EPC/HPSG evidence-based guidelines for the management of pediatric pancreatitis.

BACKGROUND: Pediatric pancreatitis is an underdiagnosed disease with variable etiology. In the past 10-15 years the incidence of pediatric pancreatitis has increased, it is now 3.6-13.3 cases per 100,000 children. Up-to-date evidence based management guidelines are lacking for the pediatric pancreatitis. The European Pancreatic Club, in collaboration with the Hungarian Pancreatic Study Group organized a consensus guideline meeting on the diagnosis and management of pancreatitis in the pediatric population. METHODS: Pediatric Pancreatitis was divided into three main clinical categories: acute pancreatitis, acute recurrent pancreatitis and chronic pancreatitis. Fifteen relevant topics (acute pancreatitis: diagnosis; etiology; prognosis; imaging; complications; therapy; biliary tract management; acute recurrent pancreatitis: diagnosis; chronic pancreatitis: diagnosis, etiology, treatment, imaging, intervention, pain, complications; enzyme replacement) were defined. Ten experts from the USA and Europe reviewed and summarized the available literature. Evidence was classified according to the GRADE classification system. RESULTS: Within fifteen topics, forty-seven relevant clinical questions were defined. The draft of the updated guideline was presented and discussed at the consensus meeting held during the 49th Meeting of European Pancreatic Club, in Budapest, on July 1, 2017. CONCLUSIONS: These evidence-based guidelines provides the current state of the art of the diagnosis and management of pediatric pancreatitis.

A prognostic tool to predict severe acute pancreatitis in pediatrics.

BACKGROUND/OBJECTIVES: Approximately 15-20% of pediatric patients with acute pancreatitis (AP) develop severe disease. Severity scoring tools were developed for adult patients, but have limitations when applied in children. We aimed to identify early predictors of severe acute pancreatitis (SAP) on hospital admission for early risk stratification of patients. METHODS: Retrospective review of AP admissions was conducted. The derivation cohort included cases at Cincinnati Children's Hospital Medical Center (CCHMC) between 2009 and 2013. Clinical data collected during the first 24 h of admission were analyzed and a predictive model was derived through statistical analysis. The performance of the model was evaluated in a validation cohort from 2 more institutions other than CCHMC. RESULTS: In the derivation cohort 19% of the 284 admissions were SAP. A generalized linear mixed effect model analysis revealed that lipase, albumin and white blood count (WBC) play a role in the development of SAP (area under the receiver operating curve (AUROC 0.76)). In the validation cohort of 165 AP cases, SAP ranged from 8 to 20% at the three institutions. Performance of the model in this cohort was comparable to the derivation model (AUROC 0.77). There were 369 encounters in the combined derivation and validation pool (AUROC 0.76). CONCLUSIONS: The prognostic severity tool with 3 variables (lipase, albumin, and WBC) obtained within 24 h of admission can be applied to predict SAP in pediatric patients.

Early Enteral Nutrition and Aggressive Fluid Resuscitation are Associated with Improved Clinical Outcomes in Acute Pancreatitis.

OBJECTIVES: To determine whether recommendations for treatment of acute pancreatitis (AP) in adults impact the outcomes of pediatric AP. STUDY DESIGN: Adult guidelines regarding early management of AP were implemented through an admission order set at Cincinnati Children's Hospital Medical Center at the beginning of the year 2014. Recommendations included administering high rates of intravenous fluid (IVF) within 24 hours of admission and enteral nutrition within 48 hours of admission. A retrospective chart review of AP admissions before and after the implementation of the recommendations was undertaken. Outcomes studied were: hospital length of stay, intensive care unit transfer rates, development of severe AP, pulmonary complications, and readmission rates post discharge from the hospital. RESULTS: The study included 201 patients. Children who received feeds within the first 48 hours and received greater than maintenance IVF within 24 hours had a shorter length of stay, less intensive care unit admissions and severe AP rates compared with the patients who remained nil per os during the first 48 hours and received lower rates of IVF. CONCLUSION: Our data support that early enteral nutrition and early aggressive IVF improve outcomes of pediatric AP.

Increased Burden of Pediatric Acute Pancreatitis on the Health Care System.

OBJECTIVES: The incidence of pediatric acute pancreatitis (AP) increased over the past 2 decades and is estimated to be 3 to 13 per 100,000. The impact of rising AP incidence on health care costs is unknown. Our aim was to examine pediatric AP admissions and associated hospital costs in the United States between years 2004 and 2014. METHODS: Acute pancreatitis admission and cost data were extracted from the Pediatric Health Information System. We determined AP admission and cost percentages each year, as well as the ratio of AP cost to admission percentages to estimate AP "burden." Length of stay, costs of hospitalization, and the effect of intensive care unit care on these estimates were examined. RESULTS: Between 2004 and 2014, AP admission percentages increased (P = 0.002). Length of stay decreased over time (P < 0.0001) and was longer for those requiring intensive care unit care (P < 0.0001). Acute pancreatitis admissions cost per day significantly increased over time (P < 0.0001). Median AP cost percentage remained 1.2 to 1.7 times higher than AP admission percentage. CONCLUSIONS: Acute pancreatitis admissions constitute an expensive burden on the health care system relative to the percentage of all admissions. If AP admissions continue to increase, the cost of AP admissions may pose a substantial financial health care burden.

A direct neuronal connection between the subparafascicular and ventrolateral arcuate nuclei in non-lactating female rats. Could this pathway play a role in the suckling-induced prolactin release?

The neuronal pathways, through which prolactin secretion is regulated during lactation, have still not been fully explored. Studies indicate that the suckling stimulus travels through the spinal cord, the brain stem, and then reaches the hypothalamus. The focus of this present experiment is to further explore the neuronal connections between the brain stem and the arcuate nucleus that may be involved in suckling-induced prolactin release. Ante- and retrograde tracing techniques were used. To chemically characterize the explored neurons neuropeptide immunohistochemistry was applied. Previous studies have indicated that the peripeduncular nucleus is a relay of the suckling stimulus in the midbrain, conveying the information to the hypothalamus. In our experiments, we have found an additional cell group in the subparafascicular parvocellular nucleus located just behind the posterior thalamus that projects to the arcuate neurons. The injection of the retrograde tracer into the ventrolateral part of the arcuate nucleus labeled cells in the lateral subdivision of the subparafascicular parvocellular nucleus. Anterograde tracing from the subparafascicular parvocellular nucleus resulted in fiber labeling in the arcuate nucleus in close apposition with dynorphin immunopositive neurons. Double labeling revealed that a subpopulations of the subparafascicular parvocellular neurons projecting to the arcuate nucleus contained tuberoinfundibular peptide of 39 residues or calcitonin gene-related peptide. The presented findings suggest that the ascending fibers from the subparafascicular parvocellular nucleus might be in the pathway involved in the suckling-induced prolactin release.