Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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On Sep 2018




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Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Calcutta National Medical College & Hospital , Kolkata




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On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
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An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2011 | Month : June | Volume : 5 | Issue : 3 | Page : 459 - 463

The Clinical Prognostic Indicators of Acute Pancreatitis by Apache II Scoring

RITHIN SUVARNA, ARAVIND PALLIPADY, NITHISH BHANDARY, HANUMANTHAPPA

Associate professor, Dept of General surgery, AJ Institute of medical sciences Mangalore, India Corresponding Author. Assistant professor, Dept of General Medicine, AJ Institute of medical sciences Mangalore, India Assistant professor, Dept of General Surgery, AJ Institute of medical sciences Mangalore, India

Correspondence Address :
Aravind P
Door No: 3-90(11) Behind Kannur Telephone Exchange
P.O Kannur, Manglore - 575007, India
Moblile No: 9448127559
E-mail address: aravindpath@ yahoo.co.in

Abstract

Background and Objectives: Acute pancreatitis is a catastrophic condition with many complications and poses a great challenge to the treating surgeon. 10-20% of the patients who develop complications will not recover with simple supportive therapy. Hence, an accurate prediction of severity and prognostic monitoring are necessary to anticipate the early and late complications, so as to consider aggressive treatment. The present study aimed at predicting the prognosis in patients with acute pancreatitis by using the APACHE II scoring system and at determining the utility of these scores in further management.

Methods and Material: 51 patients who were admitted to the AJ Institute of Medical Sciences with the clinical and radiologicalevidence of acute pancreatitis, with an elevation in the serum amylase levels, were the subjects of this study.

Results And Interpretation: The mean APACHE II scores were 6.62 and 11 in 32 uncomplicated cases and 19 complicated cases respectively.4 complicated patients who died eventually had scores which were persistently above 14. Sequential variations in the APACHE II scores correlated with the patient outcome.

Conclusion: The APACHE II scores which are calculated on admission accurately predict the outcome of the patients with acute pancreatitis. This scoring system is superior to other systems like Ranson’s criteria, because it takes into account all the major risk factors that influence the patient outcome.

Keywords

Prognostic indicators, APACHE II, Acute Pancreatitis

Acute pancreatitis has been recognized since time immemorial and has been described as the most terrible of all calamities that occur in connection with the abdominal viscera (1). In 1889, Reginald Fitz gave the classic clinical and pathological description of acute pancreatitis and opined that an early operative intervention was usually ineffective and indeed, could be hazardous (2). Fortunately, in 80-90% of the patients, acute pancreatitis is a mild self limiting disease due to oedematous interstitial inflammation, which resolves with conservative treatment. The remaining 10-20% of the patients will develop complications due to pancreatic necrosis and retroperitoneal inflammation, which will not resolve with simple supportive therapy and may be fatal. These patients require intensive care, haemodynamic monitoring and frequent laboratory and radiological evaluation (3). Many prognostic factors have been identified and many scoring systems have been proposed to predict the severity of the attack and the overall prognosis. Some of the scoring systems which are being used are Ranson’s criteria and lmrie’s Glasgrow system, the Simplified Acute Physiology Score (SAPS), the Acute Physiology And Chronic-Health Evaluation score (APACHE II) and the Medical Research Council Sepsis score (MRCS) (4) (5).

The reasons for grading acute pancreatitis clinically or by using multiple factor scoring systems or single prognostic factors are: (6) 1. For the early assessment and the accurate prediction of the severity of the disease to avoid costly and invasive monitoring and treatment in the largest group of patients, who tend to run a more benign course. 2. To compare the outcome between the centers both for an effective clinical audit and for the comparison of differing therapeutic approaches.3. To enable the selection of patients for clinical trials.

THE APACHE SYSTEM
The acute physiology score and the chronic health evaluation (APACHE) were used in the first major attempts to quantify the severity of the illness in ICU patients , by Knaus et al in 1981,and this was later modified in 1985 by the same author as APACHE II [5,6]. It contains 12 continuous variables from the original APACHE system and also takes into account the age of the patient, the pre-morbid conditions and the Glasgow coma scale (GCS). The major advantage of the APACHE II scoring system, as compared to the other systems, is that it can be used in monitoring the patient’s response to therapy, while the Ranson and the Glasgow scales are mainly meant for the assessment at presentation (7).

The APACHE II scoring system takes into account 12 variables which include, (1) Body temperature, (2) mean arterial pressure (mm Hg), (3) Heart rate(HR), (4) respiratory rate (R.R/mt), (5) Oxygenation (mm Hg), (6) PH, (7) Na (mmol/l), (8) k (mmol/l), (9) Creatinine (mg/100ml), (10) Haematocrit, (11) total leucocyte count and the (12) Glasgow coma score. To eliminate the problem of the missing values and concerns about the assumption that an unmeasured variable was normal, the measurement of all the 12 variables was made mandatory for the usage of APACHE II. The recorded values of the variables are based on the most deranged values during the past 24 hours (7) (8).

Because age and severe chronic health problems reflect a diminished physiological reserve, they have been directly incorporated into APACHE II. Also, emergency surgery and non operative patients with severe, chronic organ system dysfunction were givenfive additional points in comparison to the elective surgical patients who were given only two points, because patients with severe chronic conditions are not considered to be candidates for elective surgery (8).

Material and Methods

PATIENTS AND METHODS
Patients who were admitted to the AJ Medical College hospital, Mangalore, from 10/08/2008 to 10/12/2010, with a clinical diagnosis of acute pancreatitis which was corroborated by any one of the below mentioned criteria, were included in the study. 1. Serum amylase exceeding 1000 IU/L. 2. Signs of pancreatitis seen on ultrasonography of the abdomen or on contrast enhanced CT scan. The APACHE II Severity of The Disease Classification System which was proposed by Knaus et al was used and the scores were assigned to all patients. The end point of the patient outcomes were grouped as either uncomplicated or complicated. A complicated outcome was defined as

(A) The development of local pancreatic complications
(a) Necrosis (demonstrated by CT scan or during surgery)(b) Pseudocyst or abscess (demonstrated by ultrasound or CT scan)

(B) The development of a systemic complication (major
organ failure)

(a) Acute respiratory insufficiency (PO2<60 mm Hg. Requiring ventilation or oxygen therapy by mask for greater than 5 days) (b) Renal failure (Urine output <400ml/24 hrs with a rising blood urea and serum creatinine and with no response to 24 hrs fluid therapy) (c) Left ventricular failure and pulmonary oedema which were diagnosed clinically and supported by characteristic changes on the chest X ray.

(C) Death
The data was processed by using the dBase IV and the Excel programmes. The observations were recorded. Its sensitivity, specificity and predictive value have analyzed the diagnostic performance of the scoring system. Statistical analysis was conducted by using the Chi-square test and the Fisher’s exact test.



Results

A total of 51 patients were available for analysis during the course of the study, of which a majority was males (46). The mean age of the cohort was 40.9 yrs and the peak incidence of the disease was in the 4th decade. Pain in the abdomen was the chief complaint in all the patients and it was associated either with vomiting, distention, ascites or ileus. A history of alcohol consumption as the aetiology of pancreatitis was accounted for in 72% of the patients, while gall stones were the aetiology in 14% of the patients. In another 14% of the cases, a definite cause was not ascertained.(Table/Fig 1)(Table/Fig 2)

Outcome of the patients
Out of the 51 patients with acute pancreatitis, 32 (63%) had an uncomplicated outcome, as shown in (Table/Fig 3).

Complications were seen in 19 (37%) patients, out of which 8(16%) developed pseudo cysts. Pancreatic necrosis was observed in 2(4%) cases and 1 patient developed an abscess which was tracked down to the lumbar region. Renal failure and respiratory failure were encountered in 5 patients (10%) and in 3(6%) patients respectively. 4 patients had a fatal outcome as the sequelae to pancreatic necrosis and multi organ dysfunction syndrome (MODS).

Summary of the outcomes in patients who were group based on a range of APACHE II scores on admission.
The average APACHE II score in patients who had an uncomplicated outcome was 6.62, the score in patients with a complicated outcome was 11 and that in patients with a fatal outcome was 18.6.

Of the 15 (29%) patients who had an admission with the APACHE II score in the range of 0-5, 14 (93%) had an uncomplicated outcome and 1(7%) developed a pseudocyst.

Eighteen (35%) patients had on admission, the APACHE II score in the range of 6-10 and 15 (83%) of them had an uncomplicated outcome. 2 (11%) developed pseudocysts and 1 (6%) developed major organ failure.

Of the 9(18%) patients with an admission APACHE II score in the range of 11-15, 3(33%) had an uncomplicated outcome and 2 (22%) developed pseudocysts, 2 (22%) had necrosis/abscess and 2 (22%) developed major organ failure. Of the total 9 (18%)

patients with an APACHE II score of more than 15, 4 (44%) had a fatal outcome. Of the 4 patients with a fatal outcome, 1 had severe pancreatic necrosis and 3 died of multiple organ failure.

The APACHE II score (≥ 10) which was calculated at the time of admission, predicted 72% of the severe attacks and 76% of the mild attacks, with a positive predictive value of 68% and a negative predictive value of 78%. An on-admission APACHE II score of more than 9 predicted more number of severe attacks (75%), but less number of mild attacks (60%), with a positive predictive value of 55.5% and a negative value of 78%.

On admission APACHE II scores of more than 12 predicted less number of severe attacks (52%) and branded the more severe attacks as mild (specificity 89%).

An APACHE II score of more than 10 had the best sensitivity, specificity and predictive value (P value <0.001). Refer (Table/Fig 4) for details.

When the 14 individual components of the APACHE II score were examined, serum sodium, serum creatinine, pH, pO2, heart rate and the Glasgow coma scale were found to be significantly different in the uncomplicated group and in the complicated group. The Glasgow coma scale had the best correlation with a P value of <0.001.

The sequential APACHE II score
The APACHE II scores were repeated in 18 patients for a variable duration (a maximum of 5 days). Patients with an increase in the APACHE II score on subsequent days had a complicated outcome in the form of pseudo cysts, necrosis, organ failure or death. In patients with decreasing scores on the subsequent days, the outcome was proportionally better. All patients who had scores persistently above 14, died.

Discussion

The prospective assessment of the APACHE II Severity of Disease Classification System has been shown to provide an objective discrimination between uncomplicated, complicated and fatal attacks of acute pancreatitis within a few hours of admission to the hospital (9). The laboratory tests which are required are simple, routine and readily available. APACHE II may prove to be a useful addition to the management and the study of these patients, providing an objective indication of the severity and the possibleoutcome of an attack soon after admission to the hospital (10). Thus, it may permit an early, non – invasive selection of patients for intensive therapy of inclusion in the clinical trials.

In this study, acute pancreatitis was found nine times more commonly in males than in females and the mean age was 40.9 years. These results do not match with the results from the study of Larvin et al, where the male; female ratio was 47:53 and the mean age was 62 years. In the present study, alcohol was the aetiological factor in 60% of the patients and gallstones were the aetiological factor in 14%, contrary to alcohol being the factor in 22% and gallstones in 43% of the patients in Larvin et al’s study (9).

The mean APACHE II score on admission for uncomplicated, complicated and fatal outcomes were 6.62, 11 and 18.6 respectively. The scores were comparable with those from Wilson et al’s study, where the scores were 6.29, 9.35 and 14.2 for the respective groups (10). The wide difference in the mean APACHE II scores in the patients who had a fatal outcome could be explained by the fact that all the 4 patients who died had an APACHE II score of above 18, which had contributed to the higher mean.

In the present study, pancreatic necrosis was documented only in 4% of the patients, the reason being that necrosis could only be diagnosed by contract enhanced CT scan and confirmed by laparotomy/necropsy (11). Due to financial constraints, CT scan was done only in 6 patients in this study. Therefore, the incidence of pancreatic necrosis was probably underestimated.

By comparing the outcomes in patient groups which were based on a range of APACHE II scores, it was observed that complications like pseudo cysts, necrosis, major organ failure and death were more common when the APACHE II scores exceeded 10. In contrast to the expectations, pseudo cysts were observed in 1 patient who’s APACHE II scores on admission were less than 5. These patients presented to the hospital later than 48 hours after the onset of the symptoms, by which time the severity of the attack had subsided and the recorded scores were spuriously low (12).

It can therefore be concluded that patients with an admission APACHE II score of more than 10 are high risk patients. These patients benefit from treatment in an ICU and it is worthwhile repeating the scores everyday to monitor the clinical state in these patients, in order to detect complications and to institute therapeutic modifications and also to monitor the efficacy of the treatment which is being instituted (13).

The sensitivity, specificity, positive predictive value and negative predictive value were comparable with those of other studies(Table/Fig 5) in the prediction of the severity [4, 7]. On admission, the APACHE II scores were very sensitive for the prediction of major organ failure (92%), but they were less sensitive for the prediction of the pancreatic collection (54%). In contrast to the expectations, the APACHE II scores failed to predict the period of the hospital stay (14). As the policies with respect to discharge in the individual surgical units differed, the period of hospital stay did not reflect the severity of the disease.

Of the 14 parameters which constituted the APACHE II score, serum sodium, serum creatine, pO2, pH, heart rate and GCS were more often deranged in patients who had a complicated outcome. The Glasgow coma scale had the maximum significance (p value <0.001). (15)(16)

In patients in whom the APACHE II scores were repeated on subsequent days, it was observed that an increasing score predicted a complicated or a fatal outcome and that a decreasing score predicted an uncomplicated outcome. Therefore, the daily recording of the APACHE II score may be particularly useful to monitor the progress of the patients and also in taking a decision about the timing of the surgery for pancreatic necrosis (17).

The APACHE II system is superior to other systems like Ranson’s, because it is the only system which takes into account all the major risk factors that influence the outcome from the disease, including the acute physiological derangements, as well as the patient ability to recover, which may be diminished by advancing age or chronic disease (18). Another advantage is that it can be calculated immediately after admission and can be repeated everyday, unlike other scoring systems for acute pancreatitis. The range of the APACHE II score is wide, providing a better spread between the mild and severe attacks, because varying weights are assigned to increasingly abnormal values, rather than all or no judgements (19).

In the present study, the mortality rose steeply to 44% when the APACHE II score range was raised to greater than 16, when compared to the scores between 11 and 15. Moreover, patients with very high scores in the range of 20 to 35 died within 6 hours of admission to the hospital (20).

Conclusion

APACHE II scores which are calculated on admission accurately predict the outcome of the patients with acute pancreatitis. A score of >10 on admission significantly (p value < 0.0001) predicts a complicated outcome with a sensitivity of 72% and a specificity of 76%.

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