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Comments on the article “Clinical utility of the Revised Atlanta Classification of acute pancreatitis in a prospective cohort: Have all loose ends been tied?”
Pancreatology 15 (2015) 78
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Pancreatology journal homepage: www.elsevier.com/locate/pan
Letter to the Editor
Comments on the article “Clinical utility of the Revised Atlanta Classification of acute pancreatitis in a prospective cohort: Have all loose ends been tied?” Keywords: Acute pancreatitis Classification BUN BISAP Mild acute pancreatitis Moderately severe acute pancreatitis
Dear Sir, We read with much interest the study titled ‘Clinical utility of the Revised Atlanta Classification of acute pancreatitis in a prospective cohort: Have all loose ends been tied?’ by Talukdar et al. [1] in the JulyeAugust 2014 issue of Pancreatology. We completely agree with the authors that Revised Atlanta classification has been long sought and now has provided us clearer definitions of acute pancreatitis and its complications that would help us in improvement of clinical evaluation and treatment of patients with acute pancreatitis. However, in our opinion some aspects of this study need to be clarified for a better understanding of methods used and results provided by the authors. First, authors used BUN >20 mg/dL for calculation of the BISAP score but according to Wu et al. calculation of BISAP score should utilize BUN >25 mg/dL [2]. Using BUN >20 mg/dL to calculate BISAP score will result in overestimation of the BISAP score especially in patient with mild acute pancreatitis (MAP) and moderately severe acute pancreatitis (MSAP). Second, authors reported statistical analysis on different characteristics in MAP, MSAP and severe acute pancreatitis (SAP) in table 1. Statistical analysis should not be reported on those characteristics that were used to create these categories. For example, elevated creatinine levels are essential for defining renal failure which was a criteria for diagnosing MSAP and SAP.
Third, authors did not delineate whether extrapancreatic infections (pneumonia and UTI) included patients with hospital acquired infections. It is also not clear which patients underwent catheter insertion for monitoring of urine output which increases the risk of catheter associated infections. The data about pneumonia and UTI is very interesting especially because of equal frequencies of pneumonia and UTI in all three groups even with wide variations in length of stay and procedural intensity among these groups. This study highlights the clinical utility of Revised Atlanta classification for acute pancreatitis. The study identified a subgroup of patients who develop early multiorgan failure who run a fulminant course. We believe that clarification of the above mentioned concerns would make this study stronger.
References [1] Talukdar R, Bhattacharrya A, Rao B, Sharma M, Nageshwar Reddy D. Clinical utility of the Revised Atlanta Classification of acute pancreatitis in a prospective cohort: have all loose ends been tied? Pancreatology 2014 Jul-Aug;14(4): 257e62. [2] Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut 2008 Dec;57(12):1698e703.
Hemant Goyal*, Edwin W. Grimsley, David Parish Mercer University School of Medicine, USA *
Corresponding author. Mercer University School of Medicine, Macon, GA 31220, USA. Tel.: þ1 478 301 5862; fax: þ1 478 301 5825. E-mail address: [email protected] (H. Goyal). Available online 23 October 2014
DOI of original article: http://dx.doi.org/10.1016/j.pan.2014.06.003. http://dx.doi.org/10.1016/j.pan.2014.10.004 1424-3903/Copyright © 2014, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved.
Contents lists available at ScienceDirect
Pancreatology journal homepage: www.elsevier.com/locate/pan
Letter to the Editor
Comments on the article “Clinical utility of the Revised Atlanta Classification of acute pancreatitis in a prospective cohort: Have all loose ends been tied?” Keywords: Acute pancreatitis Classification BUN BISAP Mild acute pancreatitis Moderately severe acute pancreatitis
Dear Sir, We read with much interest the study titled ‘Clinical utility of the Revised Atlanta Classification of acute pancreatitis in a prospective cohort: Have all loose ends been tied?’ by Talukdar et al. [1] in the JulyeAugust 2014 issue of Pancreatology. We completely agree with the authors that Revised Atlanta classification has been long sought and now has provided us clearer definitions of acute pancreatitis and its complications that would help us in improvement of clinical evaluation and treatment of patients with acute pancreatitis. However, in our opinion some aspects of this study need to be clarified for a better understanding of methods used and results provided by the authors. First, authors used BUN >20 mg/dL for calculation of the BISAP score but according to Wu et al. calculation of BISAP score should utilize BUN >25 mg/dL [2]. Using BUN >20 mg/dL to calculate BISAP score will result in overestimation of the BISAP score especially in patient with mild acute pancreatitis (MAP) and moderately severe acute pancreatitis (MSAP). Second, authors reported statistical analysis on different characteristics in MAP, MSAP and severe acute pancreatitis (SAP) in table 1. Statistical analysis should not be reported on those characteristics that were used to create these categories. For example, elevated creatinine levels are essential for defining renal failure which was a criteria for diagnosing MSAP and SAP.
Third, authors did not delineate whether extrapancreatic infections (pneumonia and UTI) included patients with hospital acquired infections. It is also not clear which patients underwent catheter insertion for monitoring of urine output which increases the risk of catheter associated infections. The data about pneumonia and UTI is very interesting especially because of equal frequencies of pneumonia and UTI in all three groups even with wide variations in length of stay and procedural intensity among these groups. This study highlights the clinical utility of Revised Atlanta classification for acute pancreatitis. The study identified a subgroup of patients who develop early multiorgan failure who run a fulminant course. We believe that clarification of the above mentioned concerns would make this study stronger.
References [1] Talukdar R, Bhattacharrya A, Rao B, Sharma M, Nageshwar Reddy D. Clinical utility of the Revised Atlanta Classification of acute pancreatitis in a prospective cohort: have all loose ends been tied? Pancreatology 2014 Jul-Aug;14(4): 257e62. [2] Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut 2008 Dec;57(12):1698e703.
Hemant Goyal*, Edwin W. Grimsley, David Parish Mercer University School of Medicine, USA *
Corresponding author. Mercer University School of Medicine, Macon, GA 31220, USA. Tel.: þ1 478 301 5862; fax: þ1 478 301 5825. E-mail address: [email protected] (H. Goyal). Available online 23 October 2014
DOI of original article: http://dx.doi.org/10.1016/j.pan.2014.06.003. http://dx.doi.org/10.1016/j.pan.2014.10.004 1424-3903/Copyright © 2014, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved.