Purpose: Pancreatic necrosis is a serious complication of acute pancreatitis. The identification of simple laboratory tests to detect subjects at risk of pancreatic necrosis may direct management and improve outcome. To study the association between routine laboratory tests and the development of pancreatic necrosis in patients with acute pancreatitis. Methods: In a cohort of 185 prospectively enrolled patients with acute pancreatitis for Severity in Acute Pancreatitis study (SAPS), patients with contrast enhanced computerized tomography performed were selected (N = 129). Serum hematocrit, creatinine and urea nitrogen on admission and peak values within 48 hours of admission were analyzed. The volume of intravenous fluid resuscitation was calculated for each patient. Results: Thirty-five of 129 (27%) patients had evidence of pancreatic necrosis. Receiver operating characteristic curves for pancreatic necrosis revealed an area under the curve of 0.79 for admission hematocrit, 0.77 for peak creatinine and 0.72 for peak urea nitrogen. Binary logistic regression yielded that all three tests were significantly associated with pancreatic necrosis (P < 0.0001) with the highest odds ratio of 34.5 for peak creatinine. The volume of intravenous fluid resuscitation was similar in patients with and without necrosis. Low admission hematocrit (<44.8%) yielded a negative predictive value of 89%; elevated peak creatinine (>1.8 mg/dL) within 48 hours yielded a positive predictive value of 93%. Conclusion: We confirm that a low admission hematocrit is negatively associated with the development of necrosis in patients with acute pancreatitis. In contrast, an increase in creatinine within the first 48 hours is positively associated with pancreatic necrosis. This finding may have important clinical implications and warrants further investigation.Table: Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of admission Hct and peak Cr within 48 hours as predictive tests for the development of PNec.
Corporate scandals of the 21st century have raised criticism of auditors, reducing public trust and impairing the profession's morality. In this way, ethics has been revealed as the means through which auditors can regain their public confidence and enhance the profession's moral status. This chapter reviews the literature about ethics in auditing, discussing empirical studies related to auditors' ethical principles; integrity, objectivity, professional competence and due care, professional behavior, and confidentiality, as identified by the IFAC code of ethics. This synthesis of the literature is not exhaustive, but it includes articles published in leading academic journals in the era following the implementation of audit reform regulation in the United States and Europe. Conclusions are drawn and recommendations for future research are provided to further expand the existing literature.
Introduction: An estimated 12% of women will develop cholelithiasis during pregnancy. Nearly 70% of cases of acute pancreatitis in pregnancy are attribuTable to gallstone disease. Acute biliary pancreatitis (ABP) during pregnancy can cause serious morbidity, but there is a paucity of literature on how outcomes and management of ABP in pregnancy have changed with time. Hence, we sought to study trends of ABP and its management in pregnant women over the last two decades at a national level. Methods: We used the National (Nationwide) Inpatient Sample to identify all women (≥18 years) with an inpatient admission for ABP in the United States from 2002 to 2018. We excluded data from 2015-2016 due to less than expected incidence attribuTable to a transition from the ICD-9 to ICD-10 coding system. Baseline patient characteristics were compared between pregnant and non-pregnant women with ABP utilizing Chi-square and two sample t-tests. Trends in outcomes and management were analyzed using Cochran-Armitage and F-Tests. Results: Among 40,359 pregnant patients and 476,965 non-pregnant women hospitalized for ABP, a higher proportion of pregnant women with ABP were Hispanic (p< 0.001) and used Medicaid (p< 0.001) than non-pregnant women on univariate analysis (Table). Trend analyses from 2002-2018 revealed an increasing proportion (p< 0.001) of ABP admissions in pregnant females (Figure). An increasing trend was observed for ERCP (p< 0.001) and cholecystectomy (p< 0.001) in pregnant women admitted for ABP (Figure). Severe acute pancreatitis increased in both pregnant and non-pregnant patients across time, but a lower increase was seen in the pregnant cohort. Overall mortality in the pregnant cohort remained low (< 0.1%), ICU admission was less than 0.6%, and mean length of stay decreased from 5 days to 4 days (p< 0.001) for pregnant women with ABP. Conclusion: Over the last two decades, an increasing proportion of pregnant women are admitted with ABP, and therapeutic interventions (ERCP and cholecystectomy) are occurring more frequently with favorable hospital outcomes. These national-level data strongly support current surgical and endoscopic management guidelines of ABP in pregnancy.Figure 1.: Trends in Acute Biliary Pancreatitis in Non-Pregnant and Pregnant Women Table 1. - Baseline Characteristics for Females Admitted with Acute Biliary Pancreatitis Variable Non-Pregnant (n=476,965) Pregnant (n=40,359) p-value n % n % Age (mean, SE) 55.97 0.14 26.12 0.07 < 0.0001 Race White 251,213 52.67 14,326 35.5 < 0.0001 Black 45,633 9.57 3,668 9.09 Hispanic 81,010 16.98 13,645 33.81 Other/Missing 99,110 20.78 8,719 21.6 Median Income Low (0-25th percentile) 129,345 29.66 12,303 32.63 < 0.0001 Moderate (26th to 50th percentile) 115,539 26.5 10,597 28.11 High (51st to 75th percentile) 104,546 23.97 9,168 24.32 Very High (76th to 100th percentile) 86,648 19.87 5,633 14.94 Type of Insurance Medicare 183,908 38.62 358 0.89 < 0.0001 Medicaid 74,005 15.54 21,620 53.68 Private 156,631 32.89 14,291 35.48 Other, self-pay, no charge 61,623 12.94 4,009 9.95 Type of Hospital Rural 61,686 12.97 3,608 8.98 < 0.0001 Urban non-teaching 203,194 42.74 15,545 38.7 Urban teaching 210,542 44.29 21,014 52.32 Hospital bed size Small 70,512 14.83 4,421 11.01 < 0.0001 Medium 132,502 27.87 10,778 26.83 Large 272,408 57.3 24,966 62.16 Hospital region Northeast 83,151 17.43 5,440 13.48 < 0.0001 Midwest or North Central 100,177 21 7,850 19.45 South 182,145 38.19 15,535 38.49 West 111,491 23.38 11,533 28.58 AHRQ-Elixhauser Index < 3 317,136 66.49 37,201 92.18 < 0.0001 ≥3 159,828 33.51 3,157 7.82 Admission Day Weekday (Mon-Fri) 347,061 72.77 29,322 72.65 0.8329 Weekend (Sat-Sun) 129,899 27.23 11,037 27.35
