A Unified Treatment Algorithm and Admission Order Set for Pediatric Acute Pancreatitis.
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ABSTRACT:
SUBMITTER: Sellers ZM
PROVIDER: S-EPMC6534431 | biostudies-literature | 2019 Jun
REPOSITORIES: biostudies-literature
Publications
A Unified Treatment Algorithm and Admission Order Set for Pediatric Acute Pancreatitis.
Sellers Zachary M ZM Dike Chinenye C Zhang Ke-You KY Giefer Matthew J MJ Uc Aliye A Abu-El-Haija Maisam M
Journal of pediatric gastroenterology and nutrition 20190601 6
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Project description:BackgroundVariation in hospital management of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may prolong length of stay, increasing the risk of hospital-acquired complications and worsening quality of life. We sought to determine whether an evidence-based computerized AECOPD admission order set could improve quality and reduce length of stay.MethodsThe order set was designed by a provincial COPD working group and implemented voluntarily among three physician groups in a Canadian tertiary-care teaching hospital. The primary outcome was length of stay for patients admitted during order set implementation period, compared to the previous 12 months. Secondary outcomes included length of stay of patients admitted with and without order set after implementation, all-cause readmissions, and emergency department visits.ResultsThere were 556 admissions prior to and 857 admissions after order set implementation, for which the order set was used in 47%. There was no difference in overall length of stay after implementation (median 6.37 days (95% confidence interval 5.94, 6.81) pre-implementation vs. 6.02 days (95% confidence interval 5.59, 6.46) post-implementation, p = 0.26). In the post-implementation period, order set use was associated with a 1.15-day reduction in length of stay (95% confidence interval - 0.5, - 1.81, p = 0.001) compared to patients admitted without the order set. There was no difference in readmissions.ConclusionsUse of a computerized guidelines-based admission order set for COPD exacerbations reduced hospital length of stay without increasing readmissions. Interventions to increase order set use could lead to greater improvements in length of stay and quality of care.
| S-EPMC5975274 | biostudies-literature
Project description:BackgroundAcute necrotizing pancreatitis (ANP) can result in a significant healthcare burden. The present study aimed to develop a new scoring system to accurately and promptly identify patients with a high likelihood of mortality to determine the need for aggressive measures.MethodsWe retrospectively analyzed patients diagnosed with ANP using the National Inpatient Sample (NIS). The mortality in ANP during admission (MANP-A) scoring system was derived using multivariate Cox regression analysis and validated using receiver operating characteristic (ROC) curves in a validation cohort.ResultsA total of 22,980 hospitalizations were identified in the derivation cohort. There was a predominance of males (65%) and white race (73%). Five variables showed significant association with mortality and were selected for developing the MANP-A scoring system: age ≥60 years; acute renal failure/kidney injury; sepsis with shock; vasopressor use; and disseminated intravascular coagulation. The MANP-A score has a maximum of 5 points and the cutoff for predicting mortality was set at 2 points. The area under the curve (AUC) using the ROC curve of the derivation cohort was 0.9195, 95% confidence interval [CI] 0.8838-0.9551 (P<0.001) for 7- and 0.8954, 95%CI 0.8723-0.9185 (P<0.001) for 30-day periods. The AUC of the Validation Cohort was 0.9204, 95%CI 0.8937-0.9469 (P<0.001) for 7- and 0.9059, 95%CI 0.8893-0.9223 (P<0.001) for 30-day periods.ConclusionWe propose a simple and objective score for predicting ANP inpatient mortality at 7- and 30-day intervals with high validity.
| S-EPMC9399582 | biostudies-literature
Project description:IntroductionPediatric acute pancreatitis (PAP) has an increasing incidence and is now estimated to be almost as common as in adults. Up to 30% of patients with PAP will develop moderate or severe disease course (M/SPAP), characterized by organ failure, local or systemic complications. There is still no consensus regarding on-admission severity prediction in these patients. Our aim was to conduct a systematic review and meta-analysis of available predictive score systems and parameters, and differences between on-admission parameters in mild and M/SPAP.MethodsWe conducted a systematic search on the 14th February, 2022 in MEDLINE, Embase and CENTRAL. We performed random-effects meta-analysis of on-admission differences between mild and M/SPAP in laboratory parameters, etiology, demographic factors, etc. calculating risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI) and created forest plots. For the meta-analysis of predictive score systems, we generated hierarchical summary receiver operating characteristic curves using a bivariate model. Chi-squared tests were performed and I2 values calculated to assess statistical heterogeneity.ResultsWe included 44 studies - mostly retrospective cohorts - in our review. Among predictive score systems examined by at least 5 studies, the modified Glasgow scale had the highest specificity (91.5% for values ≥3), and the Pediatric Acute Pancreatitis Severity score the highest sensitivity (63.1% for values ≥3). The performance of other proposed score systems and values were summarized. Traumatic (RR: 1.70 95% CI: 1.09-2.67) and drug-induced (RR: 1.33 95% CI: 0.98-1.87) etiologies were associated with a higher rate of M/SPAP, while anatomical (RR: 0.6195% CI: 0.38-0.96) and biliary (RR: 0.72 95% CI: 0.53-0.99) PAP tended to be less severe.DiscussionMany predictive score systems were proposed to assess the possibility of M/SPAP course. The most commonly used ones exhibit good specificity, but subpar sensitivity. Our systematic review provides a rigorous overview of predictive options assessed thus far, that can serve as a basis for future improvement of scores via the addition of parameters with a better observed sensitivity: e.g., lipase exceeding 7-times the upper threshold, hemoglobin, etc. The addition of etiological factors is another possibility, as they can herald a more severe disease course.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=307271, PROSPERO, identifier: CRD42022307271.
| S-EPMC9561825 | biostudies-literature
Project description:Background and aimsThe revised Atlanta classification is widely used for the evaluation of acute pancreatitis (AP) severity. However, this classification cannot be used within 48 hours of AP onset. The aim of this study was to investigate the predictive factors of mortality in patients with AP on admission.MethodsWe evaluated the association between AP mortality and clinical parameters at the time of admission in patients with AP from April 2013 to December 2017 at one university hospital and one tertiary care referral center.ResultsA total of 203 consecutive patients were enrolled. Nine patients (4.4%) died despite multidisciplinary treatment. In a multivariable analysis, hematocrit ≥ 40% (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.01-1.13; P = 0.021), blood urea nitrogen (BUN) ≥ 40 mg/dL (OR, 1.26; 95% CI, 1.11-1.42; P < 0.001), base excess < -3.0 mmol/L (OR, 1.15; 95% CI, 1.04-1.26; P = 0.004), and inflammation extending to the rectovesical excavation (OR, 1.19; 95% CI, 1.10-1.30; P < 0.001) on admission were significantly associated with mortality.ConclusionAmong the imaging findings, inflammation extending to the rectovesical excavation was the only independent predictive factor for mortality in AP. This simple finding, obtained on computed tomography without contrast agent on admission, might be a promising prognostic factor for AP.
| S-EPMC6706052 | biostudies-literature
Project description:Objectives of this study were to (1) describe barriers to using clinical practice guideline (CPG) admission order sets in a pediatric hospital and (2) determine if integrating CPG order bundles into a general admission order set increases adoption of CPG-recommended orders compared to standalone CPG order sets. We identified CPG-eligible encounters and surveyed admitting physicians to understand reasons for not using the associated CPG order set. We then integrated CPG order bundles into a general admission order set and evaluated effectiveness through summative usability testing in a simulated environment. The most common reasons for the nonuse of CPG order sets were lack of awareness or forgetting about the CPG order set. In usability testing, CPG order bundle use increased from 27.8% to 66.6% while antibiotic ordering errors decreased from 62.9% to 18.5% with the new design. Integrating CPG-related order bundles into a general admission order set improves CPG order set use in simulation by addressing the most common barriers to CPG adoption.
| S-EPMC8497878 | biostudies-literature
Project description:Acute pancreatitis (AP) is a serious, mechanistically not entirely resolved side effect of L-asparaginase-containing treatment for acute lymphoblastic leukemia (ALL). To find new candidate variations for AP, we conducted a genome-wide association study (GWAS). In all, 1,004,623 single-nucleotide variants (SNVs) were analyzed in 51 pediatric ALL patients with AP (cases) and 1388 patients without AP (controls). Replication used independent patients. The top-ranked SNV (rs4148513) was located within the ABCC4 gene (odds ratio (OR) 84.1; p = 1.04 × 10-14). Independent replication of our 20 top SNVs was not supportive of initial results, partly because rare variants were neither present in cases nor present in controls. However, results of combined analysis (GWAS and replication cohorts) remained significant (e.g., rs4148513; OR = 47.2; p = 7.31 × 10-9). Subsequently, we sequenced the entire ABCC4 gene and its close relative, the cystic fibrosis associated CFTR gene, a strong AP candidate gene, in 48 cases and 47 controls. Six AP-associated variants in ABCC4 and one variant in CFTR were detected. Replication confirmed the six ABCC4 variants but not the CFTR variant. Genetic variation within the ABCC4 gene was associated with AP during the treatment of ALL. No association of AP with CFTR was observed. Larger international studies are necessary to more conclusively assess the risk of rare clinical phenotypes.
| S-EPMC8584334 | biostudies-literature
Project description:BackgroundAcute necrotizing pancreatitis (NP), a severe form of acute pancreatitis (AP), has higher mortality and worse outcome than non-necrotizing pancreatitis (non-NP). Infected NP is a devastating subgroup of NP. To date neither NP nor infected NP has robust prediction strategies, which may delay early recognition and timely intervention. Recent studies revealed correlations between disturbed gut microbiota and AP severity. Some features of intestinal microbiota have the potential to become biomarkers for NP prediction.MethodsWe performed 16S rRNA sequencing to analyze gut microbiota features in 20 healthy controls (HC), and 58 AP patients on hospital admission. The AP patients were later classified into NP and non-NP groups based on subsequent diagnostic imaging features. Random forest regression model and ROC curve were applied for NP and infected NP prediction. PIRCUSt2 was used for bacterial functional pathway prediction analysis.ResultsWe found that the three groups (HC, NP, and non-NP) had distinct microorganism composition. NP patients had reduced microbial diversity, higher abundance of Enterobacteriales, but lower abundance of Clostridiales and Bacteroidales compared with the non-NP group. Correlation analyses displayed that intestine bacterial taxonomic alterations were related to severity, ICU admission, and prognosis. By pathway prediction, species more abundant in NP patients had positive correlation with synthesis and degradation of ketone bodies, and benzoate degradation. Enterococcus faecium (ASV2) performed best in discriminating NP and non-NP patients. Finegoldia magna (ASV3) showed the maximal prediction capacity among all ASVs and had comparable accuracy with Balthazar CT to detect patients with infected NP.ConclusionsOur study suggests that NP patients have distinct intestinal microbiota on admission compared to non-NP patients. Dysbiosis of intestinal microbiota might influence NP progression through ketone body or benzoate metabolism. Enterococcus faecium and Finegoldia magna are potential predictors for NP and infected NP. Our findings explore biomarkers which may inform clinical decision-making in AP and shed light on further studies on NP pathophysiology and management.
| S-EPMC9466706 | biostudies-literature
Project description:BackgroundStandard order sets often increase the use of desirable interventions for patients likely to benefit from them. Whether such order sets also increase misuse of these interventions in patients potentially harmed by them is unknown. We measured the association between a paper-based standard admission order set with a venous thromboembolism pharmacoprophylaxis (VTEP) module and use of VTEP for patients likely to benefit from it as well as patients with unclear benefit or potential harm from it.MethodsWe conducted a retrospective cohort study using administrative and pharmacy charge data of patients admitted between 1 July 2005 and 31 December 2008 to two medical and three surgical services that implemented a standard admission order set in August 2006. The primary outcome was use of VTEP in patients with likely benefit, unclear benefit, and potential harm from VTEP prior to and following order set implementation.Key resultsA total of 8,429 patients (32%) were admitted prior to and 17,635 (68%) following order set implementation. There was a small unadjusted rise in overall VTEP use after implementation (51% to 58%, p < 0.001). In multivariable models with interrupted time series analysis, patients with potential harm from VTEP had the largest increase in VTEP use at the time of implementation [adjusted odds ratio = 1.58; 95% confidence interval (CI), 1.12-2.22]. The increased likelihood of receiving VTEP in this subgroup gradually returned to baseline (adjusted odds ratio per month = 0.98; 95% CI, 0.96-0.99).ConclusionsImplementation of a standard admission order set transiently increased VTEP in patients with potential harm from it. Order set and guideline success should be judged based on the degree to which they successfully target patients likely to benefit from the intervention without inadvertently targeting patients potentially harmed.
| S-EPMC3286563 | biostudies-literature
Project description:Acute pancreatitis is a common indication for hospital admission, increasing in incidence, including in children, pregnancy and the elderly. Moderately severe acute pancreatitis with fluid and/or necrotic collections causes substantial morbidity, and severe disease with persistent organ failure causes significant mortality. The diagnosis requires two of upper abdominal pain, amylase/lipase ≥ 3 ×upper limit of normal, and/or cross-sectional imaging findings. Gallstones and ethanol predominate while hypertriglyceridaemia and drugs are notable among many causes. Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated, with abdominal cross-sectional imaging if there is diagnostic uncertainty. Subsequent imaging is undertaken to detect complications, for example, if C-reactive protein exceeds 150 mg/L, or rarer aetiologies. Pancreatic intracellular calcium overload, mitochondrial impairment, and inflammatory responses are critical in pathogenesis, targeted in current treatment trials, which are crucially important as there is no internationally licenced drug to treat acute pancreatitis and prevent complications. Initial priorities are intravenous fluid resuscitation, analgesia, and enteral nutrition, and when necessary, critical care and organ support, parenteral nutrition, antibiotics, pancreatic exocrine and endocrine replacement therapy; all may have adverse effects. Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy. The impact of acute pancreatitis can be devastating, so prevention or reduction of the risk of recurrence and progression to chronic pancreatitis with an increased risk of pancreas cancer requires proactive management that should be long term for some patients.
| S-EPMC9454414 | biostudies-literature
Project description:Background and aimsThis study aimed to develop an interpretable random forest model for predicting severe acute pancreatitis (SAP).MethodsClinical and laboratory data of 648 patients with acute pancreatitis were retrospectively reviewed and randomly assigned to the training set and test set in a 3:1 ratio. Univariate analysis was used to select candidate predictors for the SAP. Random forest (RF) and logistic regression (LR) models were developed on the training sample. The prediction models were then applied to the test sample. The performance of the risk models was measured by calculating the area under the receiver operating characteristic (ROC) curves (AUC) and area under precision recall curve. We provide visualized interpretation by using local interpretable model-agnostic explanations (LIME).ResultsThe LR model was developed to predict SAP as the following function: -1.10-0.13×albumin (g/L) + 0.016 × serum creatinine (μmol/L) + 0.14 × glucose (mmol/L) + 1.63 × pleural effusion (0/1)(No/Yes). The coefficients of this formula were utilized to build a nomogram. The RF model consists of 16 variables identified by univariate analysis. It was developed and validated by a tenfold cross-validation on the training sample. Variables importance analysis suggested that blood urea nitrogen, serum creatinine, albumin, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, calcium, and glucose were the most important seven predictors of SAP. The AUCs of RF model in tenfold cross-validation of the training set and the test set was 0.89 and 0.96, respectively. Both the area under precision recall curve and the diagnostic accuracy of the RF model were higher than that of both the LR model and the BISAP score. LIME plots were used to explain individualized prediction of the RF model.ConclusionsAn interpretable RF model exhibited the highest discriminatory performance in predicting SAP. Interpretation with LIME plots could be useful for individualized prediction in a clinical setting. A nomogram consisting of albumin, serum creatinine, glucose, and pleural effusion was useful for prediction of SAP.
| S-EPMC9226542 | biostudies-literature