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Peter Layer

Bio: Peter Layer is an academic researcher. The author has contributed to research in topics: Procalcitonin & Pancreatitis. The author has an hindex of 2, co-authored 2 publications receiving 48 citations.

Papers
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Journal Article
01 Jan 2008-Gut
TL;DR: In this article, a clinical scoring system was developed for prediction of in-hospital mortality in acute pancreatitis using Classification and Regression Tree (CART) analysis, which was derived on data collected from 17 992 cases of AP from 212 hospitals in 2000-2001.
Abstract: Background: Identification of patients at risk for mortality early in the course of acute pancreatitis (AP) is an important step in improving outcome. Methods: Using Classification and Regression Tree (CART) analysis, a clinical scoring system was developed for prediction of in-hospital mortality in AP. The scoring system was derived on data collected from 17 992 cases of AP from 212 hospitals in 2000-2001. The new scoring system was validated on data collected from 18 256 AP cases from 177 hospitals in 2004-2005. The accuracy of the scoring system for prediction of mortality was measured by the area under the receiver operating characteristic curve (AUC). The performance of the new scoring system was further validated by comparing its predictive accuracy with that of Acute Physiology and Chronic Health Examination (APACHE) II. Results: CART analysis identified five variables for prediction of in-hospital mortality. One point is assigned for the presence of each of the following during the first 24 h: blood urea nitrogen (BUN) >25 mg/dl; impaired mental status; systemic inflammatory response syndrome (SIRS); age >60 years; or the presence of a pleural effusion (BISAP). Mortality ranged from >20% in the highest risk group to <1% in the lowest risk group. In the validation cohort, the BISAP AUC was 0.82 (95% Cl 0.79 to 0.84) versus APACHE II AUC of 0.83 (95% Cl 0.80 to 0.85). Conclusions: A new mortality-based prognostic scoring system for use in AP has been derived and validated. The BISAP is a simple and accurate method for the early identification of patients at increased risk for in-hospital mortality.

139 citations

Journal ArticleDOI
01 Dec 2008-Gut
TL;DR: It is pivotal to anticipate severe disease with reasonable accuracy, and development and validation of prognostic tools that may allow early and reliably discrimination between mild and severe disease are devoted for decades.
Abstract: Severe pancreatitis is typically associated with (multi-) organ failure originating from local and systemic complications, and requires intensive, often specialised, interdisciplinary management including complex interventions. Severity originates from a “double hit” mechanism, involving an initial phase dominated by the systemic inflammatory response syndrome (SIRS); and, often after transient improvement, subsequent deterioration due to secondary septic complications driven by infected necrosis or pseudocysts. Hence, a prolonged course with consumption of considerable resources is common, and mortality is still substantial. As prevention or early and effective treatment of complications and organ failure count among the most important management aims, it is therefore pivotal to anticipate severe disease with reasonable accuracy. On the other hand, most patients with acute pancreatitis have a mild, uneventful and uncomplicated course, characterised by absence of organ failure or deaths; they can be treated on a peripheral ward and discharged home within a few days. In these patients, unnecessary (over-) treatment should be avoided in the interest of the patient and healthcare resources. In consequence, intensive research has been devoted for decades to the development and validation of prognostic tools that may allow early and reliably discrimination between mild and severe disease. Numerous single markers (such as C-reactive protein (CRP), trypsin activation peptide (TAP), procalcitonin (PCT) and others) and complex scores (including the traditional Ranson, Glasgow and Acute Physiology …

8 citations


Cited by
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Journal ArticleDOI
TL;DR: This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa and provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research.
Abstract: Objective To develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation. Background The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric description of occurrences that are merely associated with severity. Methods A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions. Result The new international classification is based on the actual local and systemic determinants of severity, rather than description of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity-mild, moderate, severe, and critical. Conclusions This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

424 citations

Journal Article
01 Jan 2008-Gut
TL;DR: In this article, a clinical scoring system was developed for prediction of in-hospital mortality in acute pancreatitis using Classification and Regression Tree (CART) analysis, which was derived on data collected from 17 992 cases of AP from 212 hospitals in 2000-2001.
Abstract: Background: Identification of patients at risk for mortality early in the course of acute pancreatitis (AP) is an important step in improving outcome. Methods: Using Classification and Regression Tree (CART) analysis, a clinical scoring system was developed for prediction of in-hospital mortality in AP. The scoring system was derived on data collected from 17 992 cases of AP from 212 hospitals in 2000-2001. The new scoring system was validated on data collected from 18 256 AP cases from 177 hospitals in 2004-2005. The accuracy of the scoring system for prediction of mortality was measured by the area under the receiver operating characteristic curve (AUC). The performance of the new scoring system was further validated by comparing its predictive accuracy with that of Acute Physiology and Chronic Health Examination (APACHE) II. Results: CART analysis identified five variables for prediction of in-hospital mortality. One point is assigned for the presence of each of the following during the first 24 h: blood urea nitrogen (BUN) >25 mg/dl; impaired mental status; systemic inflammatory response syndrome (SIRS); age >60 years; or the presence of a pleural effusion (BISAP). Mortality ranged from >20% in the highest risk group to <1% in the lowest risk group. In the validation cohort, the BISAP AUC was 0.82 (95% Cl 0.79 to 0.84) versus APACHE II AUC of 0.83 (95% Cl 0.80 to 0.85). Conclusions: A new mortality-based prognostic scoring system for use in AP has been derived and validated. The BISAP is a simple and accurate method for the early identification of patients at increased risk for in-hospital mortality.

139 citations

Journal ArticleDOI
01 Jul 2011-Pancreas
TL;DR: The hypothesis that systemic administration of local anesthetics might improve pain and accelerate clinical recovery in acute pancreatitis is supported, and procaine treatment was associated with a stronger decrease in pain than placebo.
Abstract: Objectives Intravenous local anesthetics may ameliorate pain and clinical course in patients with major abdominal surgery. Aim To investigate their effects in acute pancreatitis. Methods Forty-six consecutive patients with acute pancreatitis randomly received intravenous procaine (2 g/24 h) or placebo for 72 hours in a double-blind fashion. Pain severity (visual analog scale, 0-100), on-demand pain medication (metamizole and/or buprenorphine), and the clinical course were monitored every 24 hours. Results Data of 44 patients were subjected to intention-to-treat analysis. Although there were no differences between groups before treatment, procaine treatment was associated with a stronger decrease in pain compared with placebo (median visual analog scale decrement, -62 vs -39, P = 0.025). Moreover, there was a greater proportion of patients with adequate (≥ 67%) pain reduction (75% vs 43%, P = 0.018), less use of additional analgesics (P = 0.042), and overall analgesic superiority (P = 0.015). Compared with placebo, the proportion of patients hospitalized after 2 weeks was reduced by 80% after procaine treatment (P = 0.012). Conclusions These findings support the hypothesis that systemic administration of local anesthetics might improve pain and accelerate clinical recovery in acute pancreatitis.

35 citations

Journal ArticleDOI
TL;DR: In this randomized trial involving patients with acute pancreatitis, early aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes.
Abstract: BACKGROUND Early aggressive hydration is widely recommended for the management of acute pancreatitis, but evidence for this practice is limited. METHODS At 18 centers, we randomly assigned patients who presented with acute pancreatitis to receive goal-directed aggressive or moderate resuscitation with lactated Ringer's solution. Aggressive fluid resuscitation consisted of a bolus of 20 ml per kilogram of body weight, followed by 3 ml per kilogram per hour. Moderate fluid resuscitation consisted of a bolus of 10 ml per kilogram in patients with hypovolemia or no bolus in patients with normovolemia, followed by 1.5 ml per kilogram per hour in all patients in this group. Patients were assessed at 12, 24, 48, and 72 hours, and fluid resuscitation was adjusted according to the patient's clinical status. The primary outcome was the development of moderately severe or severe pancreatitis during the hospitalization. The main safety outcome was fluid overload. The planned sample size was 744, with a first planned interim analysis after the enrollment of 248 patients. RESULTS A total of 249 patients were included in the interim analysis. The trial was halted owing to between-group differences in the safety outcomes without a significant difference in the incidence of moderately severe or severe pancreatitis (22.1% in the aggressive-resuscitation group and 17.3% in the moderate-resuscitation group; adjusted relative risk, 1.30; 95% confidence interval [CI], 0.78 to 2.18; P = 0.32). Fluid overload developed in 20.5% of the patients who received aggressive resuscitation and in 6.3% of those who received moderate resuscitation (adjusted relative risk, 2.85; 95% CI, 1.36 to 5.94, P = 0.004). The median duration of hospitalization was 6 days (interquartile range, 4 to 8) in the aggressive-resuscitation group and 5 days (interquartile range, 3 to 7) in the moderate-resuscitation group. CONCLUSIONS In this randomized trial involving patients with acute pancreatitis, early aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes. (Funded by Instituto de Salud Carlos III and others; WATERFALL ClinicalTrials.gov number, NCT04381169.).

29 citations

Journal ArticleDOI
TL;DR: In early assessment of AP severity, PCT has better predictive value than CRP, and similar to the APACHE II score, which is a stronger predictor of the disease severity than BISAP score.
Abstract: Background/Aim. Early assessment of severity and continuous monitoring of patients are the key factors for adequate treatment of acute pancreatitis (AP). The aim of this study was to determine the value of procalcitonin (PCT) and Bedside Index for Severity in Acute Pancreatitis (BISAP) scoring system as prognostic markers in early stages of AP with comparison to other established indicators such as Creactive protein (CRP) and Acute Physiology and Chronic Health Evaluation (APACHE) II score. Methods. This prospective study included 51 patients (29 with severe AP). In the first 24 h of admission in all patients the APACHE II score and BISAP score, CRP and PCT serum concentrations were determined. The values of PCT serum concentrations and BISAP score were compared with values of CRP serum concentrations and APACHE II score, in relation to the severity and outcome of the disease. Results. Values of PCT, CRP, BISAP score and APACHE II score, measured at 24 h of admission, were significantly elevated in patients with severe form of the disease. In predicting severity of AP at 24 h of admission, sensitivity and specificity of the BISAP score were 74% and 59%, respectively, APACHE II score 89% and 69%, respectively, CRP 75% and 86%, respectively, and PCT 86% and 63%, respectively. It was found that PCT is highly significant predictor of the disease outcome (p < 0,001). Conclusion. In early assessment of AP severity, PCT has better predictive value than CRP, and similar to the APACHE II score. APACHE II score is a stronger predictor of the disease severity than BISAP score. PCT is a good predictor of AP outcome.

28 citations