Specific prognostic factors for secondary pancreatic infection in severe acute pancreatitis.

BACKGROUND/AIMS: The aim of the present study was to investigate whether there are specific prognostic factors to predict the development of secondary pancreatic infection (SPI) in severe acute pancreatitis in order to perform a computed tomography-fine needle aspiration with bacteriological sampling at the right moment and confirm the diagnosis. METHODS: Twenty-five clinical and laboratory parameters were determined sequentially in 150 patients with severe acute pancreatitis (SAP) and univariate, and multivariate regression analyses were done looking for correlation with the development of SPI. RESULTS: Only APACHE II score and C-reactive protein levels were related to the development of SPI in the multivariate analysis. A regression equation was designed using these two parameters, and empiric cut-off points defined the subgroup of patients at high risk of developing secondary pancreatic infection. CONCLUSION: The results showed that it is possible to predict SPI during SAP allowing bacteriological confirmation and early treatment of this severe condition.

Infusion phlebitis in post-operative patients: when and why.

BACKGROUND: The most common complication of intravenous therapy is infusion phlebitis. This study was done to prospectively assess its frequency in a series of consecutive patients who will undergo surgery, and to identify which variables may predict an increased risk for phlebitis. PATIENTS AND METHODS: 400 consecutive patients who will undergo surgery in a general surgery department were included. Only the first catheter, inserted the day before surgery, was taken into account. Eighteen variables (from the infusion, the catheter and from the patient) were prospectively evaluated for their contribution to the occurrence of phlebitis. RESULTS: 60/400 patients (15%) developed phlebitis, and most of them needed insertion of a further catheter. The univariate analysis showed that patients who developed phlebitis were older, and their pre-operative levels of both blood haemoglobin and neutrophil cound were significantly higher than those in patients who did not develop phlebitis. However, the multivariate analysis only confirmed the association with blood haemoglobin levels: the risk of phlebitis sharply increased in the patients with the highest haemoglobin levels. As to the influence of time on phlebitis development, there was a significant decrease in the day-specific risk, from the 5th day on. COMMENTS: In our series, blood haemoglobin levels were found to be the only variable associated to a higher risk of phlebitis. Besides, in contrast with the recommendations by the Centers for Disease Control, no significant increase in the day-specific risk of phlebitis was found. Thus, a guideline to select the type of catheter to be inserted in an individual patient is suggested.

Methods for analysis of the occurrence of abscess in patients with pancreatitis.

OBJECTIVE: Standard survival analysis methods are useful for data involving censored cases when cures do not generally occur. If the object is to study, for instance, the development of a complication in the progress of an infectious disease, some people may be cured before complications develop. In this article, we provide methods for the analysis of data when cures do occur. An example is a study of prognostic factors for pancreatic abscess in patients with pancreatitis, some of whom leave the risk set because the pancreatitis clears. DESIGN: We present methods for estimating the survival curves and comparing hazard function for two objectives: (1) the occurrence of an abscess, irrespective of whether the patients are cured or not, and (2) the occurrence of an abscess for patients who, at that stage, have not been cured. PATIENTS: We illustrate the applications of the methods using a sample of 50 patients with severe pancreatitis. RESULTS: To study the occurrence of an abscess, regardless of whether the patients are cured or not, we show that the appropriate strategy is to assign to the cured patients an infinite time to the appearance of an abscess. If the cured were considered censored at the moment the pancreatitis cleared, this would result in an overestimation of the hazard of presenting an abscess. On the other hand, if the objective is to compare the occurrence of abscess according to an exposure for patients who have not been cured, one needs to censor the cured patients at the time they are cured. CONCLUSIONS: For the analysis of survival data in the context of infectious diseases when cure is possible, it is important to use a censoring strategy that is pertinent to the specific aims of the study. Considering cures as censored at the time of cure is not always appropriate.

[Pseudotumorous hyperplasia of the caudate lobe of the liver in a patient with Alagille syndrome]. / Hiperplasia seudotumoral del lóbulo caudado del hígado en una paciente con síndrome de Alagille.

The Alagille's syndrome consists in hypoplasia of the intrahepatic biliary ducts associated to congenital abnormalities of different organs. It is usually diagnosed in infancy due to cholestasis with good prognosis. The case of a 31-year old women who presented prominent chin, micrognathia, flattening of the nasal bone, infundibular stenosis of the pulmonary artery and cholestasis is reported. Ultrasonography demonstrated a lesion in the space of the hepatic caudate lobe with punction showing sinusoidal dilatation and infiltration of some portal spaces by lymphocytes, eosinophils and neutrophils. Samples of liver tissue obtained during laparotomy showed an absence of intrahepatic biliary ducts in the right and left lobes and preservation of those of the caudate lobe, which was also increased in size with a pseudotumoral appearance. The patients was asymptomatic with slight anicteric cholestasis at 16 months of diagnosis. The rarity of these forms of Alagille's syndrome with areas free of hypoplasia of the intrahepatic biliary ducts are of note.

A prospective randomized trial comparing somatostatin and sclerotherapy in the treatment of acute variceal bleeding.

Somatostatin and endoscopic sclerotherapy are widely used in the treatment of acute variceal bleeding. Although objective evidence does exist about the advantages of either treatment, data comparing both procedures are scarce. In order to compare the effectiveness and safety of somatostatin and sclerotherapy in the treatment of acute variceal bleeding, 70 consecutive cirrhotic patients suffering from esophageal variceal hemorrhage and meeting the inclusion criteria were randomly assigned to treatment with somatostatin (35 patients) or sclerotherapy (35 patients). No differences in age, sex, alcohol intake, etiology of cirrhosis and severity of liver failure were found between groups. Failure of treatment (defined as persistence of bleeding despite therapy or subsequent rebleeding within the 48-hr trial period) occurred in seven patients (20%) in the somatostatin group and in six (17.1%) in the sclerotherapy group (NS). Early rebleeding occurred in seven of 28 patients (25%) in the somatostatin group and in five of 29 (17.2%) in the sclerotherapy group (NS). Mortality within the first 6 wk was no different between both groups: 10 (28.5%) and eight (22.8%) in the somatostatin and sclerotherapy groups, respectively. Sclerotherapy, but not somatostatin, was associated with major complications in five cases (14.2%) (p = 0.026), two of which resulted in patient's death. These results suggest that somatostatin is safer, and as effective as sclerotherapy, in controlling acute variceal bleeding until an elective treatment can be established.

Comparative study on the antithrombotic efficacy of hirudin, heparin and a low-molecular weight heparin in preventing experimentally induced venous thrombosis.

In a random, blind study, we compared the antithrombotic potential of unfractioned heparin, a low-molecular weight heparin (LMWH) and a recombinant hirudin (r-hirudin) given subcutaneously in a jugular vein thrombosis model in rabbits. All drugs and placebo were injected subcutaneously 2 h before inducing experimental thrombosis. A good thromboprophylactic effect was obtained with either LMWH and r-hirudin as compared with placebo. By contrast, no significant differences were found between groups in bleeding time. We also found a small (non-significant) prolongation of the activated partial thromboplastin time in the r-hirudin-treated animals. As for thrombin time, r-hirudin-treated rabbits exhibited too much sensitivity, with noncoagulable end-points. In our study, r-hirudin at the dose used seemed to be as effective as LMWH is in the prophylaxis of venous thrombosis.

Sequential combination of methotrexate (MTX), 5-fluorouracil (FU), and high-dose folinic acid (FA) in advanced colorectal cancer: double biochemical modulation?

Thirty evaluable patients were treated with methotrexate (MTX) 200 mg/m2, i.v. infusion over 60 minutes, 24 hours prior to the administration of 5-fluorouracil 600 mg/m2, and folinic acid 200 mg/m2, i.v. infusion over 60 minutes, every 2 weeks. A partial or complete response was achieved in 12 patients (40%), and disease stable in 10 patients (33%). Median actuarial survival was 18 months. Side effects, which were within acceptable limits, included 11 cases of stomatitis (5 Grade 3), 3 cases of leukopenia (Grade 2) and 12 cases of mild nausea and vomiting. We conclude that the present combination is active in metastatic colorectal cancer with mild toxicity. These results are being confirmed and a randomized trial is being carried out to prove that this combination holds therapeutic advantage.

Nonoperative management of splenic injuries.

The traditional management of splenic trauma has undergone major revision in recent years. Given the physiological importance of the spleen, certain controversy has arisen regarding the most appropriate method of managing this type of trauma. Nonoperative therapy in children has proven to be successful not only in the case of kidney lesions but also for splenic lesions. Nonoperative management carried out in the authors' hospital on a group of 56 patients (49 adults and seven children over the age of 7 years) has proved successful in 37 cases. The success of this technique requires a well-formulated protocol, diagnostic methods (ultrasound and computed tomography), rigorous patient control in the emergency room during the initial phase (first 48 hours), the availability of a medical team if surgical intervention becomes necessary (persistent or recurrent hemorrhage), and complementary measures which facilitate the cicatrization of the splenic injury (bed rest, antibiotic therapy).

[Correlation of etiology and severity in a series of 506 cases of acute pancreatitis]. / Correlación etiología-gravedad en una serie de 506 pancreatitis agudas.

We present a retrospective study on 506 patients with acute pancreatitis (AP), admitted in our hospital in the last five years (1984-1988). The goal of the paper is to establish a possible correlation between the severity and the etiology of the AP. Depending on the severity of the acute attack, and according to the Ranson's prognostic signs and the findings of the abdominal CAT, we have classified AP in three grades: mild, moderate and severe. 52% of AP were of biliary etiology, 25.7% alcoholic, and in 17.0% of the cases the responsible agent was not demonstrated. In relation with severity, the distribution was as follows: mild, 184 (36.4%), moderate, 254 (50.2%) and severe, 68 (13.4%). Among the cases of biliary and alcoholic etiology, 14.7% and 9.2%, respectively, were severe. Postoperative AP were severe in 71.4% of the cases. Systemic complications were more frequent in the severe forms, particularly of biliary etiology. Pancreatic abscesses and fistulas were also more frequent in biliary pancreatitis; on the other hand, pseudocysts and ascites were more common in alcoholic pancreatitis. Overall mortality was 2.8% (14 patients). Mortality was 19.1% in the severe forms. In relation to etiology the mortality was as follows: 3.7% in biliary AP; 0.8% in alcoholic AP; 14.3% in postoperative AP; and 2.3% in the idiopathic AP.

[Biliary peritonitis after hepatic biopsy: favorable course with conservative medical treatment]. / Peritonitis biliar postbiopsia hepática: evolución favorable con tratamiento médico conservador.

In a 53-year-old woman a percutaneous liver biopsy was performed with tru-cut to study persistent hypertransaminasemia. The patient did not present extrahepatic cholestasis. Immediately after biopsy the patient had a picture of biliary peritonitis that evolved favorably with conservative medical treatment, including hemodynamic resuscitation, antibiotic therapy, analgesic treatment and monitoring by the resuscitation service. A review is made of the literature on this complication of liver biopsy and treatment is discussed.