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Introduction: Acute pancreatitis (AP) following drug-induced hypertriglyceridemia is a rare clinical phenomenon. Immune checkpoint inhibitors have revolutionized treatment for a variety of solid organ and hematological malignancies. Pembrolizumab is a programmed cell death receptor-1 (PD-1) inhibitor that has shown promising responses in many advanced cancers. However, a constellation of immune-related adverse events has also been described. There are reports of pembrolizumab-induced hypertriglyceridemia, but AP as a result of this side effect remains an exceedingly rare clinical sequela. Case report: We delineate a case of a patient with stage IVB non-small-cell lung cancer who developed progressive abdominal pain and nausea following administration of pembrolizumab for four months. Laboratory studies revealed increased serum lipase and triglyceride levels at 12,562 IU/L and 16,901 mg/dL, respectively. The diagnosis of AP was made based on the revised Atlanta classification criteria. After ruling out alternative causes, pembrolizumab-induced hypertriglyceridemia was considered the likely etiology of AP. Management and outcome: The patient was transferred to the medical intensive care unit for close monitoring. Treatment was initiated with intravenous fluids, pain medications, and an insulin infusion. However, her hypertriglyceridemia levels remained persistently elevated, necessitating therapeutic apheresis. She recovered well with no complications after triglyceride apheresis. Discussion: AP following pembrolizumab-associated hypertriglyceridemia remains a rare clinicopathologic entity. Given the widespread clinical use of immune checkpoint inhibitors, knowledge of such rare adverse events is crucial. Evaluation of serum triglyceride levels before and after initiating pembrolizumab therapy may be mandated, especially in patients with metabolic comorbidities. [ABSTRACT FROM AUTHOR]

Objective Despite evidence-based guidelines stating that lipase alone should be used in the diagnosis of suspected acute pancreatitis, health care providers continue to order amylase or amylase and lipase together. The purpose of this study was to assess the utilization of appropriate laboratory testing related to the diagnosis of acute pancreatitis. Methods The study used a retrospective cross-sectional design. The timeframe was from January 1, 2020, to December 31, 2020. A retrospective chart review was used to collect data for the following: patient-provider encounter notes, patient demographics, provider demographics, differential and final diagnosis, and laboratory test results. Data analysis include stratification of categorical variables and calculation of cost savings. Results For the 12-month period, this study found 2567 (9.3%) of all amylase and lipase tests to be unnecessary. Amylase tests (1881; 73.2%) made up the most unnecessary tests followed by lipase tests (686; 26.7%). An analysis of test-ordering behavior by providers revealed that 81.5% of all unnecessary tests were ordered by MDs. Finally, this study estimated a total cost savings of $128,350 if all unnecessary tests were eliminated. Conclusion Our study demonstrated that amylase and lipase tests have been overutilized in the diagnosis of acute pancreatitis. [ABSTRACT FROM AUTHOR]

Autoimmune pancreatitis type 2 is a relatively novel entity with some still controversial issues. The current diagnostic algorithm relies on imaging studies and histology. Therapy includes corticosteroids with consequently low risk of relapse in the following year. However, the pathogenesis remains unclear, and data are insufficient for long-term prognosis. We have treated a 17-year-old boy whose autoimmune pancreatitis type 2 was revealed during surgery for a pre-existing biliary tract anomaly with concurrent protozoal infection. We discuss the co-occurrence of these conditions in terms of eventual pathogenesis correlation and combined effect on long-term prognosis. [ABSTRACT FROM AUTHOR]

Acute pancreatitis is a gastrointestinal emergency where diagnosis is based on typical symptoms, increased serum lipase concentration, and abdominal imaging. Local complications and organ failure in severe acute pancreatitis regularly necessitate treatment in the intensive care unit and are associated with increased mortality rates. Only optimal interdisciplinary treatment can improve the prognosis of patients with severe acute pancreatitis. This article gives guidance on the initial diagnostic and etiological examinations as well as on the evaluation of organ failure and the severity assessment according to common classification systems. Furthermore, the endoscopic management of biliary pancreatitis and infected necrosis is discussed and the basics of targeted volume therapy, nutrition, and indications for antibiotic treatment are reviewed. [ABSTRACT FROM AUTHOR]

The article presents the discussion on case study of 15-year-old male with an acute onset of abdominal pain in the epigastric region. Topics include differential diagnosis and a lipase level should be assessed when a patient presents with symptoms of acute pancreatitis; and patient did not report any trauma or co-ingestions including alcohol or tobacco.

Bisphosphonates are widely used to treat several clinical conditions. Zoledronic acid is one of these classes, commonly used for the treatment and prevention of osteoporosis, hypercalcemia of malignancy, Paget's disease, and multiple myeloma. Side effects associated with zoledronic acid include fever, fatigue, arthralgia, myalgia, nausea, and bone pain. Liver damage caused by bisphosphonate is rare. No cases of acute pancreatitis have been described in the literature. We describe a 74-year-old woman who presented with features of acute pancreatitis 3 days following the first dose of intravenous zoledronic acid infusion administered to treat postmenopausal osteoporosis. Supportive treatment was given for 5 days. She was discharged without any problems. [ABSTRACT FROM AUTHOR]

Although SARS-CoV-2 commonly affects the respiratory system, several other major organ systems can be involved, including the gastrointestinal. The main gastrointestinal manifestations are diarrhoea, nausea, and vomiting. Few cases of acute pancreatitis along with COVID-19 infection have been reported. Current evidence stresses that both clinical and radiographic studies can be suggestive of acute pancreatitis in COVID-19 patients, even without any respiratory symptoms. We report a case of a female patient who presented with severe epigastric pain and vomiting and was diagnosed with acute pancreatitis on a COVID-19 infection. The patient had an otherwise unremarkable medical history. Upper respiratory symptoms were developed on day 2 of her hospital stay. Acute pancreatitis was attributed to the COVID-19 infection, following the exclusion of other common causes of pancreatitis. Our case points out that acute pancreatitis can be developed in asymptomatic COVID-19-infected patients as well as those with a mild form of COVID-19 infection. [ABSTRACT FROM AUTHOR]

Objective: Gallstone disease is among the most common known causes of acute pancreatitis. In our study, we examined the role of the length-diameter of the choledochus, the Wirsung diameter and the angle of the choledochal-Wirsung junction, which may cause obstruction in the etiology of acute pancreatitis. We aimed to recommend prophylactic cholecystectomy for asymptomatic patients whose anatomical features may affect acute attacks and to prevent attacks. Materials and Methods: Patients who were diagnosed with uncomplicated cholelithiasis and patients who were diagnosed with acute biliary pancreatitis and admitted to our clinic between January 2019 and August 2022 were retrospectively examined. Conservative follow-up of patients with uncomplicated cholelithiasis continued. Patients with acute biliary pancreatitis were treated with treatments recommended by current guidelines. In the MRCP imaging performed in our hospital, the length-diameter, Wirsung diameter and junction angle with the common bile duct were measured and compared by a single radiologist. Results: A total of 149 patients were included in the study. Among the groups, the age of the control group was found to be significantly lower (p<0.001). There was no significant difference between the groups in terms of common bile duct diameter or Wirsung diameter. Although the common bile duct length parameter was found to be high in patients with acute pancreatitis (p=0.013), the common bile duct-Wirsung junction angle was significantly lower (p=0.036). Conclusion: In our study, a high Choledoc length increased the risk of acute biliary pancreatitis, and a low angle between the Choledoc and Wirsung increased the risk of acute biliary pancreatitis. [ABSTRACT FROM AUTHOR]

Background: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most prevalent complication of ERCP. Oxidative stress has been mentioned as a cause of PEP. Objectives: As preclinical and clinical studies have shown that CoQ10 has anti-inflammatory and antioxidant effects, the present study was designed to examine whether oral CoQ10 addition to rectal indomethacin decreases the rate/severity of PEP. Methods: A prospective double-blind clinical study was done on 347 patients undergoing ERCP. All participants received 100 mg rectal indomethacin just before ERCP. Also, patients were asked to consume CoQ10 (200 mg) or an identical placebo for 1 h before the procedure. The occurrence and severity of PEP were determined in the participants. The levels of amylase, lipase, and malondialdehyde (MDA) were also measured 12 h after ERCP. Results: The total rate of PEP was equal to 12.1% in intention-to-treat (ITT) and 13% in per-protocol (PP) analyses. A meaningful difference was observed in the rate and severity of PEP between the CoQ10 and placebo arms (9.8% vs 14.4% in ITT and 10.2% vs 15.1% in PP, sequentially). Secondary levels of amylase, lipase, and MDA were lower in the CoQ10 arm than in the placebo arm (P = 0.032, 0.022, and 0.036, sequentially). Conclusions: A combination of oral CoQ (200 mg) plus rectal indomethacin (100 mg) could decrease the PEP rate and severity meaningfully compared to the use of indomethacin alone. [ABSTRACT FROM AUTHOR]

Acute pancreatitis (AP) can develop into life-threatening conditions such as systemic inflammatory response syndrome (SIRS) or multiple organ dysfunction syndrome. Thirtynine of 54 client-owned dogs admitted to the Referral Animal Medical Center and diagnosed with AP within 24 hr of onset were retrospectively reviewed to assess early predictors of progression from AP to SIRS. The patients were divided into SIRS (SIRS occurring after AP) and non-SIRS (AP occurring but no SIRS) groups. The population and mean values of laboratory variables within 24 hr of admission were assessed and compared between both groups. There were significantly more dogs with abnormal lactate levels in the SIRS group (80.00%) than non-SIRS group (11.10%). Other parameters did not differ significantly. Mean lactate level values were significantly higher at 3.64 ± 1.75 mmol in the SIRS group compared to 1.68 ± 0.52 mmol in the non-SIRS group. The increased energy required by activated immune cells may lead to metabolic changes characterized by anaerobic glycolysis and increased lactate production. This study's results suggest blood lactate monitoring in the early stages of progression from AP to SIRS in small animal clinical practice. Measuring lactate levels at the early stages of pancreatitis could lead to rapid therapeutic intervention for SIRS and ultimately reduce mortality. [ABSTRACT FROM AUTHOR]

Aim: The idiographic case study aimed to explore the trust of a person with chronic pancreatitis in healthcare professionals. Design: An interpretive phenomenological idiographic case study. Methods: Data collection was carried out through a semistructured in-depth interview with a 29-year-old man with chronic pancreatitis. The purposive sampling of the participant was carried out according to feasibility criteria. Interpretative phenomenological analysis was used with the assistance of Atlas.ti 9 for data analysis. Results: Five interconnected personal experiential themes reflecting the trust of the participant in healthcare professionals were identified: Trust in healthcare professionals as an inner feeling; Active and partnership approach of healthcare professionals; Paternalistic approach and lack of interest of healthcare professionals in the patient; Expertise of healthcare professionals; and Linking trust in health professionals with the hospital ward environment, with 22 experiential statements. Conclusion: The participant considered trust to be an internal feeling of expectation that healthcare professionals would help him actively solve his health problems. The findings promote the implementation of patient-centered care and the partnership approach in the care of patients with chronic pancreatitis. The personal experience themes identified provide information for further qualitative research aimed at a deeper understanding of the lived experience of trust for patients with chronic pancreatitis. [ABSTRACT FROM AUTHOR]

Paediatric chronic pancreatitis (CP) is a rare and debilitating pathology that often requires invasive diagnostics and therapeutic interventions either to address a primary cause such as a pancreaticobiliary malunion or to deal with secondary complications such as chronic pain. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are two endoscopic modalities that have an established diagnostic role in paediatric CP, and their therapeutic utilisation is increasing in popularity. Surgical decompression of the obstructed and dilated pancreatic duct plays a role in alleviating pancreatic duct hypertension, a common association in CP. Surgery equally has a role in certain anatomical abnormalities of the pancreaticobiliary draining system, or occasionally in some CP complications such as drainage of a symptomatic pancreatic pseudocyst. [ABSTRACT FROM AUTHOR]

Diabetic Ketoacidosis (DKA) presents as an acute emergency in children with type 1 diabetes mellitus. The mortality associated with DKA is more in developing countries and in children less than 5 years of age. Cerebral edema, sepsis, shock and renal failure are the identified causes for mortality. Severe hyperlipidemia and pancreatitis are less recognised causes for mortality in children with DKA. We report a 6-year-old female child who presented with lipemic serum due to severe hyperlipidemia associated with DKA. With adequate management of DKA as per the guidelines, hyperlipidemia also resolved and no further episodes were noted on follow up. Knowledge about this rare entity could help the clinicians regarding the prompt recognition, evaluation and management of hyperlipidemia and thus help in reduction of mortality associated with the same. [ABSTRACT FROM AUTHOR]

The incidence of hypertriglyceridaemic pancreatitis is increasing. Hypertriglyceridaemia may be associated with false lowering of serum amylase and lipase in vitro. A retrospective study of serum lipase levels in 26 individuals who had acute pancreatitis diagnosed based on clinical criteria together with changes on computer tomography in the setting of severe hypertriglyceridaemia over a 5‐year period from January 2017 to December 2021 was performed. Serum lipase levels were in the normal range in two patients (7.7%) and less than three times the upper end of the reference interval in 11 individuals (42%). Awareness of the potential for normal and nonsignificantly elevated serum lipase levels in the setting of hypertriglyceridaemic pancreatitis is important to avoid a missed diagnosis, to enable appropriate short‐ and long‐term management and to prevent recurrent episodes. [ABSTRACT FROM AUTHOR]

Introduction. The underlying pathophysiology of diabetes mellitus after acute pancreatitis is unknown and overall risk of developing diabetes postacute pancreatitis in children is understudied. The objective of our study was to describe the frequency of islet cell autoimmunity and abnormal glucose testing in pediatric patients in the year following their index case of acute pancreatitis. Materials and Methods. Data were obtained from a single-center observational cohort study of patients with their first episode of acute pancreatitis. Islet cell autoantibody titers were measured on stored plasma collected from acute pancreatitis diagnosis, at 3 months and at 12 months postacute pancreatitis attack. Abnormal glucose testing was defined as the presence of prediabetes or diabetes, as defined by American Diabetes Association criteria. Results. Eighty-four patients with acute pancreatitis and islet cell autoantibody data were included, 71 had available glucose measures. Median age at first acute pancreatitis attack was 14 years (IQR 8.7–16.3) and 45/84 (54%) were females. Twenty-four patients (29%) were positive for at least one of four islet cell autoantibodies (IAA, GADA, IA-2A, and ZnT8A) and 6 (7%) had two or more positive islet cell autoantibodies. Nineteen patients out of 71 (27%) had abnormal glucose testing at or postacute pancreatitis diagnosis. A higher proportion (37%, 7/19) with abnormal glucose testing had severe acute pancreatitis compared to those with normal glucose testing (13%, 7/52) (p = 0.04). Patients with normal glucose testing were more likely to be positive for one or more islet cell autoantibodies (31%, 16/52) compared to those with abnormal glucose testing (0%, 0/19) (p = 0.004). Conclusions. Islet cell autoimmunity is more common in children after their index acute pancreatitis attack (29%) than in the general population (7%–8%). While the frequency of prediabetes and diabetes postacute pancreatitis is high, other mechanisms besides islet cell autoimmunity are responsible. [ABSTRACT FROM AUTHOR]

Acute pancreatitis (AP) is a life-threatening condition for which a wide range of etiological factors are considered. While gallstones and alcohol consumption are the leading causative agents, infectious microorganisms are assumed to be involved in some AP cases. During the ongoing coronavirus disease-2019 (COVID-19) pandemic, a coincidence of mild AP and COVID-19 has been reported, and hereby, we present the first cases of COVID-19/AP comorbidity from Iran. We present two cases of AP that occurred in patients with COVID-19 without any other risk factors with different outcomes. One of them had a mild AP and recovered, while the other patient suffered from a severe AP and expired. Also, it was noted that the first patient did not have any COVID-19 symptoms but abdominal pain, which probably was related to AP. Conclusion: Based on this report, COVID-19 can be considered in the AP cases that do not have an underlying risk factor, regardless of the severity of AP and the presence of COVID-19 symptoms. [ABSTRACT FROM AUTHOR]

Copyright of Turkish Journal of Trauma & Emergency Surgery / Ulusal Travma ve Acil Cerrahi Dergisi is the property of KARE Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background. Autoimmune pancreatitis (AIP) usually responds dramatically to steroid therapy. Occasionally, however, misdiagnosed patients have undergone pancreaticoduodenectomy. This study is aimed at providing useful information to improve the accuracy of diagnosis before surgery and thus avoid unnecessary resections in patients with AIP. Methods. From January 2015 to February 2020, a series of patients were enrolled, having undergone pancreaticoduodenectomy for presumed malignancy. AIP diagnoses were confirmed by postoperative pathology. The demographic and clinical data of the AIP patients were evaluated. The main diagnostic criteria (HISORt, Asian, and ICDC) for AIP were applied to assess whether and how unnecessary surgery could have been avoided. Results. A total of 124 cases of pancreaticoduodenectomy were performed for presumed malignancy. Six patients were diagnosed with benign disease and five with AIP. The prevalences of benign disease and AIP were 4.8% and 4%, respectively. Four patients were female and 1 male, with a mean age of 60.0 years old. Jaundice, pain, and weight loss were observed in 100%, 20%, and 40% of AIP patients, respectively. The radiologic features of the AIP patients were a diffusely enlarged gland (40.0%), a focally enlarged gland (40.0%), pancreatic ductal dilatation (60.0%), upstream parenchymal atrophy (20.0%), bile duct thickening (66.0%), and bile duct stricture (40.0%). Based on the diagnostic criteria for AIP, surgery could have been avoided in two cases. Conclusions. IgG4 measurement and integrated use of major diagnostic criteria should be emphasized in every patient eligible for pancreaticoduodenectomies. [ABSTRACT FROM AUTHOR]

(1) Introduction: Acute pancreatitis (AP) remains a global burden of cost for healthcare services. We found a high degree of heterogeneity in cost-related reports and a scarcity of data regarding the cost of AP episodes in European and Asian populations. We aimed to estimate the median daily cost of hospitalisation (DCH) of AP in our population. Our secondary aims included estimating the total cost of hospitalisation (TCH) and the total cost of AP in Romania, as well as assessing the correlation between median DCH and ward, age, sex, length of stay (LoS), intensive care unit (ICU), outcome, severity, morphology, and aetiology of AP. (2) Material and methods: This retrospective cohort study included 1473 cases recruited from the electronic health records of the University Emergency Hospital of Bucharest. Statistical tests used included Kolmogorov–Smirnov, Kruskal–Wallis with post-hoc Dunn–Bonferroni, and Pearson correlation two-tailed. (3) Results: We found a median DCH of AP of USD 203.8 and a median TCH of USD 1360.5. The total yearly cost of AP in Romania was estimated at around USD 19 million. The majority of males with AP (61.8%) were mostly discharged as healed/ameliorated (83.8%); a majority had local complications (55.4%), which were mostly alcohol-related (35.1%). Regarding the aetiology, biliary-related AP was a cost driver, with significant statistical differences observed in all studied groups (p < 0.01). Morphology assessment revealed that acute necrotic collections were associated with high cost and meaningful disparities among the groups (p < 0.01). Cost was also associated with severity, with significant deviations among all groups (p < 0.01). Outcome-at-discharge as deceased correlated with higher costs, with substantial differences within groups (p < 0.01). The need for an intensive care unit was also a large driver of cost (p < 0.01). Females were prone to more expensive costs (p < 0.01). Surgical cases necessitated more financial resources (p < 0.01). (4) Conclusions: To the best of our knowledge, this is the first study on the cost of AP in Romania. Our findings showed that the drivers of increased AP costs might be older age, ICU, intra-hospital mortality, severe AP, local complications such as acute necrotic collections, biliary aetiology, and female sex. We found large heterogeneity and scarcity regarding cost-related data in the literature. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impact of high-dose versus conventional-dose continuous hemodiafiltration on treatment efficacy and inflammatory markers in athletes with severe pancreatitis. Methods: A total of 112 athletes with severe pancreatitis, admitted to our hospital from May 2019 to August 2021, were randomly divided into two groups. The control group received conventional-dose continuous hemodiafiltration, while the study group was treated with high-dose continuous hemodiafiltration. Results: The clinical efficacy in the high-dose group was significantly better than the control group (P<0.05). After treatment, the high-dose group showed significant improvements in clinical indicators, with lower levels of CRP, TNF-α, PCT, AMY, and Scr compared to the control group (P<0.05). Serum phosphorus, albumin, and cholesterol levels improved more in the high-dose group post-treatment (P<0.05). Vital signs such as body temperature, heart rate, and respiratory rate also showed greater improvement in the high-dose group, with significant differences noted compared to the control group (P<0.05). Both groups experienced a significant decrease in APACHE II scores post-treatment. Conclusion: High-dose continuous hemodiafiltration is more effective in treating severe pancreatitis in athletes, enhancing clinical indicators and reducing inflammatory markers. This treatment approach also positively impacts vital blood parameters, contributing to a quicker recovery and restoration of physical functions in athletes with severe pancreatitis [ABSTRACT FROM AUTHOR]

This review discusses chronic pancreatitis in pediatric patients starting with its definition and epidemiology. The focus is on the pathophysiology, etiology, clinical manifestations, diagnosis, differential diagnoses, laboratory studies, imaging studies, complications, and management. Pancreatitis is an important condition in the field of pediatric gastroenterology and general clinicians should have basic knowledge of this condition to help infants, children, and adolescents who develop this complex disorder. [ABSTRACT FROM AUTHOR]

This treatise discusses acute pancreatitis in pediatric patients starting with its definition and epidemiology with focus on pathophysiology, etiology, clinical manifestations, diagnosis, differential diagnoses, laboratory/imaging studies, complications, and management. Acute pancreatitis is an important condition in the field of pediatric gastroenterology and general clinicians should have basic knowledge of this condition to help infants, children, and adolescents who develop this complex disorder. [ABSTRACT FROM AUTHOR]

Acute pancreatitis, a potentially fatal disease, with symptoms including nausea and/or vomiting, indigestion, and abdominal pain, is known to range from a mild self-limiting state up to a more severe and lethal form. This review aims to provide a clearer picture to improve understanding the role of viral agents in the development of acute pancreatitis. Common databases including PubMed, Google Scholar, and Scopus were used for the literature search. In this review search terms including virus, viral, infection, and specific descriptive terms for a virus were considered in different combinations. Various causative agents are recognized in the development of acute pancreatitis as one of the most frequent gastrointestinal diseases, such as gallstones, alcoholism, and hypertriglyceridemia. Microbial pathogens with about 10% of acute pancreatitis cases, mainly viruses, among other factors, are thought to play a role in this regard. Once the pancreatitis diagnosis has been made, depending on the causative agent, the management approach and specific interventions affect the final outcome. Virus-induced acute pancreatitis in patients should be considered. Advanced diagnostic tests such as PCR, in situ hybridization, and biopsy can help for a better understanding of the role of viruses in causing acute pancreatitis. Improvement in the tests will lead to timely diagnosis, treatment, and better management of pancreatitis. [ABSTRACT FROM AUTHOR]

Copyright of Namık Kemal Tıp Dergisi is the property of Galenos Yayinevi Tic. LTD. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

A case study of 19-year-old woman is presented with a history of trisomy 21, obesity, and atopic dermatitis presented to the emergency department with epigastric pain and vomiting. Topics include examines prior to presentation, her family reported that the patient had several episodes of nonbloody, nonbilious emesis and had been unable to tolerate any oral intake without emesis.

An answer is presented to the question concerning concurrent acute kidney injury and pancreatitis in a female patient and focuses on differential diagnosis for acute kidney injury during acute pancreatitis.

Current researches define the best management tactics in patients with acute pancreatitis. It includes early diagnosis, determination of etiological factors, adequate visualization, assessment of the severity of the disease. The purpose of the work is to consider recommendations for acute pancreatitis after the IAP/EPC recommendations 2012. The article presents a systematic overview of current guidelines for acute pancreatitis, cited the Medline database from 2013 till 2021. The main criteria for timely diagnosis are highlighted. The approach to determine the etiological reason of the disease is considered. The importance of establishing the severity of clinical course of acute pancreatitis is indicated, for which clinical, laboratory and radiological methods of examination, various integrated scales are used. The indications and terms of imagine procedures (ultrasonography, computed tomography, magnetic resonance imaging) use are determined. Acute pancreatitis is most oftenly associated with biliary or ethyltoxic factors. The diagnosis can usually be made if you know what laboratory parameters and imaging methods should be used in the initial diagnosis and in the course of the disease. Prediction and assessment (reassessment) of the disease is very important to determine the necessary rapid treatment. [ABSTRACT FROM AUTHOR]

Objective: Pancreatitis is the most frequently observed complication after endoscopic retrograde chola ngiop ancre atogr aphy. Several preventive methods for post-endoscopic retrograde chola ngiop ancre atogr aphy pancreatitis have been developed. A pilot study was conducted to determine whether aggressive periprocedural hydration with lactated Ringer's solution reduces the incidence of post-endoscopic retrograde chola ngiop ancre atogr aphy pancreatitis. Methods: The study included 32 patients who required endoscopic retrograde chola ngiop ancre atogr aphy for diagnostic or therapeutic purposes. Patients were randomized (1: 1) to receive either aggressive hydration with lactated Ringer's solution (n = 16) or standard hydration with the same solution (n = 16). Oral intake was stopped after midnight and endoscopic retrograde chola ngiop ancre atogr aphy began at 10:00 am. Hourly fluid requirements of patients in the aggressive hydration group were calculated based on the 4-2-1 formula (4 mL/kg/h for the first 10 kg, 2 mL/kg/h for the next 10 kg, and 1 mL/kg/h thereafter) and fluid requirements of 10 hours were met in 2 hours from 08:00 to 10:00 am before endoscopic retrograde chola ngiop ancre atogr aphy. At the 4th and 24th hours following endoscopic retrograde chola ngiop ancre atogr aphy, serum amylase and lipase levels, volume overload, and other complications were assessed. Acute pancreatitis was defined and ranked in accordance with the 2012 Atlanta Classification criteria. Results: Of all patients, 34% (11/32) developed pancreatitis after endoscopic retrograde chola ngiop ancre atogr aphy, compared with 12.5% (2/16) in the aggressive hydration group and 56.3% (9/16) in the standard hydration group. Pancreatitis was significantly less prevalent in the aggressive hydration group (P = .009). All observed cases of pancreatitis were mild. Conclusion: According to this pilot study, aggressive hydration with lactated Ringer's solution reduces the risk of post-endoscopic retrograde chola ngiop ancre atogr aphy pancreatitis. [ABSTRACT FROM AUTHOR]

Objective: The precut sphincterotomy technique is widely used for difficult biliary cannulation during the endoscopic retrograde chola ngiop ancre atogr aphy procedure. Even though an accepted risk factor for post-endoscopic retrograde cholangiopancreatography is a risk factor for pancreatitis, there are numerous studies showing whether this risk is technique-related or due to prolonged procedure time and recurrent cannulation attempts. The study's primary aim was to evaluate the incidence of post-endoscopic retrograde chola ngiop ancre atogr aphy pancreatitis in early precut procedures compared to the standard technique in patients with difficult biliary cannulation. The secondary aim was to compare complications and cannulation success. Methods: In this prospective, single-center, randomized clinical trial, patients referred for therapeutic biliary endoscopic retrograde chola ngiop ancre atogr aphy and difficult biliary cannulation were divided into 2 groups. The first group was the early precut group (group A) and the second group was the late precut group (group B). Post-endoscopic retrograde chola ngiop ancre atogr aphy pancreatitis was defined as upper abdominal pain associated with at least a 3-fold rise in serum pancreatic enzymes above the normal level more than 24 hours after the procedure. Results: Three hundred patients were enrolled in the study. Nine of 150 patients (6%) in group A and 21 of 150 patients (14%) in group B developed postendoscopic retrograde chola ngiop ancre atogr aphy pancreatitis (odds ratio 2.33). Successful biliary cannulation without precutting was performed in 25 patients in group B, whereas delayed precutting was required in the remaining 125 patients. Compared to the delayed precut group (19/125, 15.2%), the incidence of postendoscopic retrograde chola ngiop ancre atogr aphy pancreatitis was significantly lower in the early precut group (9/150, 6%) (odds ratio 3.3). The "late precut" subgroup had a post-endoscopic retrograde chola ngiop ancre atogr aphy pancreatitis rate with an odds ratio of 2.5 compared to the group with cannulation without precut. These data suggest that the post-endoscopic retrograde chola ngiop ancre atogr aphy pancreatitis risk among patients who received a late precut was higher than among patients who had an early precut or could be cannulated after repetitive efforts. Conclusion: Early precutting is an effective technique for patients with challenging biliary tract cannulation and can significantly reduce post-endoscopic retrograde chola ngiop ancre atogr aphy pancreatitis incidence. Recurrent biliary cannulation attempts constitute a real risk factor for this complication. [ABSTRACT FROM AUTHOR]

Aim: In this study, we aimed to evaluate the etiological, clinical, and laboratory characteristics of children with pancreatitis and the changes in these data over the years. Materials and Methods: Children hospitalized with a diagnosis of pancreatitis between January, 2011 and January, 2021 were evaluated retrospectively. The etiology, demographic characteristics, laboratory findings, and changes over the years were analyzed. Results: A total of 111 cases were enrolled, 72 (64.9%) in the acute pancreatitis (AP) group and 39 (35.1%) in the acute recurrent pancreatitis and chronic pancreatitis (ARP/CP) group. The most common causes of AP were idiopathic (27.8%), cholelithiasis (26.4%), and infections (8.4%). In ARP/CP assessments, idiopathic (35.9%), trauma (15.4%), and drugs (10.3%) were the most frequent etiologies. During the first five-year period, only 14 patients were diagnosed with pancreatitis, but in the second five years, 97 patients were diagnosed with pancreatitis. In both periods, the most frequent diagnosis was idiopathic pancreatitis (42.9% and 28.9%, respectively). While trauma (14.3%) and infections (14.3%) were the most common etiologies in the first five years, cholelithiasis (20.6%) and drugs (9.3%) were the most common in the second five years. Conclusion: There was a significant increase between the first and the second five-year periods in pancreatitis-related hospitalizations. The most common cause of pancreatitis in all groups was still unknown. The cholelithiasis ratio increased from 7.1% to 20.6% in the second fiveyear period. Additionally, drugs played a bigger role in pancreatitis at a high rate of 9.3% over the years. Additionally, it was seen that the administration of octreotide treatment decreased over the years. [ABSTRACT FROM AUTHOR]

Acute pancreatitis is rare in pregnancy; however, the associated morbidity and mortality make prompt diagnosis and appropriate management essential.1,2 Although most cases are mild and improve with limited interventions, severe cases require a multidisciplinary approach in a critical care setting. The main principles of management include identification of an etiology to guide therapy, fluid resuscitation, electrolyte repletion, early nutritional support, and pain management. Antibiotics are not indicated for prophylaxis and should be reserved for cases with a suspected infectious process. Surgical management is indicated in select cases. Management in pregnant patients has few differences which are outlined below. [ABSTRACT FROM AUTHOR]

Context.--The pancreatobiliary tract exhibits a spectrum of heterogeneous fibroinflammatory conditions that may be the result of a primary immune-mediated mechanism, or a reaction to neoplasm. This often results in significant overlap regarding clinical presentation, symptoms, radiographic findings, serology, and histopathology between inflammatory and neoplastic lesions of the pancreas, which can lead to inadvertent surgical intervention. Among the multitude of primary fibroinflammatory pancreatic diseases, autoimmune pancreatitis, including type 1 and type 2 autoimmune pancreatitis, and immunoglobulin G4--related sclerosing cholangitis (IgG4-RSC) are particularly challenging and require a multidisciplinary perspective to reliably make a diagnosis. This is of particular significance because these diseases typically have a favorable prognosis and readily respond to steroid therapy. Objective.--To present a multimodal approach to highlight distinctive and overlapping qualities that will aid in the diagnosis of these entities. Data Sources.--The review and analysis of literature describing autoimmune pancreatitis types 1 and 2 and IgG4-RSC. Conclusions.--Diagnosis of autoimmune pancreatitis types 1 and 2 and IgG4-RSC requires a multimodal approach that relies on clinical, radiographic, serologic, histopathologic, and immunohistochemical correlation. [ABSTRACT FROM AUTHOR]

Context.--A variety of inflammatory processes affect the pancreatobiliary tree. Some form mass lesions in the pancreas, mimicking pancreatic ductal adenocarcinoma, and others cause strictures in the bile ducts, mimicking cholangiocarcinoma. Acute pancreatitis, chronic pancrea- titis, autoimmune pancreatitis, and paraduodenal groove pancreatitis have distinct cytopathologic features that, when correlated with clinical and imaging features, may lead to correct classification preoperatively. In biliary strictures sampled by endobiliary brushing, the uniform features are the variable presence of inflammation and reactive ductal atypia. A potential pitfall in the interpre- tation of pancreatobiliary fine-needle aspiration and duct brushing specimens is ductal atypia induced by the reactive process. Recognizing cytologic criteria that differentiate reactive from malignant epithelium, using ancillary testing, and correlating these features with clinical and imaging findings can lead to the correct preoperative diagnosis. Objective.--To summarize the cytomorphologic features of inflammatory processes in the pancreas, describe the cytomorphology of atypia in pancreatobiliary specimens, and review ancillary studies applicable for the differential diagnosis of benign from malignant ductal processes for the purpose of best pathology practice. Data Sources.--A PubMed review was performed. Conclusions.--Accurate preoperative diagnosis of benign and malignant processes in the pancreatobiliary tract can be achieved with application of diagnostic cytomorphologic criteria and correlation of ancillary studies with clinical and imaging findings. [ABSTRACT FROM AUTHOR]

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The article describes the case of weight loss, abdominal pain and vomiting in a 17-year-old female patient. Topics discussed include the patient's medical history, results of the patient's physical examination and computed tomography scan, and the differential diagnosis of abdominal pain, weight loss and vomiting.

Purpose: The study aimed to determine the performance of advanced magnetic resonance imaging (MRI), including a multiparametric MRI-index, for diagnosing and severity grading of chronic pancreatitis (CP) at various functional stages with focus on detection of CP with preserved pancreatic function. Methods: Fifty-four CP patients and 35 healthy controls underwent MRI including assessment of pancreatic volume, main pancreatic duct (MPD) diameter, T1 relaxation time, magnetic resonance elastography (MRE) derived stiffness, and intravoxel incoherent motion (IVIM) diffusion-weighted imaging. Patients were categorized into three subgroups: Preserved pancreatic function (n = 14), partial pancreatic insufficiency (exocrine insufficiency or diabetes, n = 25), and complete pancreatic insufficiency (exocrine insufficiency and diabetes, n = 15). A multiparametric MRI-index was based on ordinal logistic regression analysis. Diagnostic performances of MRI parameters for diagnosing CP at different functional stages were determined using receiver operating characteristic (ROC) analysis. Results: All MRI parameters differed across CP subgroups and healthy controls (all P < 0.001), except for IVIM. T1 relaxation time (ROC area under the curve (ROC-AUC) 0.82), MRE (ROC-AUC 0.88), and MRI-index (ROC-AUC 0.86) showed the highest performance for detecting patients with preserved pancreatic function (early CP) vs. healthy controls. For detecting preserved pancreatic function vs. partial insufficiency, pancreatic volume, MRI-index, and T1 relaxation time performed best (all ROC-AUC > 0.75), with the MRI-index tending to outperform MRE (ROC-AUC 0.77 vs. 0.63; P = 0.10). Conclusion: Quantitative assessments of T1 relaxation time and MRE-derived stiffness seem promising for diagnosing CP at different functional stages and may together with multiparametric MRI-index be used for early identification, staging and monitoring of CP. [ABSTRACT FROM AUTHOR]

Introduction: To report on a clinical case of a pancreatic pseudocyst that evolved to rupture and to understand the main therapeutic approaches adopted for pancreatic pseudocysts, thus fostering a better approach to such cases. Case report: Female patient, 30 years old, with pseudocystoadenoma and acute abdomen due to cystic rupture. Discussion: The therapeutic forms for pancreatic pseudocysts are expectant management, drainage (endoscopic and percutaneous) and surgical treatment. Results: The best approach addresses the treatment of the patient's clinical condition and pancreatic pseudocyst. For this to happen, a clinical evaluation, by means of complementary examinations, is required. [ABSTRACT FROM AUTHOR]

Introduction: Drug-induced pancreatitis has been increasingly recognized, but it is frequently encountered as an inconspicuous etiology. The underlying mechanisms of injury vary with different drugs. Tamoxifen is a frequently used anticancer drug that acts by selective modulation of the estrogen receptor in patients with breast cancer. Tamoxifen-induced hypertriglyceridemia is a relatively rare etiological factor for acute pancreatitis. However, acute pancreatitis secondary to this adverse effect remains an exceedingly important clinicopathologic entity. Case report: We hereby delineate a rare case of acute pancreatitis secondary to hypertriglyceridemia in a patient who was on tamoxifen treatment for the past 3 years. Her serum lipase and triglyceride levels were markedly elevated at 14,285 IU/L and 20,344 mg/dL, respectively. The diagnosis was considered based on the findings of a standard diagnostic workup and exclusion of alternative causes of acute pancreatitis. Management and outcome: The patient was instituted prompt treatment with intravenous insulin infusion and gemfibrozil. The clinical outcome was favorable with no complications. Tamoxifen was permanently discontinued and was replaced with letrozole. Discussion: This article illustrates that acute pancreatitis should be considered in the differential diagnoses of abdominal pain and elevated pancreatic enzymes in patients undergoing tamoxifen treatment. It also underscores the importance of pre- and post-tamoxifen lipid screening, especially in patients with a history of dyslipidemia and diabetes mellitus. It will facilitate an expedient detection of hypertriglyceridemia, potentially saving patients from associated morbidity and mortality. [ABSTRACT FROM AUTHOR]

Background: Acute pancreatitis is one of the most common complications following endoscopic retrograde cholangiopancreatography (ERCP), which can be life-threatening if the treatment is postponed. This study aimed to evaluate the effect of non-steroidal anti-inflammatory drugs (suppository diclofenac) on preventing post-ERCP pancreatitis (PEP). Materials and Methods: In this double-blind, randomized clinical trial, 219 patients referred to our ERCP unit who passed inclusion and exclusion criteria were randomly assigned to two groups: group A (103 patients) received a diclofenac suppository 30 minutes before and immediately after ERCP. In Group B (116 patients), a diclofenac suppository was prescribed only before the procedure. Patients were evaluated regarding clinical signs and symptoms of pancreatitis for 24 hours. Also, serum amylase level was checked at baseline, 6, and 24 hours after the procedure. The study protocol was approved by the Ethics Committee of the Iran University of Medical Sciences (IR.IUMS.FMD. REC.1399.190). Also, the study protocol was registered in the Iranian Registry for Clinical Trials (IRCT20191231045969N2). Results: The PEP was seen in three patients in group A and seven patients in group B, which was not significantly different (P=0.341). The severity of pancreatitis was mild in all patients except one in group B, who developed moderate PEP. Moreover, in 97.71 % of cases, ERCP was successful for the first time, and in 94.18 % of group A and 89.66% of group B, no complications of bleeding or perforation were detected. Conclusion: Administration of rectal diclofenac before and after ERCP had no significant effect on the prevention of pancreatitis compared with pre-ERCP administration. [ABSTRACT FROM AUTHOR]

Background: Acute pancreatitis is a serious gastrointestinal disease that is an important target for drug safety surveillance. Little is known about the accuracy of ICD-10 codes for acute pancreatitis in the United States, or their performance in specific clinical settings. We conducted a validation study to assess the accuracy of acute pancreatitis ICD-10 diagnosis codes in inpatient, emergency department (ED), and outpatient settings.Methods: We reviewed electronic medical records for encounters with acute pancreatitis diagnosis codes in an integrated healthcare system from October 2015 to December 2019. Trained abstractors and physician adjudicators determined whether events met criteria for acute pancreatitis.Results: Out of 1,844 eligible events, we randomly sampled 300 for review. Across all clinical settings, 182 events met validation criteria for an overall positive predictive value (PPV) of 61% (95% confidence intervals [CI] = 55, 66). The PPV was 87% (95% CI = 79, 92%) for inpatient codes, but only 45% for ED (95% CI = 35, 54%) and outpatient (95% CI = 34, 55%) codes. ED and outpatient encounters accounted for 43% of validated events. Acute pancreatitis codes from any encounter type with lipase >3 times the upper limit of normal had a PPV of 92% (95% CI = 86, 95%) and identified 85% of validated events (95% CI = 79, 89%), while codes with lipase <3 times the upper limit of normal had a PPV of only 22% (95% CI = 16, 30%).Conclusions: These results suggest that ICD-10 codes accurately identified acute pancreatitis in the inpatient setting, but not in the ED and outpatient settings. Laboratory data substantially improved algorithm performance. [ABSTRACT FROM AUTHOR]

Purpose: Brazil nuts (Bertholletia excelsa) are consumed world-wide and have become a new trend in weight loss supplementation. We present a unique case of severe hypertriglyceridemia-associated acute pancreatitis following daily usage of a Brazil nut supplement product. Summary: A Hispanic female presented with severe hypertriglyceridemia and acute pancreatitis several months after starting a Brazil nut weight loss supplement in the setting of poorly controlled Type 2 Diabetes Mellitus. Her initial triglyceride level was undetectably high >10,000 mg/dL but improved rapidly following euglycemic insulin infusion and supplement cessation. The patient was managed with supportive care, started on oral fibrate therapy after abdominal symptoms improved, and was discharged to home in stable condition. Conclusion: It is essential for pharmacists to maintain a high index of suspicion for patients taking complementary and alternative medications and supplements who present with acutely altered laboratory parameters or onset of acute disease. In this instance, a patient was found to have profound hypertriglyceridemia with onset of acute pancreatitis following usage of a Brazil nut weight loss supplement. [ABSTRACT FROM AUTHOR]

A 4-year-old male child presented with complaints of abdominal pain and vomiting along with yellowish discoloration of the eyes. Investigations were suggestive of acute pancreatitis and double gall bladder (GB) with dilated common bile duct (CBD) with intraluminal calculi and Type II choledochal cyst. He underwent surgical resection of double GB with dilated CBD with hepatico-docho-jejunostomy. On follow-up, the patient was asymptomatic. Our case highlights the importance of preoperative diagnosis to deal with increased operative difficulty and complications. [ABSTRACT FROM AUTHOR]

Background: Acute pancreatitis (AP) is a common digestive disease with increased incidence globally but without internationally licenced pharmacological therapy. Moderately severe and severe acute pancreatitis (MSAP/SAP) contributes predominately for its morbidities and mortality and has been managed in West China Hospital for decades using the traditional Chinese medicinal formula chaiqin chengqi decoction (CQCQD). The current study tests whether the early administration of CQCQD will result in improved clinical outcomes in predicted MSAP/SAP patients.Methods: This is a single-centre, randomised, controlled, double-blind pragmatic clinical trial. AP patients aged 18-75 admitted within 72 h of onset will be assessed at admission for enrolment. We excluded the predicted mild acute pancreatitis (Harmless Acute Pancreatitis Score > 2 at admission) and severe organ failure (Sequential Organ Failure Assessment [SOFA] score of respiratory, cardiovascular, or renal systems > 3) at admission. Eligible patients will be randomly allocated on a 1:1 basis to CQCQD or placebo control administration based on conventional therapy. The administration of CQCQD and placebo is guided by the Acute Gastrointestinal Injury grade-based algorithm. The primary outcome measure will be the duration of respiratory failure (SOFA score of respiratory system ≥ 2) within 28 days after onset. Secondary outcome measures include occurrence of new-onset any organ failure (SOFA score of respiratory, cardiovascular, or renal system ≥ 2) and new-onset persistent organ failure (organ failure lasts > 48 h), dynamic surrogate biochemical markers and clinical severity scores, gut-centred treatment modalities, local complications status, intensive care need and duration, surgical interventions, mortality, and length of hospital stay. Follow-up will be scheduled on 6, 12, and 26 weeks after enrolment to assess AP recurrence, local complications, the requirement for surgical interventions, all-cause mortality, and patient-reported outcomes.Discussion: The results of this study will provide high-quality evidence to appraise the efficacy of CQCQD for the early management of AP patients.Trial Registration: Chictr.org.cn Registry ( ChiCTR2000034325 ). Registered on 2 July, 2020. [ABSTRACT FROM AUTHOR]

Background: Acute pancreatitis (AP) is a common digestive system disease, and its incidence is increasing year by year. Although some clinical studies have indicated that cholecystectomy can reduce the risk of recurrent pancreatitis after acute biliary pancreatitis (ABP), it is not clear whether cholecystectomy would affect the severity of subsequent AP. Methods: In this study, we combined computed tomography scoring index (CTSI), bedside index for severity in AP (BISAP), and clinical manifestations grading of AP with propensity score matching (PSM), after correction for baseline confounding factors, to respectively explore the influence of cholecystectomy on the severity of subsequent pancreatitis in 527 AP patients. Results: The results showed that ABP (231/527) is more common in female patients and elderly patients (P < 0.001). Age, amylase, creatinine, blood urea nitrogen, and aspartate aminotransferase levels of patients with ABP at admission were higher than those of non-biliary pancreatitis (296/527), and the levels of albumin, hematocrit, and blood glucose were lower (P < 0.050). Further, compared with the unresected group (458/527), patients after cholecystectomy (69/527) had less white blood cells and higher level of albumin (P < 0.050). Patients had lower clinical manifestation grade (P = 0.019) and CTSI grade (P < 0.008) after cholecystectomy. After PSM correction, there was no difference in biochemical parameters between the cholecystectomy group and the non-cholecystectomy group, but differences in clinical manifestation grade (P = 0.039) and CTSI grade (P = 0.013) remained. We also found that cholecystectomy reduced the frequency of biliary pancreatitis (30.4% vs. 45.9%, P < 0.050). Finally, we found that cholecystectomy could reduce the severity of subsequent idiopathic AP. Conclusion: Cholecystectomy could reduce the severity of subsequent idiopathic AP and the frequency of biliary pancreatitis. [ABSTRACT FROM AUTHOR]

Background: Chronic pancreatitis (CP) is defined according to the recently proposed mechanistic definition as a pathological fibro-inflammatory syndrome of the pancreas in individuals with genetic, environmental, and/or other risk factors who develop persistent pathological responses to parenchymal injury or stress.Methods: The clinical practice guidelines for CP in Japan were revised in 2021 based on the 2019 Japanese clinical diagnostic criteria for CP, which incorporate the concept of a pathogenic fibro-inflammatory syndrome in the pancreas. In this third edition, clinical questions are reclassified into clinical questions, background questions, and future research questions.Results: Based on analysis of newly accumulated evidence, the strength of evidence and recommendations for each clinical question is described in terms of treatment selection, lifestyle guidance, pain control, treatment of exocrine and endocrine insufficiency, and treatment of complications. A flowchart outlining indications, treatment selection, and policies for cases in which treatment is ineffective is provided. For pain control, pharmacological treatment and the indications and timing for endoscopic and surgical treatment have been updated in the revised edition.Conclusions: These updated guidelines provide clinicians with useful information to assist in the diagnosis and treatment of CP. [ABSTRACT FROM AUTHOR]

In 1995, Yoshida et al. proposed first the concept of "autoimmune pancreatitis" (AIP). Since then, AIP has been accepted as a new pancreatic inflammatory disease and is now divided two subtypes. Type 1 AIP affected immunoglobulin G4 (IgG4) and implicates the pancreatic manifestation of IgG4-related disease, while type 2 is characterized by neutrophil infiltration and granulocytic epithelial lesions (GEL). Recent research has clarified the clinical and pathophysiological aspects of type 1 AIP, which is more than type 2 among the Japanese population. However, many details remain unclear about the pathogenesis and progression of this disease. In this review, we discuss the current knowledge and recent advances relating to type 1 AIP. [ABSTRACT FROM AUTHOR]

Acute pancreatitis is a common presentation in Emergency Department. Elevated amylase and lipase levels are one of three important criteria to diagnose acute pancreatitis. Out of amylase and lipase, the latter is considered more specific for acute pancreatitis. We report a case of acute pancreatitis where serum lipase levels remained always within normal limits. On review of published literature on acute pancreatitis with normal lipase levels, 23 such case reports were retrieved. A brief review, of all these cases including the case presented here, had unknown etiology in 50% of cases followed by alcohol and gallstone. Pain abdomen was the commonest presentation followed by vomiting. Normal discharge could be done in 71% of cases and 17% of patients were non-survivors. Hence, normal lipase cannot rule out acute pancreatitis on its own. A typical presentation of acute pancreatitis needs radiological workup like an Ultrasound abdomen or CT scan with IV contrast (if not contraindicated) before refuting its possibility. [ABSTRACT FROM AUTHOR]