery Department, Spain.
| | - Neus Garcia Monforte
- Hospital Universitari Parc Taulí, General and Digestive Surgery Department, Spain.
| | | | - Pere Rebasa Cladera
- Hospital Universitari Parc Taulí, General and Digestive Surgery Department, Spain.
| | | | | | | | | |
Collapse
|
|
22
|
Gonçalves-Bradley DC, Iliffe S, Doll HA, Broad J, Gladman J, Langhorne P, Richards SH, Shepperd S. Early discharge hospital at home. Cochrane Database Syst Rev 2017; 2017:CD000356. [PMID: 28651296 PMCID: PMC6481686 DOI: 10.1002/14651858.cd000356.pub4] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Early discharge hospital at home is a service that provides active treatment by healthcare professionals in the patient's home for a condition that otherwise would require acute hospital inpatient care. This is an update of a Cochrane review. OBJECTIVES To determine the effectiveness and cost of managing patients with early discharge hospital at home compared with inpatient hospital care. SEARCH METHODS We searched the following databases to 9 January 2017: the Cochrane Effective Practice and Organisation of Care Group (EPOC) register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and EconLit. We searched clinical trials registries. SELECTION CRITERIA Randomised trials comparing early discharge hospital at home with acute hospital inpatient care for adults. We excluded obstetric, paediatric and mental health hospital at home schemes. DATA COLLECTION AND ANALYSIS: We followed the standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes. MAIN RESULTS We included 32 trials (N = 4746), six of them new for this update, mainly conducted in high-income countries. We judged most of the studies to have a low or unclear risk of bias. The intervention was delivered by hospital outreach services (17 trials), community-based services (11 trials), and was co-ordinated by a hospital-based stroke team or physician in conjunction with community-based services in four trials.Studies recruiting people recovering from strokeEarly discharge hospital at home probably makes little or no difference to mortality at three to six months (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.57 to 1.48, N = 1114, 11 trials, moderate-certainty evidence) and may make little or no difference to the risk of hospital readmission (RR 1.09, 95% CI 0.71 to 1.66, N = 345, 5 trials, low-certainty evidence). Hospital at home may lower the risk of living in institutional setting at six months (RR 0.63, 96% CI 0.40 to 0.98; N = 574, 4 trials, low-certainty evidence) and might slightly improve patient satisfaction (N = 795, low-certainty evidence). Hospital at home probably reduces hospital length of stay, as moderate-certainty evidence found that people assigned to hospital at home are discharged from the intervention about seven days earlier than people receiving inpatient care (95% CI 10.19 to 3.17 days earlier, N = 528, 4 trials). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).Studies recruiting people with a mix of medical conditionsEarly discharge hospital at home probably makes little or no difference to mortality (RR 1.07, 95% CI 0.76 to 1.49; N = 1247, 8 trials, moderate-certainty evidence). In people with chronic obstructive pulmonary disease (COPD) there was insufficient information to determine the effect of these two approaches on mortality (RR 0.53, 95% CI 0.25 to 1.12, N = 496, 5 trials, low-certainty evidence). The intervention probably increases the risk of hospital readmission in a mix of medical conditions, although the results are also compatible with no difference and a relatively large increase in the risk of readmission (RR 1.25, 95% CI 0.98 to 1.58, N = 1276, 9 trials, moderate-certainty evidence). Early discharge hospital at home may decrease the risk of readmission for people with COPD (RR 0.86, 95% CI 0.66 to 1.13, N = 496, 5 trials low-certainty evidence). Hospital at home may lower the risk of living in an institutional setting (RR 0.69, 0.48 to 0.99; N = 484, 3 trials, low-certainty evidence). The intervention might slightly improve patient satisfaction (N = 900, low-certainty evidence). The effect of early discharge hospital at home on hospital length of stay for older patients with a mix of conditions ranged from a reduction of 20 days to a reduction of less than half a day (moderate-certainty evidence, N = 767). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).Studies recruiting people undergoing elective surgeryThree studies did not report higher rates of mortality with hospital at home compared with inpatient care (data not pooled, N = 856, low-certainty evidence; mainly orthopaedic surgery). Hospital at home may lead to little or no difference in readmission to hospital for people who were mainly recovering from orthopaedic surgery (N = 1229, low-certainty evidence). We could not establish the effects of hospital at home on the risk of living in institutional care, due to a lack of data. The intervention might slightly improve patient satisfaction (N = 1229, low-certainty evidence). People recovering from orthopaedic surgery allocated to early discharge hospital at home were discharged from the intervention on average four days earlier than people allocated to usual inpatient care (4.44 days earlier, 95% CI 6.37 to 2.51 days earlier, , N = 411, 4 trials, moderate-certainty evidence). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence). AUTHORS' CONCLUSIONS Despite increasing interest in the potential of early discharge hospital at home services as a less expensive alternative to inpatient care, this review provides insufficient evidence of economic benefit (through a reduction in hospital length of stay) or improved health outcomes.
Collapse
|
|
23
|
Pendharkar SA, Plank LD, Windsor JA, Petrov MS. Quality of Life in a Randomized Trial of Nasogastric Tube Feeding in Acute Pancreatitis. JPEN J Parenter Enteral Nutr 2016; 40:693-698. [DOI: 10.1177/0148607115574290] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
| | - Lindsay D. Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - John A. Windsor
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Maxim S. Petrov
- Department of Surgery, University of Auckland, Auckland, New Zealand
| |
Collapse
|
|
24
|
Antonini F, De Minicis S, Macarri G, Pezzilli R. Are we ready for early discharge of patients with mild non-alcoholic acute interstitial pancreatitis? Pancreatology 2016; 16:322-323. [PMID: 27156148 DOI: 10.1016/j.pan.2016.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 04/12/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Filippo Antonini
- Department of Gastroenterology, A.Murri Hospital, Polytechnic University of Marche, Fermo, Italy.
| | - Samuele De Minicis
- Department of Gastroenterology, A.Murri Hospital, Polytechnic University of Marche, Fermo, Italy
| | - Giampiero Macarri
- Department of Gastroenterology, A.Murri Hospital, Polytechnic University of Marche, Fermo, Italy
| | - Raffaele Pezzilli
- Pancreas Unit, Department of Digestive Diseases and Internal Medicine, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| |
Collapse
|
|
25
|
Abstract
PURPOSE OF REVIEW To summarize recent data on classification systems, cause, risk factors, severity prediction, nutrition, and drug treatment of acute pancreatitis. RECENT FINDINGS Comparison of the Revised Atlanta Classification and Determinant Based Classification has shown heterogeneous results. Simvastatin has a protective effect against acute pancreatitis. Young black male, alcohol, smoldering symptoms, and subsequent diagnosis of chronic pancreatitis are risk factors associated with readmissions after acute pancreatitis. A reliable clinical or laboratory marker or a scoring system to predict severity is lacking. The PYTHON trial has shown that oral feeding with on demand nasoenteric tube feeding after 72 h is as good as nasoenteric tube feeding within 24 h in preventing infections in predicted severe acute pancreatitis. Male sex, multiple organ failure, extent of pancreatic necrosis, and heterogeneous collection are factors associated with failure of percutaneous drainage of pancreatic collections. SUMMARY The newly proposed classification systems of acute pancreatitis need to be evaluated more critically. New biomarkers are needed for severity prediction. Further well designed studies are required to assess the type of enteral nutritional formulations for acute pancreatitis. The optimal minimally invasive method or combination to debride the necrotic collections is evolving. There is a great need for a drug to treat the disease early on to prevent morbidity and mortality.
Collapse
Affiliation(s)
- Rupjyoti Talukdar
- aAsian Institute of Gastroenterology/Asian Healthcare Foundation, Hyderabad, Telangana, India bDivision of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | |
Collapse
|
|
26
|
Abstract
The medical treatment of acute pancreatitis continues to focus on supportive care, including fluid therapy, nutrition, and antibiotics, all of which will be critically reviewed. Pharmacologic agents that were previously studied were found to be ineffective likely due to a combination of their targets and flaws in trial design. Potential future pharmacologic agents, particularly those that target intracellular calcium signaling, as well as considerations for trial design will be discussed. As the incidence of acute pancreatitis continues to increase, greater efforts will be needed to prevent hospitalization, readmission and excessive imaging in order to reduce overall healthcare costs. Primary prevention continues to focus on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and secondary prevention on cholecystectomy for biliary pancreatitis as well as alcohol and smoking abstinence.
Collapse
Affiliation(s)
- Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | |
Collapse
|